Hyska J, Mersini E, Mone, I, Bushi E, Sadiku E, Hoti K, Bregu A.

Assessment of knowledge, attitudes and

practices about public health nutrition among students of the University of Medicine in Tirana, Albania (Original
research). SEEJPH 2014, posted: 13 January 2014. DOI 10.12908/SEEJPH-2014-01.

ORIGINAL RESEARCH

Assessment of knowledge, attitudes and practices about public health

nutrition among students of the University of Medicine in Tirana, Albania

Jolanda Hyska1,2, Ehadu Mersini1, Iris Mone2, Entela Bushi1, Edite Sadiku2, Kliti Hoti2,
Arjan Bregu1
1
Institute of Public Health, Tirana, Albania;
2
University of Medicine, Tirana, Albania.

Corresponding author: Jolanda Hyska, MD, PhD, Institute of Public Health;

Address: Rr. “Aleksander Moisiu”, No. 88, Tirana, Albania;
Telephone: +355672052972; Email: lhyska@yahoo.it

1
Hyska J, Mersini E, Mone, I, Bushi E, Sadiku E, Hoti K, Bregu A. Assessment of knowledge, attitudes and
practices about public health nutrition among students of the University of Medicine in Tirana, Albania (Original
research). SEEJPH 2014, posted: 13 January 2014. DOI 10.12908/SEEJPH-2014-01.

Abstract

Aim: the aim of this survey was twofold: (i): to assess medical students’ knowledge, attitudes
and practices regarding nutrition in general, in order to identify their level of competences in
the field of nutrition which will be useful in their future role of providers/health care
professionals, and; (ii) to assess the knowledge, attitudes and practices regarding the discipline
of public health nutrition in order to identify the needs for improving the curriculum of this
subject in all the branches of the University of Medicine in Tirana.
Methods: A cross-sectional study was conducted in June-July 2013 including a representative
sample of 347 students at the University of Medicine in Tirana, Albania (61% females and
39% males; overall mean age: 23±2 years; response rate: 87%). A nutritional questionnaire,
adopted according to the models used in previous international studies, was used to assess the
level of knowledge, attitudes and practices among the university students.
Results: Overall, about one third of the students was not satisfied with the quality and quantity
of nutritional education and demanded a more scientifically rigorous curriculum. In general,
students’ knowledge about infant feeding practices was adequate. However, there were gaps in
the students’ knowledge regarding the commencement of breastfeeding, or the duration of
exclusive breast-feeding. Furthermore, there was evidence of an insufficient level of
knowledge among students regarding diet and nutrition in general and their health impact,
especially on development and prevention of chronic diseases.
Conclusion: This survey identified significant gaps in the current curriculum of public health
nutrition at the University of Medicine in Tirana. Our findings suggest the need for
intervention programs to improve both the quantitative and the qualitative aspects of nutrition
curricula in all the branches of the University of Medicine Tirana, in accordance with the
professional expectations of this teaching institution, as well as the urge for a movement
towards a more integrated curriculum and problem-based learning approach.

Keywords: Albania, diet, knowledge, nutrition, students, university of medicine.

2
Hyska J, Mersini E, Mone, I, Bushi E, Sadiku E, Hoti K, Bregu A. Assessment of knowledge, attitudes and
practices about public health nutrition among students of the University of Medicine in Tirana, Albania (Original
research). SEEJPH 2014, posted: 13 January 2014. DOI 10.12908/SEEJPH-2014-01.

Introduction
It is argued that the amount of nutritional education in the teaching curricula of different
medical schools remains inadequate and does not meet the needs of this important area of
health sciences (1,2). Hence, many studies show that family physicians generally have little
training in nutrition (3-5). Furthermore, several studies have shown that the vast majority of
medical students and incoming interns are dissatisfied with their education in medical nutrition
and feel unprepared to counsel patients on nutritional topics (6-8). Therefore, it is largely
recognized that there is a critical need for improvements of teaching programs related to
nutrition in medical schools and public health schools along with an increased education of the
general population at large (9-11).
Public health nutrition is a discipline introduced already in all branches of the University of
Medicine in Tirana, the Albanian capital. However, there is no scientific evidence regarding
the level of attitudes and knowledge in this field among the students at all levels and branches
of this teaching institution in Tirana, which is the only Medical University in Albania.
In this context, the aim of this survey was twofold: (i): to assess medical students’ knowledge,
attitudes and practices regarding nutrition in general, in order to identify their level of
competences in the field of nutrition which will be useful in their future role of
providers/health care professionals, and; (ii) to assess the knowledge, attitudes and practices
regarding the discipline of public health nutrition in order to identify the needs for improving
the curriculum of this subject in all the branches of the University of Medicine in Tirana.

