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 Table of Contents  
Year : 2022  |  Volume : 1  |  Issue : 3  |  Page : 144-155

Nutrition knowledge of caregivers working in health and education centers for children with special healthcare needs

1 Department of Clinical Nutrition and Dietetics, College of Health Sciences, University of Sharjah, Sharjah 27272, United Arab Emirates; Nuffield Department of Women’s & Reproductive Health, University of Oxford, Oxford OX1 2JD, UK
2 Department of Clinical Nutrition and Dietetics, College of Health Sciences, University of Sharjah, Sharjah 27272, United Arab Emirates
3 Department of Nutrition and Health, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain 15551, United Arab Emirates
4 Department of Clinical Nutrition and Dietetics, College of Health Sciences, University of Sharjah, Sharjah 27272, United Arab Emirates; Department of Nutrition and Food Technology, Faculty of Agriculture, Jordan University of Science and Technology, Irbid 22110, Jordan

Date of Submission31-Mar-2022
Date of Decision24-Jun-2022
Date of Acceptance02-Jul-2022
Date of Web Publication27-Jul-2022

Correspondence Address:
Leila Cheikh Ismail
Department of Clinical Nutrition and Dietetics, College of Health Sciences, University of Sharjah, Sharjah 27272
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/abhs.abhs_26_22

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Background: Children with special healthcare needs are recognized as a high-risk group for malnutrition. Caregivers have a strong influence on the dietary habits of their students, therefore, adequate nutrition knowledge among caregivers and educators has a great potential in improving the health of children. The purpose of this study is to assess the level of nutrition knowledge and demographic influences of knowledge among caregivers working in health and education centers. Methods: a cross-sectional, web-based survey was conducted among educators and caregivers working at Sharjah City for Humanitarian Services to assess their nutritional knowledge using a modified validated general nutrition knowledge questionnaire. Results: 233 participants completed the survey. The basic recommendations about reducing the intake of sugary, salty, and fatty foods and consuming more water and vegetables were best acknowledged. However, an inadequate level of knowledge was identified regarding specified number portion. For instance, more than half of the participants were aware of the need to consume more vegetables and fruits while only 10% knew the minimum number of servings to consume in a day. The overall nutrition knowledge score was adequate at 46.30 (55.1%). Caregivers with nutrition qualifications and who have four children had a significantly higher knowledge score. Older age was associated with better diet-disease relationship knowledge. Conclusions: The level of nutrition knowledge among caregivers and health workers was insufficient. However, periodic nutrition education reinforcement among health caregivers should be considered.

Keywords: Caregivers, children, nutrition knowledge, special needs

How to cite this article:
Cheikh Ismail L, Abu Qiyas S, Mohamad MN, Osaili TM, Obaid RR, Saleh ST, Kassem H, Al Dhaheri AS, Al Daour R, Al Rajaby R, Hasan HA, Hashim MS. Nutrition knowledge of caregivers working in health and education centers for children with special healthcare needs. Adv Biomed Health Sci 2022;1:144-55

How to cite this URL:
Cheikh Ismail L, Abu Qiyas S, Mohamad MN, Osaili TM, Obaid RR, Saleh ST, Kassem H, Al Dhaheri AS, Al Daour R, Al Rajaby R, Hasan HA, Hashim MS. Nutrition knowledge of caregivers working in health and education centers for children with special healthcare needs. Adv Biomed Health Sci [serial online] 2022 [cited 2022 Dec 3];1:144-55. Available from: http://www.abhsjournal.net/text.asp?2022/1/3/144/352497

  Background Top

Children with Special Healthcare Needs (CSHCN) are considered a nutritionally vulnerable community of children and adolescents. The American Academy of Pediatrics and the Maternal and Child Health Bureau define CSHCN as children who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who require health and other related services of a type or amount beyond what is required by children generally. CSHCN are recognized as a high-risk group for malnutrition [1,2]. They are more likely to develop comorbidities such as obesity, underweight, and endocrine disorders as well as suffer from several nutritional problems [2]. Previous studies comparing CSHCN to their typically growing counterparts, reported a higher prevalence of growth alterations, [2,3] poor feeding, [4],[5],[6] and gastrointestinal and metabolic disorders [3,7] among the CSHCN group. Parental nutritional status in addition to several other medical, physiological, and behavioral risk factors was found to influence nutrition outcomes in CSHCN [3].

