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Children
are the major repository of South Africas potential human capital
for the future. The fact that children are the workers, scientists,
parents, leaders and civil society participants of tomorrow
means that their survival, health, nutrition and educational
progress are key issues for reconstruction and development today1
.
Nelson
Mandela, May 1996.
Against
the background of prevailing undernutrition and its coexistence
with micronutrient malnutrition, the Directorate: Nutrition
of the Department of Health, within the scope of its Integrated
Nutrition Programme (INP), has included the development of guidelines
for a national micronutrient food fortification programme as
part of its strategic and operational plans. However, the formulation
of such a national food fortification programme requires information
regarding nutrient intake as well as the identification of suitable
food fortification vehicle(s) which are consumed sufficiently
frequently and in sufficient quantities by the target population,
and which do not pose risks for toxicity. Additionally, it is
well recognised that the successful implementation of any intervention
programme depends, among other factors, on appropriate nutrition
education. The paucity of such data on a national basis has,
therefore, necessitated the proposed survey.
OBJECTIVES
OF THE SURVEY
Primary
Objectives:
- To
determine usual food consumption of children aged 1 - 9 years
(12 - 108 months) in South Africa
- To
assess the usual nutrient intake of children aged 1 - 9 years
in South Africa
- To
identify factors impacting on food consumption
- To
determine anthropometric status
Secondary
Objectives:
Using
the baseline data obtained from the primary objectives, propose/recommend:
- Appropriate
food(s) for fortification
- Appropriate
nutrition education material
SURVEY
METHODOLOGY
A
cross-sectional survey of a nationally representative sample
of children aged 1 - 9 years in South Africa using the Census
1996 data (see also Appendix: Protocol)
- The
survey population comprised of all the children aged 1 - 9
years in South Africa. The initial survey sample was adapted
by means of 50% over-sampling to allow for a defined drop-out
rate, an overrepresentation of the children living in high-risk
areas as well as the defined requirements for the dietary
questionnaires employed in the survey. A total of 156 Enumerator
Areas (EAs) were included in the survey, 82 of which were
urban and 74 non-urban. A total of 3120 children were included
in the survey
- Validated
questionnaires [socio-demographic, 24-hour recall (24-H-RQ),
quantitative food frequency (QFFQ), food procurement and household
inventory [FPHIQ; in every high-risk household (HH) as well
as one randomly selected HH in all other EAs] were developed
specifically for the survey and were administered by trained
fieldworkers. The Hunger Scale Questionnaire (HSQ) was completed
by the mother/caregiver of the child
- A
training manual, a video and food models were developed and
employed, as appropriate, for the administration of the questionnaires
- Anthropometric
status assessment included height, weight as well as mid upper
arm and head circumference (the latter two are not presented
in this report)
- Quality
control measures were employed throughout the survey.
MAIN
FINDINGS
Socio-demographic
Data
Findings
- Of
the 3120 children that were originally designed to have been
included in the survey, data was obtained for a total of 2894
children, which amounts to a 93% response
- The
information for the completion of the questionnaires was in
the greatest majority of cases provided by the mother or a
grandparent of the child and can therefore be considered reasonably
reliable, within the specifications of the methodology employed.
The same majority of household members were responsible for
feeding the child
- In
one out of ten HHs the mother was the head of the HH and this
tended to be more often the case in HHs in formal and informal
urban areas. One out of ten mothers of children of all age
groups had no formal education. In almost one out of five
HHs the head of the HH was unemployed. Unemployment was overall
higher in rural, tribal and informal urban areas. One third
of the HHs in the survey had a monthly income of between R
100,00 R 500,00. This income range was characteristic of HHs
in rural, tribal and informal urban areas as well as of HHs
on commercial farms
- One
out of four and one out of five HHs at the national level
spent respectively between R 0,00 R 50,00 and R 50,00
- R 100,00 on food weekly
- Approximately
six out of ten HHs nationally obtained their water from an
own tap, whereas one out of four HHs obtained their water
from a communal tap
- One
out of two HHs had both a radio and a television set in working
order, with the radio being the most common means of receiving
information
- A
very significant percentage of the countrys population still
lives under adverse socio-economic conditions. Although a
trend towards an improvement in some of these conditions appears
to be taking place, it is only the long-term socio-economic
upliftment of the population that is likely to ensure the
improvement of the nutritional status of the community at
large.
Recommendations
- Government
should accelerate and expand its current policies and programmes
on job creation. This is seen as one of the most crucial recommendations
in this report, which must be afforded the greatest priority
- The
Welfare Department should consider immediate steps in increasing
the income for the low income HHs in the country, especially
in the rural areas and particularly on commercial farms. This
could be achieved in close consultation with farmers and take
the form of income generation activities rather than hand
outs. The latter, however, should be considered, at least
in the short-term, as part of any such programme in order
to achieve a measure of immediate relief. Due consideration
should for instance been given to making special loans available
to these groups or to developing the social capital aspects
related to increased economic growth and consumption
- Social
security programmes aimed at female headed HHs should be developed,
which should incorporate development
- Families,
but particularly mothers/caregivers and grandparents, should
be targeted for any relief and education programmes. Particular
emphasis should be placed on the education and empowerment
of women
- The
radio should primarily be used, together with television,
for disseminating information on expanded/new relief programmes
and nutrition education as well as quality child care programmes
- The
achievement of these aims should be addressed within the current
framework of the Integrated Nutrition Programme (INP) of the
Directorate: Nutrition 8
.