Methods
A cross-sectional study was conducted in June-July 2013 including a representative sample of
347 students at the University of Medicine in Tirana, the capital of Albania.

Study population
The study population consisted of a simple random sample of 347 students (out of 400 invited;
response rate: 86.7%) of the University of Medicine in Tirana pertinent to the following
branches: Medicine (26.8%), Nursing (32.9%), Pharmacy (21.9%) and Dentistry (18.4%). The
sampling frame consisted of a list of all students who had undertaken a course on public health
nutrition (280 medical students; 110 dentistry students; 108 pharmacy students; 312 nursing
students). The response rate was somehow lower among the medical students (81.5%)
compared with students from the other branches. On the other hand, the overall response rate
was similar among male and female students.

Data collection
A nutritional questionnaire, adopted according to the models used in previous international
studies, was used to assess the level of knowledge, attitudes and practices among the university
students.
The first part of the questionnaire concerned the attitudes of the students about nutritional
education in their respective faculties/schools. The attitudes were measured by means of an
indicative scale from 1 to 5 regarding students’ concordance with several statements (1=
strongly disagree; 5= strongly agree) (7).
The second part of the questionnaire concerned the level of knowledge of the students about
nutrition in general (4,5).

3
 Hyska J, Mersini E, Mone, I, Bushi E, Sadiku E, Hoti K, Bregu A. Assessment of knowledge, attitudes and
practices about public health nutrition among students of the University of Medicine in Tirana, Albania (Original
research). SEEJPH 2014, posted: 13 January 2014. DOI 10.12908/SEEJPH-2014-01.

Data analysis
SPSS (Statistical Package for Social Sciences) version 19.0 was used for data analysis. Data
were presented as frequency tables (for categorical variables) and as measures of central
tendency (mean scores) [for numerical variables].

Results
Overall, the survey sample included 136 (39.2%) male students and 211 (60.8%) female
students (overall mean age: 22.8±2.1 years).

Students’ attitudes about their education in the discipline of nutrition

Overall, the students were somewhat satisfied with the quantity (mean score: 3.3; range from 1
[lowest] to 5 [highest]) and quality (mean score: 3.2) of the nutritional education in the course
of their studies (Table 1). Students reported that more time should have been dedicated to the
topic of nutrition at the University of Medicine in Tirana (overall mean score: 3.5), especially
including more material relevant to the personal health and wellbeing (mean score: 3.8).
Conversely, students were quite neutral regarding the scientific rigor of the teaching
curriculum (overall mean score: 2.9).

Table 1. Students’ attitudes about their education in the discipline of nutrition

Total Medicine Dentistry Pharmacy Nursing
Students’ attitudes
(N=347) (N=93) (N=64) (N=76) (N=114)
I am satisfied with the quantity of my nutrition
3.26 2.69 2.81 3.47 3.83
education.
I am satisfied with the quality of my nutrition
3.18 2.71 2.84 3.22 3.71
education.
My medical school nutrition curriculum should
have had more time specifically dedicated to
3.46 3.67 3.42 3.70 3.17
the topic of nutrition (independent of organ
system-based studies).
My medical school nutrition curriculum should
have had more nutrition content formally 3.38 3.91 3.36 3.21 3.07
integrated into the organ system-based courses.
My medical school nutrition curriculum should
have included more online materials available 2.90 3.32 2.52 3.05 2.67
for independent study.
My medical school nutrition curriculum should
have included more material relevant to my 3.80 4.31 3.81 3.37 3.68
personal health and wellbeing.
My medical school nutrition curriculum should
2.89 3.32 3.39 2.58 2.46
have been more scientifically rigorous.

Students of the Faculty of Medicine were the most unsatisfied group with regard to the quantity
(mean score: 2.7) and quality (mean score: 2.7) of the information obtained in the nutrition
course, considering that:
• More time should be dedicated to the topic of nutrition in the course of their studies
(mean score: 3.7);
• More nutrition content should be formally integrated into the organ system-based
courses (mean score: 3.9);
• The curriculum should include more material relevant to personal health and well-being
(4.3);

4
Hyska J, Mersini E, Mone, I, Bushi E, Sadiku E, Hoti K, Bregu A. Assessment of knowledge, attitudes and
practices about public health nutrition among students of the University of Medicine in Tirana, Albania (Original
research). SEEJPH 2014, posted: 13 January 2014. DOI 10.12908/SEEJPH-2014-01.