While parents are considered the primary caregivers for their children, with CSHCN, there can be several additional caregivers with different responsibilities. Teachers and healthcare workers who spend a considerable amount of time with CSHCN play a substantial part in facilitating the children’s development and progress [8]. Research suggests that CSHCN can especially benefit from a constructive teacher-student relationship [9]. This is particularly important because the literature indicates that teachers have a strong influence on the dietary habits of their students in many ways, including the use of rewards, role-modeling, and the initiation and implementation of nutritional intervention programs in schools [10,11]. Likewise, malnutrition in children can be decreased if healthcare workers had proper nutrition knowledge and provide accurate and sufficient nutrition guidance to informal (family) caregivers frequently [12].

The buildup of multiple hardships, starting before conception and continuing throughout prenatal and early life, can lead to cognitive and physical developmental delays [13]. Physical and cognitive development in childhood is influenced by interaction and maturation. A cross-sectional study of preschool children in Brazil found that children exposed to three or more adverse experiences in childhood had lower communication, gross motor, fine motor, and personal-social domain scores than children with no adverse childhood experiences [14]. Developmental delays begin to surface in the first year of life, get worse in early childhood, and persist into adulthood [13]. Early childhood development requires nurturing care defined by the World Health Organization (WHO) as “a caregiving environment that is sensitive to children’s health and nutritional needs, responsive, emotionally supportive, and developmentally stimulating and appropriate, with opportunities for play and exploration and protection from adversities” [15].

Adequate nutrition early in life enables children to reach their developmental potential by easing the acquisition of developmental competencies for socio-emotional, behavioral, academic, and economic accomplishments [13]. Conversely, early life malnutrition insults can irreversibly impact cognition and behavior later in life. Literature investigating the long-term effects of early childhood malnutrition showed that reduced intelligence quotient (IQ) and intellectual abilities, poorer academic performance and decision-making, and attention deficits are more prevalent among malnourished children compared to control groups [16]. The effects of micronutrient deficiencies on child development have also been reported. Several studies have linked previous [17] and existing [18,19] iron deficiency in children with lower academic performance in school. Stunting (low height for weight as a result of chronic malnutrition) has also been linked to multiple micronutrient deficiencies, such as Vitamin A, D, and Zinc, as well as several genetic and environmental factors [20].

Good nutrition is an essential component of sound health. It has an integral role in health promotion, prevention, and treatment of chronic disease. The past half-century has seen an increasing burden of noncommunicable diseases (NCDs) on public health worldwide; principally cardiovascular diseases (CVDs), cancer, diabetes, and chronic respiratory disease [21]. The positive impact of diet and nutrition on decreasing the burden of NCDs has been well-studied over the years and has been identified as one of the most controllable factors for long-term wellbeing [22],[23],[24]. Promoting healthy lifestyle habits and good dietary habits has become crucial in the past few decades to combat the effects of urbanization, vast economic development, and smart marketing of more westernized dietary patterns [25,26]. Thus, nutrition education on a community level or for hospitalized patients is a cost-effective method for health promotion and disease treatment [27]. It is well-established that healthcare givers and educators in the broad sense are considered trusted health information providers by the public [28]. In this manner, the ability of caregivers to provide evidence-based and appropriate nutrition and health knowledge is crucial to provide a significant contribution to the nutrition knowledge of patients and people of the community [24,29].

As the burden of nutrition-related diseases remains and continues to rise, it is imperative to study the current nutritional knowledge among caregivers as they are providing trusted information to the public. In the United Arab Emirates (UAE) NCDs account for 77% of all deaths [30]. Despite the promising potential of improving the nutrition knowledge and practices of caregivers on improving the health of CSHCN, the literature on the subject remains scarce. The present study aims to assess the nutrition knowledge of caregivers working in health and education centers for CSHCN in Sharjah, United Arab Emirates (UAE).

  Materials and methods Top

Study design and participants

A descriptive cross-sectional study was conducted in Sharjah, UAE between October 2017 and January 2018 to assess the nutritional knowledge among caregivers and educators. The target population included a convenience sample of caregivers and educators of children with special needs working at Sharjah City for Humanitarian Services (SHCS) during the study period. SCHS is a local non-profit organization founded in 1979 as a branch of the Arab Family Organization in the Gulf region to develop the social services for the Arab family needs [31]. A total of 233 subjects agreed to participate in the study.

