Digital Versus Hybrid Interventions in Promoting Nutrition Knowledge Among Saudi Adolescent Girls

• Hybrid therapy (Behavioral): Hybrid intervention that combined face-to-face educational sessions with the integration of technological advancements. They attended weekly 40-minute interactive educational sessions over the course of a month. The educational materials encompass information regarding the components of a healthy balanced diet and an active lifestyle.Throughout the intervention, participants were provided with a range of behavior change techniques to support participants in applying the educational content to improve their dietary and lifestyle habits. The employed behavior change techniques were SMART (specific, measurable, achievable, relevant, time-bound) goal setting, reviewing behavioral goals, problem-solving and environmental restructuring. The technological support for this intervention included the use of a smartphone diet tracker app called MyFitneesPal as well as communication with the interventionists via WhatsApp.
• Fully digital (Behavioral): Fully digital intervention, where they received the same educational materials through WhatsApp twice a week over the course of one month. The educational materials were presented through easily understandable posters, brief videos, and followed by short quizzes to reinforce the acquired knowledge. Additionally, the digital intervention incorporated the same behavior change strategies that were utilized in the hybrid group. Participants were also introduced to MyFittnessPal application in order to help them track their dietary habits and monitor their progress since it is considered a tool for self-monitoring and promoting healthy dietary behaviors throughout the intervention period.

Primary outcomes

• Nutrition knowledge [From enrollment to the end of treatment at 4 weeks]: Nutritional Knowledge was assessed using a validated dietary questionnaire, distributed in Arabic (24). The questionnaire comprised 10 items, with a maximum score of 10 points. Each correct response was awarded 1 point, while incorrect answers or uncertain responses received a score of zero. The final score was derived by summing the total points. To classify NK levels, modified Bloom's cut-off points were employed: a score of 80-100% (8-10 points) indicated good NK, 50-79% (5-7.9 points) represented moderate knowledge, and scores below 50% (<5 points) denoted low knowledge. For analytical purposes, these categories were dichotomized into satisfactory NK (>80% correct) and unsatisfactory NK (<80% correct) (7,25).

Secondary outcomes

• Generalized Anxiety Disorder Scores (GAD) [From enrollment to the end of treatment at 4 weeks]: Anxiety levels were measured using the GAD-7. This is a 7-item validated questionnaire (28), which is widely used to screen for and quantify the severity of GAD. The Arabic version of this tool has been adopted by the Saudi Arabian Ministry of Health for initial anxiety screening. Each item is rated on a 4-point Likert scale, ranging from 0 (not at all) to 3 (nearly every day), with total scores ranging from 0 to 21. Higher scores reflect greater anxiety levels. Anxiety was defined using a cutoff score of 10 or above, which differentiated between minimal to mild anxiety and moderate to severe anxiety (28).
• Dietary habits [From enrollment to the end of treatment at 4 weeks]: Dietary habits were evaluated using a questionnaire adapted from research on food consumption frequencies in Qatar, which share similar characteristics with Saudi Arabia. The questionnaire assessed the frequency of consumption of various food groups, including vegetables, fruits, carbohydrates (e.g., bread, rice, pasta), proteins (e.g., chicken, beef, fish), and dairy products (e.g. yoghurt and cheese). Participants responded to questions such as, "How often do you consume fresh fruits/green leafy vegetables/fish? To evaluate dietary variety, the study employed the Healthy Plate Variety Score, calculated using a modified methodology based on Jones et al. (2015). This approach involved dichotomizing food intake from the five main groups into two categories (daily intake vs. non-daily). Foods consumed daily received a score of 1, while those not consumed daily received a score of 0 with a potential maximum score of 5.0.
• Anthropometric measurements (Body mass index) [From enrollment to the end of treatment at 4 weeks]: Body measurements were obtained using standardized equipment following established operating procedures. Trained senior dietitians objectively assessed the height and weight of adolescents using a mechanical combined scale and a stadiometer (Detecto). Prior to measurement, a technician ensured that the equipment was properly calibrated. Height was recorded to the nearest 0.1 cm while participants were barefoot and dressed in minimal clothing. Weight was measured and documented to the nearest 0.1 kg. The Body Mass Index (BMI) was calculated by dividing the weight in kilograms by the square of the height in meters. Weight status was classified according to the criteria set by the World Health Organization (WHO): underweight was defined as a BMI of less than 18.5 kg/m², normal weight ranged from 18.5 to 24.9 kg/m², overweight was categorized as a BMI between 25.0 and 29.9 kg/m², and obesity was indicated by a BMI of 30.0 kg/m² or higher.

Sex: Female, ages: 15 Years to 19 Years, accepts healthy volunteers

Inclusion Criteria:

* Healthy
* Adolescents (15-19 years old)
* Reliable internet access
* Willing to participate

Exclusion Criteria:

* Has chronic disease/s
* <15 years and >19 years
* No internet access
* Not willing to participate

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• Informed Consent Form (PDF, 2023-09-01)

• Mai A Ghabashi, PhD, Principal investigator, Umm Al-Qura University