• In addition, medical students felt that the teaching curriculum should be more
scientifically rigorous (mean score: 3.3) [Table 1].

However, almost similar attitudes were encountered among the students of the Faculty of
Dentistry, but their mean scores were slightly higher compared to the students of the Faculty of
Medicine.
Unlike the students of the Faculty of Medicine and Dentistry, students of the Faculty of
Pharmacy appeared to be more satisfied with the quantity (mean score: 3.5) and the quality
(mean score: 3.2) of the nutritional education; nonetheless, they considered that more time
should be dedicated to the topic of nutrition in the course curriculum (mean score: 3.7), but
were generally satisfied regarding the scientific rigor of nutrition curriculum (mean score: 2.6).
Conversely, students of the Faculty of Nursing were the most satisfied group with regard to the
quantity (mean score: 3.8) and quality (mean score: 3.7) of the nutritional education in their
branch. Their most obvious demand, however, was that more material relevant to personal
health and wellbeing should be included in the teaching curriculum (mean score: 3.7) [Table
1].
Overall, about one third of the students was not satisfied with the quality and quantity of
nutritional education and demanded a more scientifically rigorous curriculum.
Three out of four students demanded a more practical and useful curriculum regarding personal
health and well-being; more than half of the students demanded an integrated curriculum into
the organ system-based; and half of the students suggested that more time should be dedicated
to the teaching curriculum independent of organ system-based studies (Table 1).

Students’ knowledge about infant feeding practices

Overall, the level of students’ knowledge about infant feeding practices was satisfactory, as the
percentage of correct answers for every question was in the range from 70%-92% (Table 2).

Table 2. Students’ knowledge on infant feeding practices

Item Correct Wrong Don’t know
According to WHO, the optimal duration for breastfeeding an
71.8% 21.3% 6.9%
infant is a minimum of twelve months.
Infant formula contains all ingredients found in human breast
1.4% 97.1% 1.4%
milk.
Infants consuming breast milk have fewer ear infections than
91.9% 4.6% 3.5%
infants consuming formula.

The percentage of wrong answers was higher among the students of the Faculty of Pharmacy,
followed by the students of the Faculty of Dentistry (29.7% and 7.8% respectively).
About 82% of the students knew “the most appropriate age to introduce other foods in the
infant’s diet”, whereas one out of three students of the Faculty of Dentistry gave a wrong
answer (data not shown).
Regarding the “commencement of breastfeeding”, 70% of the students did not know the
recommended initiation of breastfeeding, which was especially apparent for students of the
Faculty of Nursing and Medicine (80% and 76%, respectively), although the nutrition
curriculum of these two faculties regarding infant feeding practices is much more expanded
than the other two faculties (data not shown in the tables).
Most of the students (about 77%) stated that exclusive breast feeding is important because
“breast milk is the ideal food”, 10% of the students considered that “breastfeeding creates a

5
 Hyska J, Mersini E, Mone, I, Bushi E, Sadiku E, Hoti K, Bregu A. Assessment of knowledge, attitudes and
practices about public health nutrition among students of the University of Medicine in Tirana, Albania (Original
research). SEEJPH 2014, posted: 13 January 2014. DOI 10.12908/SEEJPH-2014-01.

physical/spiritual bond between mother and baby”, and 9% of the students believed that
“breastfeeding protects the mother from pregnancy”.
Regarding the duration of exclusive breastfeeding, the opinion of the students was divided
between the period of 6-9 months, and only 1.3% of the students considered that
“breastfeeding should not be extended more than 1 month” (not shown).

Students’ knowledge on the health impact of diet and nutrients

Regarding the questions that aimed at assessing the students’ general knowledge about the
health impact of diet and nutrients, students of the Faculty of Medicine, generally, exhibited
the highest level of knowledge compared to the other branches (Table 3).
Especially, medical students reported correctly on the following: “the nutrient that helps
prevent thrombosis” (100%); “the nutrient closely related to the prevention of neural tube
defects” (97%); “zinc is not an antioxidant” (87%); and “potassium has protective effect
against hypertension” (75%). However, none of them knew that “excess proteins promote loss
of Ca”; “Albanians are advised not to consume more than 30% fat” (8%); and “fruits and
vegetables have a preventive role in the development of some types of cancer” (10%) [Table 3].