A web link connecting to the online survey was shared with the caregivers at SHCS who agreed to participate in the study. The link was distributed using e-mail invitations through the institution’s internal emailing system. Participation was voluntary and the subjects were free to withdraw at any time. No monetary incentives were provided for participation and no personal identification data was collected. An information sheet was provided on the first page of the online survey explaining the objective of the study and only consenting participants proceeded to the questions.

The study was conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures involving human subjects were approved by the Research Ethics Committee at the University of Sharjah (REC-22-03-22-S) and the SCHS institution management. An electronic informed consent was obtained from all participants.

Survey questionnaire

A modified version of the General Nutrition Knowledge Questionnaire (GNKQ) was adopted to measure nutrition knowledge [32]. The GNKQ is a self-administrated, reliable, and validated questionnaire and was previously used to assess general nutrition knowledge in the UK, Australia, and Ireland [33],[34],[35],[36]. Minor modifications were made to the original questionnaire to adjust for the UAE population in terms of commonly consumed foods [37]. For example, Quiche (pie crust filled with eggs) was replaced with Balaleet (eggs and vermicelli) which is a commonly consumed breakfast dish in the UAE. Moreover, some items were omitted to further fulfill the objectives of the study (mainly those related to nutrition knowledge about pork and alcohol as they are banned in the Emirate of Sharjah) resulting in a maximum score of 84 compared to 110 in the original version [32].

The questionnaire was translated to Arabic and reviewed by the research team for any discrepancies between the English and Arabic versions. A pilot test was conducted on 25 subjects before commencing the study. Based on the results of the pilot test, minor changes in wording were incorporated to ensure understandability and feasibility. The pilot test data was not included in the analysis. A master key was developed by a panel of six nutrition experts with a consensus on the correct answer to each question. The survey was then prepared on Google Forms in Arabic.

The questionnaire comprised of four main sections, dietary guideline recommendations (section A); nutrients content of foods (section B); everyday food choices (section C), and links between diet and disease (section D). Socio-demographic characteristics including gender, age group, nationality, level of education, marital status, number of children, and perceived health status were also collected. Altogether, a total of eighty-four items were used to assess nutrition knowledge and the scores were distributed over four sections: Section A (nine items: fifteen points); section B (ten items: thirty-five points); section C (thirteen items: thirteen points); and section D (sixteen items: twenty-one points). Correct responses from each section were added to give a section score, and the four section scores were summed to give an overall knowledge score. Participants answered different types of question styles, including multiple-choice, yes/no, or agree/disagree. The internal consistency of the GNKQ scale was assessed using Cronbach’s alpha test for each section and it was determined as follows: dietary guideline recommendations 0.81; nutrients content of foods 0.8; everyday food choices 0.79; and links between diet and disease 0.82.

Statistical analyses

Descriptive statistics for the sociodemographic characteristics and frequency of correct responses were reported as counts and percentages. A chi-square test was used to determine the association between different categorical variables. Means and standard deviation (SD) were used for continuous variables. A 70% cutoff was used to determine the level of knowledge as adequate (above 70%) or inadequate (below 70%) for each component of the questionnaire [38]. Total and sub-scores were calculated based on the total number of correct answers. Total knowledge scores were derived for each participant based on the sum of correct answers to all questions which can range between 0 and 84. Moreover, sub-scores were calculated for each section of the questionnaire. Knowledge sub-scores can range between 0 and 15 (Section A), 0 and 35 (Section B), 0 and 13 (Section C) and 0 and 21 (Section D). Higher scores indicate a higher level of knowledge. Differences between knowledge scores were determined using an independent t-test and a one-way ANOVA test. Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) ver. 26·0 (IBM, Chicago, IL, USA). Results were significant for p-value < 0.05.

  Results Top

Sociodemographic characteristics

A total of 233 caregivers participated in the study. Key sociodemographic characteristics of the study participants are summarized in [Table 1]. The majority of participants were between 31 and 40 years old. The male to female ratio was 1:3 (25.3% males). As shown in the table, most participants were of non-GCC Arabian nationalities (72.5%), married (81.5%), had no children (25.8%), and completed a bachelor’s degree (76.4%). Of the 233 participants, less than 10% had nutrition-related qualifications.
Table 1: Sociodemographic characteristics of study participants (n = 233).

