Gastronot: a pilot project for promoting healthy eating habits using mixed-method study design

Introduction

Malnutrition in children is a serious public health problem that can affect child growth and development, leading to a variety of disorders and even death.^1–3 Malnutrition is common in developing countries, including Indonesia.⁴ Malnutrition is a deficiency, excess, or nutritional imbalance resulting from inadequate nutrient intake.^5,6 Indonesia is currently experiencing a double burden of malnutrition, that is, an increase in cases of overweight/obesity, and still having unresolved undernutrition problems.^4,7 About one in three children under five years old experience stunting, and one in ten children experience wasting.¹ Wasting defined as low weight-for-height which indicates recent and severe weight loss. Stunting defined as low height-for-age as a result of chronic or recurrent undernutrition.⁸ Micronutrient insufficiency is also on the rise in Indonesia.⁹ Malnutrition in children, especially throughout their growing stage, cannot be isolated from children's eating habits, according to empirical data collected in the field and in academia.^6,10,11 Numerous studies have been carried out to establish why children are prone to developing bad eating habits.^12,13 For instance, children who suffer from overnutrition risk noncommunicable diseases (NCD), including obesity, hypertension, type 2 diabetes, and cardiovascular diseases.^14–16 Therefore, modifying a child's eating habits into healthier ones can lower the risk of developing a diet-related illness in the following years into adulthood.^17,18

In order to combat malnutrition, the Indonesian government has undertaken communication, information, and education programs centered balanced nutrition. It was visualised with Tumpeng Gizi Seimbang or Balanced Nutrition Diet Pyramid and Isi Piringku or My filled Plate.^19–21 The method used is direct delivery, such as social marketing, competitions, and the appointment of ambassadors for a balanced nutrition diet. In addition, there was indirect delivery, such as training and teaching in various health institutions and schools, workshops, and role play. The media used are electronic, printed, online, and audio media.²² However, these efforts are still ineffective in increasing public knowledge about balanced nutrition. In Indonesia, the prevention of malnutrition problems has been centered on the policy, with adults or parents as the primary target. Since the messages are aimed at children, it is required to use a particular or distinct intervention method on children in order to encourage them to eat healthier. An approach engaged in delivering messages is using the gamification method or game-based learning approach.²³

Game-Based Learning is part of a serious game developed to bring participants engaging and immersive learning experiences to meet expected learning goals. Game-based Learning enhances participants' cognitive and affective aspects to achieve expected learning goals used in different areas.^14,24 Game-Based Learning designs learning activities that gradually introduce learning concepts to increase participants' knowledge. A well-designed game can engage and motivate participants by satisfying the participants' basic psychological needs.²⁵ Games also offer challenges that match the player's current abilities. For example, the independence of in-game decision-making reflects autonomy in real life so that the game creates a space that motivates participants to make behavioural changes.^26,27

A systematic review regarding game-based Learning and gamification to improve diet and nutritional habits concluded that gamification positively influenced dietary behaviour and nutritional knowledge.²⁸ Some research conducted on elementary school students shows that the game-based learning approach in nutrition education increases nutrition knowledge, improves eating and drinking habits, and has a positive attitude towards gaming.¹⁴ As well, serious games can improve eating habits by enhancing nutrition knowledge and attitudes, according to other studies.²⁹ Games can also increase children's courage to explore new healthy foods and reduce eating unhealthy snacks. Game-Based Learning is a new approach that can improve children's knowledge about nutrition and induce healthier eating habits.

To the best of our knowledge, there is a scarcity of game-based approaches for raising children's awareness of good eating habits in Indonesia. This paper will describe the program to deliver the campaign of balanced nutrition using a game-based learning approach. We proposed a pilot project to explore how an interactive (game-based) learning and gamification program can be designed, optimised, and implemented.

Methods

The study comprised of two parts using a mixed-method study design. The first step was a qualitative one based on individual interviews and a focus group discussion. The second part was the development of the board game based on the findings from the first part.