Table 3. Students’ knowledge about diet and health

Item Total* Medicine* Dentistry* Pharmacy* Nursing*
A nutrient believed to help prevent thrombosis is: omega-3 fat 100 28.1 50 28.9
Excess of which nutrient may increase body
proteins 0 4.7 7.9 14
calcium loss?
What is the type of dietary fiber helpful in
soluble fiber 67.7 42.2 28.9 15.8
lowering the blood cholesterol level?
monounsaturated
The major type of fat in olive oil: 54.8 31.2 22.4 16.7
fat
Compared with unprocessed vegetable oil,
more trans fats 37.6 9.4 42.1 16.7
hydrogenated fats contain:
The nutrient is protective against hypertension potassium 75.3 14.1 44.7 45.6
If a person habitually consumes 10 tablets a day
of vitamin mineral supplements, which nutrient is vitamin E 66.7 21.9 39.5 24.6
least likely to cause toxicity
The most concentrated source of vitamin B12 is Meat 43 6.2 18.4 31.6
Which substance raises the blood HDL-
alcohol 41.9 9.4 17.1 22.8
cholesterol level
Nutrition Recommendations for Albanian
under 30% of
recommends that the diet should contain the 7.5 9.4 25 21.9
daily energy
following percentage of energy as fat
Nutritional recommendations for Albanian
no more than 6 g
recommends that the diet should contain the 44.1 3.1 19.7 37.7
iodized salt
following type and percentage of salt
A type of food believed to have a preventive Fruits and
9.7 34.4 57.9 41.2
effect on varioustypes of cancer is vegetables
The number of kilocalories in one gram of fat is 9 kkal 100 96.9 96.1 94.7
Which of the following is not an antioxidant
Zinc 86 46.9 80.3 48.2
nutrient
The nutrient strongly associated with the
Folate 96.8 73.4 77.6 71.1
prevention of neural tube defects is
*
Percentages of correct answers.

6
Hyska J, Mersini E, Mone, I, Bushi E, Sadiku E, Hoti K, Bregu A. Assessment of knowledge, attitudes and
practices about public health nutrition among students of the University of Medicine in Tirana, Albania (Original
research). SEEJPH 2014, posted: 13 January 2014. DOI 10.12908/SEEJPH-2014-01.

Discussion
Our findings indicate that students of the University of Medicine in Tirana are not sufficiently
satisfied with the quantity and quality of the knowledge obtained on public health nutrition,
demanding more time to be dedicated to the topic of nutrition in the undergraduate curriculum
including especially more material relevant to personal health and wellbeing. Such
requirements and demands were more pronounced among students of the Faculty of Medicine
and Dentistry.
Students’ knowledge about infant feeding practices were relatively satisfactory among the
students of the Faculty of Medicine, and less so among students of the other faculties.
However, there were also apparent gaps in the knowledge of medical students regarding the
commencement of breastfeeding, or the duration of exclusive breastfeeding. Our findings in
this regard are compatible with previous reports from studies conducted elsewhere (12-14).
Regarding students’ general knowledge about diet and its impact on the development or
prevention and treatment of diseases, especially of chronic diseases, it was often encountered
an overrated concept about the role/influence of the dietary fat and individual health,
suggesting insufficient knowledge among students regarding the specific role and impact of
carbohydrates and proteins. Similar findings have been previously reported in the UK (13,14),
Canada (15,16) and the USA (17).
On the other hand, students included in the current survey did not have updated information
regarding the “Albanian Recommendations for a Healthy Nutrition”, which points to the need
for case-based teaching, and updated scientific rigor.
Overall, the current survey identified gaps in the current curriculum of public health nutrition
which suggests the need for appropriate changes and amendments to the curriculum in all the
branches of the University of Medicine in Tirana (General Medicine, Public Health, Nursing,
Pharmacy and Dentistry). From this perspective, our study provides useful baseline
information which should be eventually used to close the knowledge and competence gaps in
the current teaching and training programs offered by the University of Medicine in Tirana.
In addition, the assessment of knowledge, attitudes and practices of the students on nutritional
aspects in general is a basic precondition for understanding their competences and roles as
future health care providers and health professionals, hence, evaluating healthy nutrition as an
important element in the prevention and treatment of a number of non-communicable diseases
which are currently highly prevalent in Albania (5,18). From this point of view, our study
makes a useful contribution in the Albanian context.
In conclusion, our study suggests the need for intervention programs to improve both the
quantitative and the qualitative aspects of nutrition curricula in all the branches of the
University of Medicine Tirana, in accordance with the professional expectations of this
teaching institution, as well as the urge for a movement towards a more integrated curriculum
and problem-based learning approach.