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Dietary guideline recommendations

The proportion of participants with correct answers to the first section of the GNKQ is shown in [Table 2]. This section covered dietary recommendations by experts and participants’ related knowledge. Correct responses to expert recommendations on foods to be increased or decreased in the diet ranged from 52.8% to 88.4%. Most participants were aware of unhealthy foods they need to cut down on such as sugary foods (88.4%), fatty foods (83.3%), salty foods (77.2%), and processed meat (74.2%). Moreover, they were aware of the need to consume higher amounts of water (86.7%) and vegetables (83.3%), however, a lesser proportion was recorded in foods such as fruits (64.4%) and high fiber foods (52.8%). No significant difference between males and females was recorded. Interestingly, only 10% of the participants were aware of the minimum number of servings of fruits and vegetables to consume. About half of the participants recognized experts’ recommendations to consume reduced-fat dairy products and cut down on saturated fat with more females answering correctly compared to males (p=0.014, p=0.047 respectively). The vast majority of participants answered correctly with regards to consuming breakfast daily (93.6%). As for the components of My Plate, less than half of the participants were aware of the proper proportion of starchy food on the plate (46.8%) with a significantly higher percentage of females answering correctly (p=0.002).
Table 2: The proportion of participants with correct answers on dietary guideline recommendations by gender (n = 233).

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Nutrients content of foods

[Table 3] shows participants’ results on sources of nutrients and food groups. The knowledge level in this section ranged from 10.3% to 94.4%. Adequate knowledge was reported on foods high or low in certain nutrients. These included foods low in added sugar such as breast milk (85.8%) and melon (78.1%), foods high in added sugar such as ice cream (85.4%), and ketchup (76.8%) which was significantly higher among females (p=0.001). Moreover, the majority of participants correctly identified breakfast cereals as low in sodium (76.8%), canned soup as high in sodium (79.4%), oats as a high fiber source (85.4%), poultry as a high protein source (91.8%), pasta and potato as starchy foods (92.3% and 94.4%, respectively), and cheese and nuts as non-starchy foods (83.7% and 72.1%, respectively). Nonetheless, inadequate knowledge level was evident in few nutrient sources’ food items, such as less than two-thirds of participants identified cheese, baked beans, and nuts as good sources of protein. A similar proportion identified white rice, eggs, and pasta as low-fiber food sources.
Table 3: The proportion of participants with correct answers on nutrients content of foods by gender (n = 233).

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Everyday food choices

[Figure 1] shows the proportion of participants answering correctly when asked to choose healthy everyday foods. Correct responses ranged from 18% to 79.4%. An adequate level of knowledge was recorded in choosing the healthiest sandwich option (75.5%) and soup option (76.8%). However, a low level of knowledge was found with regards to awareness of high vitamin and antioxidant-containing vegetables (25.3%) and the best alternative to chips (15.0%). Females reported adequate knowledge with significantly higher correct responses compared to males in choosing the healthy dessert option (42.0%), lowest fat option soup (78.7%), and choosing herbs as the best salt substitute (67.2%, p=0.030). Participants were asked to read provided nutrition food labels for two different products. Only 18% of the participants were able to answer correctly when asked to identify the higher caloric content of two given products.
Figure 1: Proportion of participants with correct answers on selected questions form everyday food choices section by gender (n = 233). Correct answers by order (Herbs; thick cut-chips; Broccoli, carrot and tomato; Tuna salad sandwich + fruit + low fat yogurt + water; Roast turkey, mashed potatoes and vegetables; Spicy pumpkin soup and carrots; Natural yogurt), p-value based on Chi-square test, significance set at <0.05.

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Diet-disease relationship

The last section of the questionnaire included questions on the diet-disease relationship and weight management. [Table 4] shows that general awareness was adequate regarding high blood pressure and high sodium diets (79.4%) and bowel disease and low fiber diets (71.7%). Nonetheless, a moderate level of knowledge was recorded in terms of tooth decay and high sugar diets (67.5%) and low levels of knowledge with regards to the consumption of animal fat and high blood cholesterol (48.9%). More than two-thirds of participants were aware of the role of reducing fat consumption and its relation to preventing heart disease. However, only a third of participants correctly associated reducing red meat with the prevention of cancer and reducing refined foods with diabetes. Participants’ perception of common misperceptions about weight management was also assessed in this section. The majority of participants thought that to maintain a healthy weight they should cut down fat completely (60%), consume high protein diets (90.6%) and that bread consumption causes weight gain (73.8%). However, about two-thirds perceived the positive effects of consuming fiber in weight management. [Figure 2] shows the proportion of participants answering correctly on selected recommendations for a healthy weight. Over 80% of participants correctly identified refraining from eating while watching TV and monitoring eating with females answering more correctly (p=0.012 and p=0.024, respectively). Besides, the majority of participants thought that weight monitoring and reading food labels help them maintain a healthy weight (86.7% and 85.8%, respectively). However, less than half of the participants knew that taking supplements and grazing throughout the day are ineffective in maintaining a healthy weight.
Table 4: The proportion of participants with correct answers on links between diet and by gender (n = 233).