In the first part, in-depth interviews were conducted with six informants ranging from health officers responsible for the nutrition programs to understand government targets and available programs, nutritionist specialists, and healthy food practitioners for information regarding ideal healthy food. We also interviewed mothers to understand the nutrition knowledge and skills needed to make nutritious food. In-depth interviews were conducted in the informants' workplaces or homes. Time used for interviews ranged from 30 minutes to 2.5 hours. The instruments used were an in-depth interview guide with notes and a tape recorder to record data.

To develop the game, we conducted a Focus Group Discussion (FGD) attended by 14 people. They were involved in nutrition programs from the Health Office Bandung and the Office of Bandung City. Also attended Public health expert, Health promotion expert, Family Health and Nutrition expert, Game designer, Nutritionist Association, Nutrition Specialist association, organic farmer, organic farm community representatives, and community representatives (housewives). The FGD lasted for three hours. All participants for the interview and FGD gave their written consent.

The instruments used in the FGD and interviewed were unstructured interview guides developed in the discussion as needed. Unstructured interviews were chosen because they provide an opportunity to get the best in-depth data compared to other interviewing techniques.³⁰ Informed consent was obtained from all individual participants included in the study. Data were recorded by notes and with a tape recorder. We tested the validity of the data and its analysis to establish its credibility. We used triangulation and assessing its transferability, dependability, and confirmability.

The focus group discussion and in-depth interview recording results were transcribed ad verbatim (precisely as spoken): the thematic analysis method used to identify and analyse's themes. The study constructs the themes from the data collected. They were objectively and systematically computed to produce descriptive descriptions of the text content. Thematic analysis was chosen because the central theme was already known (nutrition campaign). This analysis is used to summarise many details into concepts, models, or a more general picture. The guideline in data management is inductive study served to search for themes, patterns, and categories for the source analysis in the data.

The second stage was developing the game using information from the analysis. Authors engaged professional game developers to assist with the development of the game. The process from the idea to the board game development took around three months. Finally, the board game was tested on 88 children aged 10-13 years old through gameplay sessions using a convenience sampling method through a voluntary approach. Before the activities, consent was given by parents verbally.

To evaluate the ability of the board game to deliver the messages, we conducted pre and post-test to the children. Knowledge of balanced nutrition was measured using a questionnaire of 10 questions. A questionnaire of 10 questions was used to assess attitude variables, while five questions were used to assess behavioral variables. With a cut point as follows, if the score is >80% means good; 60-80% is sufficient, and not sufficient is less than 60%. Software STATA MP 16 from Stata Corp used for data analysis to determine differences in respondents' knowledge, behaviour, and attitudes about balanced nutrition before and after gameplay sessions. Meanwhile, to find out the differences in knowledge, attitudes, and behaviour between the groups involved in gameplay, the Independent T-Test and Mann Whitney test was used as alternatives with an error rate of 5%. The study was conducted from August 2019 until June 2020.

This study has obtained ethical approval No. 389/Komite Etik FK/VIII/2019 from the Health Research Ethics Committee of Faculty of Medicine Universitas Islam Bandung.

Results

The findings are organized around the themes identified by the research focus group discussion, which are based on elements that have a significant impact on the nutrition campaign. Much of this is reported in the present tense, as that was the way it was articulated. In order of presentation, the themes were challenged to deliver the campaign, environment and provide fun and exciting messages. The themes are further described below.

Informants from the FGD are in the table below.

Campaign Messages

In these themes, some sub-themes emerge, such as the knowledge of nutrition that needs to be delivered. There was the concept of My Filled Plate, the proportion of food to fill each plate at every meal, the concept of eating various foods, and the idea of the recommended number of meals per day. It should also incorporate the concept of nutritional deficiencies and overload. It should include an understanding of the division of nutrients into carbohydrates, protein, fat, vitamins, and minerals. Also noteworthy was the concept of the number of calories needed by the body to meet the recommended calorie requirements (not far above or less than the required, ideal calorie).