Acknowledgements
This survey was supported by the World Health Organization (Tirana Office and the Office for
Europe) in the framework of the Joint Program of Nutrition “Reducing malnutrition among
children”, funded by the Spanish Millennium Development Goals.

Conflicts of interest: none declared.

References
1. Adams KM, Kohlmeier M, Zeisel SH. Nutrition education in U.S. medical schools:
latest update of a national survey. Acad Med 2010;85:1537-42.

7
Hyska J, Mersini E, Mone, I, Bushi E, Sadiku E, Hoti K, Bregu A. Assessment of knowledge, attitudes and
practices about public health nutrition among students of the University of Medicine in Tirana, Albania (Original
research). SEEJPH 2014, posted: 13 January 2014. DOI 10.12908/SEEJPH-2014-01.

2. Torti FM, Adams KM, Edwards LJ, Lindell KC, Zeisel SH. Survey of Nutrition
Education in U.S. Medical Schools – An Instructor-Based Analysis. Med Educ Online
2001;6:8.
3. Vetter ML, Herring SJ, Sood M, Shah NR, Kalet AL. What do resident physicians
know about nutrition? An evaluation of attitudes, self-perceived proficiency and
knowledge. J Am Coll Nutr 2008;27:287-98.
4. Temple NJ. Survey of nutrition knowledge of Canadian physicians. Athabasca
University, Alberta, Canada. J Am Coll Nutr 1999;18:26-9.
5. Hyska J, Bushi E, Luzati A, Bizhga J. Nutritional knowledge of primary care
physicians in Tirana, Albania. MEDICUS 2012; Vol XVII:200-206. Available from:
http://www.medalb.com/gazeta/Medicus17.pdf (accessed: January 05, 2014).
6. Spencer EH, Frank E, Elon LK, Hertzberg VS, Serdula MK, Galuska DA. Predictors of
nutrition counseling behaviors and attitudes in US medical students. Am J Clin Nutr
2006;84:655-62.
7. Walsh CO, Ziniel SI, Delichatsios HK, Ludwig DS. Nutrition attitudes and knowledge
in medical students after completion of an integrated nutrition curriculum compared to
a dedicated nutrition curriculum: a quasi-experimental study. BMC Med Educ
2011;11:58. DOI: 10.1186/1472-6920-11-58.
8. Weinsier RL, Boker JR, Feldman EB, Read MS, Brooks CM. Nutrition knowledge of
senior medical students: a collaborative study of southeastern medical schools.
Am J Clin Nutr 1986;43:959-68.
9. Makowske M, Feinman RD. Nutrition education: a questionnaire for assessment and
teaching. Nutr J 2005;4:2. DOI: 10.1186/1475-2891-4-2.
10. Cooksey K, Kohlmeier M, Plaisted C, Adams K, Zeisel SH. Getting nutrition education
into medical schools: a computer-based approach. Am J Clin Nutr 2000;72(3
Suppl):868S-876S.
11. Lo C. Integrating nutrition as a theme throughout the medical school curriculum. Am J
Clin Nutr 2000;72(3 Suppl):882S-889S.
12. Ray S, Udumyan R, Rajput-Ray M, Thompson B, Lodge KM, Douglas P, et al.
Evaluation of a novel nutrition education intervention for medical students from across
England. BMJ Open 2012;2:e000417. DOI: 10.1136/bmjopen-2011-000417.
13. Kafatos A. Is clinical nutrition teaching needed in medical schools? Ann Nutr Metab
2009;54:129-30.
14. Nightingale JM, Reeves J. Knowledge about the assessment and management of
undernutrition: a pilot questionnaire in a UK teaching hospital. Clin Nutr 1999;18:23-7.
15. Adams KM, Kohlmeier M, Powell M, et al. Invited Review: nutrition in medicine:
nutrition education for medical students and residents. Nutr Clin Pract 2010;25:471-80.
16. Collier R. Canadian medical students want more nutrition instruction. CMAJ
2009;181:133-4.
17. Frantz DJ, Munroe C, McClave SA, et al. Current Perception of nutrition education in
U.S. Medical schools. Curr Gastroenterol Rep 2011;13:4.
18. Burazeri G, Kark JD. Hostility and acute coronary syndrome in a transitional post-
communist Muslim country: a population-based study in Tirana, Albania. Eur J Public
Health 2011;21:469-76.
___________________________________________________________

© 2014 Hyska et al.; This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.