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Figure 2: Proportion of participants answering correctly on recommendations for a healthy weight by gender, correct answers are provided between brackets, p-value based on Chi-square test, significance set at <0.0.5.

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Demographic variation in nutrition knowledge

[Table 5] indicates the association of total scores and sub-scores with different sociodemographic characteristics. The mean nutrition knowledge score for all participants was 46.30 ± 10.36 (55.1%) out of the highest possible score. Overall, total knowledge did not differ between different ages, however, participants who were 31 years and above were more aware of the diet-disease relationship and weight management section (P = 0.005). Females answered more correctly in all sections of the questionnaire compared to males, however, only they were more significantly aware with regards to choosing everyday food (P = 0.025). Moreover, participants who reported having four children and nutrition-related qualifications had a significantly higher level of awareness with regards to nutrient sources and diet-disease associations (P = 0.010, 0.037 and P = 0.012, P = 0.030) respectively and had significantly higher total knowledge scores (P = 0.006 and P = 0.014) respectively. In contrast, the nutrition knowledge score was not significantly associated with marital status, level of education, and nationality.
Table 5: Univariate analysis of demographic variance in nutrition knowledge (n = 233)1.

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  Discussion Top

To the best of our knowledge, this study is the first to evaluate the level of nutrition understanding among caregivers and health workers of children with special needs using a validated questionnaire in the UAE. The General Nutrition Knowledge questionnaire used in the current study has been used in previous studies to assess nutritional knowledge among members of the healthcare team, people in the community, and athletes. The General Nutrition Knowledge questionnaire provides a useful and reliable scale to assess nutrition knowledge and its relation to dietary practices [32].

Results indicated that only half of our study participants had adequate knowledge in all areas concerned including ‘experts’ advice’, ‘nutrient sources’, ‘choosing everyday foods’, and ‘diet-disease relationship’. These findings were similar to kindergarten teachers in China [39] and lower than scores reported for Australian nurses, [40] Canadian public nurses [41] and American rural nurses [42]. Similar findings were reported among schoolteachers [11] and workers in Ireland [43]. The low level of knowledge in the current study may reflect low interest, lack of education, or lack of perceived importance of general nutrition in their lives and jobs. These results highlight the need to target this group through nutrition education programs and the messages included to be adjusted for their level of knowledge.

Although participants had low nutrition knowledge, it is worth mentioning that basic dietary knowledge of participants such as eating more fruits and vegetables was better compared to more detailed information about applying this knowledge and making sound food choices. For instance, basic knowledge of the need to increase fruit and vegetable consumption was good but participants lacked the knowledge of how many servings to consume daily or which vegetables contain the most antioxidants and vitamins. This was comparable to other studies among university students and staff in Sharjah and adults in Australia [37,44].

There are growing rates of metabolic disorders among the Arab population that are primarily influenced by sedentary lifestyle habits and adoption of unhealthy dietary habits such as low intake of fruits and vegetables, high consumption of energy-dense fast foods, eating away from home, and frequent snacking [45],[46],[47]. Furthermore, it was recently reported that unhealthy lifestyle and eating behaviors along with physical inactivity were exacerbated among residents of the Middle East and North Africa region (MENA) and the UAE during the COVID-19 pandemic [48],[49],[50]. Therefore, it became of the utmost importance to develop public health campaigns that support individuals in making healthier lifestyle choices via modern technology such as social media.

Consistent results of an inadequate awareness or usage of dietary guidelines regarding food groups and portion sizes as only half of the participants were aware of how much starch should contribute to their plate following My Plate guidelines. Similar results were found in agreement with our study among Saudi mothers, where half of the sample correctly identified food groups on the My Plate image [51]. It was found that awareness of such guidelines was positively associated with better and healthier dietary intakes [52]. Also, only one in five participants manifested good basic food label reading skills which are considered very low and indicate insufficient knowledge about food labels. Evidence shows that among multiple types of food labels, front-of-package labels and traffic lights labels were most successful in helping shoppers make healthier food choices [53]. This indicates the need for more education and proper reading on food labels for better food options.