The second stage was the development of Gastronot using the game-based approach. Gastronot, a board game created by the author, is based on the same concept. This game-based approach used Balanced Diet Journal, Balanced Nutrition Pyramid, and My Filled Plate as the main message and content. Players' main goal is to collect foods and arrange them to fulfil the nutritional needs based on the suggested composition and proportion in the above messages.

To accommodate the prioritised contents of knowledge, the two main messages of the program are translated into the game scoring mechanic. Using the Balanced Nutrition Journal as the primary reference, the game scoring mechanics will consist of several components: - Balanced Nutrition Pyramid presented as a part of the whole scoring system. In addition, each Food Ingredients Card will contain several Nutrition components (based on the data by Health Office), and players can gain scores by collecting these components within the appropriate suggested amount. Five types of nutrition to be collected during the game are Carbohydrates, Protein, Fat, vitamins & minerals, and Water. The actual values of nutrition on each food ingredient are scaled and modified accordingly for gameplay purposes but still represent the good and correct information.

Below is the tool used in the board game and the reward system (see Figures 1-3).

Figure 1. Flow chart of Gastronot board game.

Figure 2. Grocery card and parameters.

Figure 3. Scoring board and point.

My Filled Plate is translated as the second part of the scoring system. Collected foods are to be arranged in 3 lines representing the three main meals during a day. Based on the My Filled Plate campaign information, players can get more scores by setting the cards in correct compositions. The game focused on ensuring that each meal consists of various types of food (Staple Food - Side - Vegetables - Fruits). The scoring system/mechanic will be presented on the player boards to remind the players of their main goals and objectives constantly.

We also want to make sure that the participants are aware of the many types of dietary ingredients. For that purpose, players can get additional scores at the end of the game by collecting as many unique food ingredients as possible (more variety of foods = more scores assets of the board game). In two elementary schools, 88 children participated in a gameplay trial.

For the analysis, two data sets were excluded since they were not complete. The children were accompanied by their teachers, who were also involved in the gameplay sessions. Informed consent was given by the parents or guardians of the children before the intervention. Table 1 lists the characteristics of the participants in the focus group discussion. Table 2 shows respondent's characteristics and Table 3 shows the results of the pre- and post-test results.

Table 1. Participants characteristic.

Participants	Gender	Age	Job description
P1	Male	40	NGO on social change
P2	Female	35	Health Office of Bandung City, Students, Children and Teenager Health
P3	Female	30	Health Office of Bandung City, Family Health and Nutrition
P4	Female	28	Media expert
P5	Female	55	Health and Nutrition Doctor Association
P6	Female	54	Public Health Expert
P7	Male	35	Game designer
P8	Male	40	Game designer
P9	Male	32	Permaculture activist
P10	Male	47	Organic farmer
P11	Female	35	Community representatives (housewife)
P12	Female	30	Media expert
P13	Male	30	NGO on social change
P14	Male	26	Permaculture activist

Table 2. Respondents' characteristics.

Variable	n	%
Gender
Boys	34	39.53
Girls	52	60.47
Age
10 years old	27	31.40
11 years old	36	41.86
12 years old	20	23.26
13 years old	3	3.49
Know about balance nutrition
Yes	44	51.16
No	42	48.84
Total	86	100,00

Table 3. Differences in knowledge, attitudes and behavior of respondents before and after game play session.

Variable	N	Mean	SD	Sig	z*
Knowledge
Pre	86	37.94	14.41	0.021	−2.302
Post	86	41.13	16.26
Attitude
Pre	86	79.94	6.54	0.485	*−0.699
Post	86	79.30	11.18
Practice
Pre	86	72.33	19.92	0.410	−0.825
Post	86	70.47	24.11

* Mann Whitney

The result from the pre and post-test can be seen in Table 3.

Table 3 above shows that the average score of respondents' knowledge about balanced nutrition before playing was 37.94, then increased to 41.13 after. Based on the Wilcoxon test, the z-value is −2.302, and the p-value is 0.021. There is a significant difference between respondents' knowledge before and after playing the game.

On the attitude variable, the average score of respondents about balanced nutrition before the game session was 79.94, then decreased to 79.30 after playing the game. However, there is no significant difference between respondents' attitudes before and after the gameplay session.

In the behavioural variable, the average score of respondents before playing the games was 72.33. It decreases to 70.47 after the game. Based on the Wilcoxon test, the z-value is −0.825, and the p-value is 0.410. There was no significant difference between the behaviour of respondents before and after the gameplay session.

Discussion

Behaviours that can last for life are usually gained during the childhood period.^1–4 Knowledge delivery was the first and foremost step in bringing the children toward a balanced diet and healthy eating habits. Therefore, education about nutrition is essential to improve the quality of life and health for the children to have better adulthood. Whenever nutritional education and information are given to children, they can build their awareness in choosing healthy food. This study engages game-based learning/gamification design to ensure that participants learn essential information with motivation and engagement. This factor is significant in Learning.²³

In our study, the campaign to improve nutrition was implemented in various schools using lectures and other activities initiated by each school and District Health Centers. However, the program still struggles in delivering the content in the best way possible and requires continuous improvement in its method and delivery media. It is clear since our study showed that almost half of the students (49%) never heard about Balanced Nutrition Diet Pyramid as the main message in the campaign.

The main goal of our study was to develop the board game to deliver the contents of the campaign, mainly focusing on four pillars of a Balanced Nutrition Diet such as food types and suggested portions, hygiene, and the benefits of regular exercises. It also incorporated the food composition of My Filled Plate. The understanding needs to be appropriately delivered to children since children should consume the proper quantity and a variety of food for an adequate, healthy, and balanced diet. Based on the theme from the FGD, the game content focus aligned with an ongoing campaign that incorporated the national program Balanced Nutrition Diet Pyramid and a guidance campaign of My Filled Plate.²⁰

We chose Gastronot as the game's name since we were inspired by the daring character of space exploration. It combined the word Astronaut (or Astronot in Bahasa Indonesia) with Gastronomy. The name is also served as a reminder for children to be more adventurous in choosing food ingredients. As in several studies, children tend to choose only one of two types of food. The board game Gastronot aims to show that food comes in wide varieties.

The findings revealed that there has been a significant rise in participants' awareness of information on the Balanced Nutrition Diet, particularly about a complete meal proportion (i.e., the Fill My Plate campaign). A statistically significant difference between respondents' knowledge before and after playing the game was found. The findings were similar to some studies that found that students tend to have better post-intervention scores after education about nutrition.^14,18,32

The game-based learning session was engaging for the participants. According to the data analysis of the post-questionnaire, it had a positive impact on the level of awareness regarding balanced nutrition knowledge. As per our observations, the majority of the children were engaged and participated in the game throughout the session. They could reiterate the information from the game during the debriefing session. The game-based learning approach in this study strengthened the findings from other studies that concluded that game-based Learning and gamification effectively improve nutrition knowledge.^14,28,33

Although not statistically significant, we observed a decline in attitude and practice score following the gameplay sessions. It could be because the children were still unfamiliar with the game-based approach. This finding contradicts the prior study on the nutrition game.^33,34 In this study, some children were not acquainted with a quantitative measurement tool (using questionnaires) and were confused about filling it out. To them, it was more like an exam and they were striving to find the right answer rather than filling it out based on their knowledge.

The author saw that schools are vital to education about nutrition, which correlates with some studies.^17,22 However, education methods through traditional ways that only provide information should be limited. Instead, active participation in nutrition education becomes very important to teach an exciting and effective method of knowledge transfer. Using game-based learning methods to deliver the information will help children acquire healthy eating habits and, ideally, improve their quality of life.

Conclusions

The game-based learning approach with the Gastronot board game showed promising results in promoting sustainable diet and healthy eating habits among elementary school children. Most children showed engagement and participated in the game for the whole session. They could reiterate the information from the game during the debriefing session, and results showed a significant increase in participants' awareness of the information about the Balanced Nutrition Diet. Our findings from implementing the game-based learning approach to promote a healthy diet shed some light on how we can incorporate games (and gamification) to motivate an effective learning process and public participation to overcome some public health issues.

Data availability