Diet-disease knowledge among study participants varied from low to moderate although this area has received much attention in research [54],[55],[56]. In the current study, the awareness of the relationship between low fiber intake and bowel disorders, sodium and high blood pressure, and low-fat diet and heart diseases was satisfactory. These findings are alarming as there has been a long-standing body of research and community education about the implications of such dietary habits [56,57]. A critical finding is the poor understanding of the association between sugar and tooth decay among the participants who are health care providers for people with special needs. Knowing that lack of self-care for oral hygiene among the children will let them prone to developing abnormal oral conditions and tooth decay, especially with the presence of insufficient support from their parents and guardians [58,59]. Including the topic of food-related oral health among other nutrition and diet-disease prevention education sessions will be a need topic for the health care providers.

Weight management encompasses numerous controversies and false claims about dieting, weight loss, and maintenance and is a topic of debate among researchers, dietitians, healthcare professionals, and the general public [60]. The findings of this study indicated an alarmingly low level of knowledge concerning the most common weight management facts. Nonetheless, participants were better informed about general recommendations for a healthy weight such as refraining from eating while watching Tv and practicing food labels reading. Optimal strategies identified for weight loss and management include creating a healthy calorie deficit, focusing on the type of food, and meal timing [60],[61],[62]. Therefore, emphasis should be put on finding creative ways to provide valid and reliable information to prevent any misconceptions and misunderstandings related to weight loss and maintenance.

This study showed a demographic variation in nutrition knowledge levels. Findings show that females were more knowledgeable compared to males in all sections of the questionnaire although they were more aware of choosing healthy food options than males. This can be explained by the fact that women are generally more concerned about dietary recommendations and health and consequently have a better knowledge level [63],[64],[65]. Moreover, older age was associated with a better level of knowledge where people who were 40 years+ scored better than any other age group. This may indicate that educators and health workers gain knowledge and acquire better dietary habits with experience [41,66]. Acquiring reliable nutrition information is essential in making informed food choices and motivating healthier eating habits.

  Conclusion Top

In conclusion, the present study assessed the level of general nutrition knowledge in caregivers and health workers for children with special needs and revealed that their level of knowledge needs improvement. The findings of the study suggest the necessity to improve knowledge, provide more reliable nutrition information detailed nutritional information and particularly focus on the practical aspect of applying this knowledge to choosing healthier options and maintaining healthy body weight. This could be achieved by assigning a nutritionist to SHCS centers to provide periodic nutrition education to staff, children, and their families.

Moreover, it is imperative to implement nutrition-centered educational interventions to target this population as their level of knowledge has a profound impact on the children, they take care of. Future research needs to recruit larger numbers of educators and caregivers with equal representation to provide a better understanding of their knowledge and design proper intervention strategies that eventually pour in the benefit of the children they are responsible for.

Study limitations

The present research has acknowledged limitations. Firstly, the use of self-reported online questionnaires may have attributed to under or over-reporting. Also, the convenient sampling approach used may have potentially reduced the representativeness of the group. Lastly, the sample may not be completely representative as the questionnaire was filled by more females than males consequently overestimating the true level of awareness in this group. Nonetheless, the study has multiple strengths including the use of the GNK questionnaire as this tool successfully identified gaps in nutrition knowledge concerning dietary behavior and identified the aspects that need further education. Besides, this study provides important insight as there are no available data to date assessing the nutritional knowledge among this group.

Authors’ contributions

LCI, TMO, HH, and MH conceived the research concept. LCI, TMO, RRSO, ASA, and MH developed the research design. LCI, TMO, SAQ, HK, RAD, RAR, and MH performed fieldwork and data analysis. MNM and STS conducted data analysis. LCI, SAQ, MNM, STS, and HS prepared the first draft and all reviewers reviewed and approved the final draft of the manuscript. All authors are responsible for the contents and integrity of this manuscript.

Ethical statement

The study protocol was approved by the Research Ethics Committee at the University of Sharjah and the SCHS institution management (March 2019).

Declaration of patient consent

An electronic informed consent was obtained from all participants before taking part in the research study.

Financial support and sponsorship

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Data availability statement

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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