The Directorate should also re-evaluate its current programmes
on development in terms of definition and goals in relation
to its core business of nutrition and expertise.
ANTHROPOMETRIC
STATUS
Findings
- One
out of ten of all children aged 1 9 years was underweight
and just more than one in five was stunted. Furthermore, younger
children (1 3 years of age) were most severely affected,
as were those that lived in the rural areas and on commercial
farms in particular. The level
of
maternal education was an important determinant for these
nutritional disorders
- By
contrast, one out of thirteen children was overweight in the
formal urban areas, a prevalence that was higher among children
(one out of eight children) of well educated mothers
- At
the national level the nutritional status of younger children
(12 - 71 months of age) has not improved but does also not
appear to have deteriorated, when compared with the South
African Vitamin A Consultative Group (SAVACG) national data
of 1995. In this regard, however, it should be borne in mind
that the present survey placed particular emphasis on the
high risk segments of the population and as such it has captured
a greater percentage of households of lower socio-economic
status than the SAVACG survey.
Recommendations
- Stunting
should be addressed within the current framework of the INP,
which is based on an integrated nutrition strategy for South
Africa. It is also strongly recommended that the Directorate:
Nutrition is provided with the necessary, additional and needed
resources to attain the aims and objectives of the INP
- The
findings of the present survey clearly identify the younger
child (1 - 3 years of age), as a prime target group for intensified
nutritional intervention, and the mother/caregiver for nutrition
promotion (i.e. facilitation of healthy feeding practices
including complementary feeding, quality child care and decision
making) as well as education. At present, both these aims
should be concurrently achieved within the existing health
facility-based and community-based nutrition
programmes
- The
supplementary foods that are provided with on-going programmes
should be re-evaluated/modified and should not simply concentrate
on energy content but also on dietary quality and micronutrient
composition. The provision of supplementary foods is seen
as an interim, but crucially essential measure, in view of
the extent of the prevailing poverty and food insecurity.
In the longer-term, the need for continued supplementary feeding
must be weighed against socio-economic development
- The
correct management of infectious diseases, especially diarrhoea
and HIV/AIDS should form an integral part of any such supplementary
feeding programmes
- In
terms of priorities, all children who are stunted or overweight
should be targeted according to prevalence and prevailing
provincial priorities
- Due
consideration should be given to accelerating the creation
of crche (child care) facilities within the community and
at the work place, especially in provinces with a high prevalence
of stunting as well as in disadvantaged communities within
provinces, which have a high prevalence of stunting
- Similarly,
the creation of health facility-based rehabilitation centres
should be accelerated for the intensive treatment, supervision
and follow-up of severely malnourished children
- Mothers/caregivers
should be educated according to the prevailing needs of their
environment. Both aspects of malnutrition, namely under- and
over-nutrition, as well as the importance of micronutrients
in child growth should form part of any education programme.
In particular, the mothers/caregivers of malnourished children,
apart from being educated, should also concurrently have access
to and engage in income generating programmes. Additionally,
they should be trained in the rehabilitation of their children
as home-based rehabilitation is considered to be more cost-effective
than facility-based rehabilitation
- The
Directorate: Nutrition should engage both universities and
research organisations to conduct research on the monitoring
and evaluation of any such schemes that are implemented. In
this regard, particular attention should be given to the long-term
benefits afforded to children by such schemes
- The
Directorate: Nutrition should establish a Consultative Group,
such as the National Food Consumption Survey Group, specifically
mandated to monitor growth as well as the prevention, identification
and treatment of malnutrition
- An
anthropometric assessment of children in the age range of
the present survey should be repeated in three/five years
with a view to assessing progress achieved
- In
terms of nutrition surveillance, the Directorate: Nutrition
should reassess/re-evaluate the parameters currently monitored
since these do not include those that reflect progress in
the commonest nutritional disorder in the country, stunting.
Repeated assertions that such measures are difficult to implement
are largely based on personal attitudes and the limitations
of proposed international policies, which may be inappropriate
in relation to the specific needs of the country. Initially,
this should be introduced gradually and selectively for children
living in the high risk areas as identified by the present
survey
- The
findings of the present survey should be disseminated as soon
as possible to all health workers and regional staff.
NUTRIENT
INTAKE (24-H-RQ AND QFFQ)
- In
general terms, one out of two children had an intake of approximately
less than half of the recommended level for a number of important
nutrients
- The
great majority of children consumed a diet deficient in energy
and of poor nutrient density to meet their micronutrient requirements
- The
nutrient intake of children living in rural areas was overall
considerably poorer than that of children living in urban
areas
- All
variables associated with household food insecurity were associated
with a poorer dietary intake and a poorer anthropometric status,
particularly stunting and underweight
- For
South African children as a whole, the dietary intake of the
following nutrients was less than 67% of the RDAs:
- Energy
- Calcium
- Iron
- Zinc
- Selenium
- Vitamin
A
- Vitamin
D
- Vitamin
C
- Vitamin
E
- Riboflavin
- Niacin
- Vitamin
B6
- At
the national level, the five most commonly eaten foods included
maize, white sugar, tea, whole milk and brown bread. With
a few exceptions, this pattern, rather than the actual frequency,
appears to be fairly consistent in all Provinces
- A
significant correlation was found at the national level between
energy intake and stunting
- The
consumption of animal products (milk and dairy products, eggs,
meat, fish) was significantly correlated with stunting and
underweight. This was the case overall for children in all
age groups, in five of the nine Provinces and for children
living in formal urban areas
- Overall
and within the limitations of the two methodologies employed,
the findings on nutrient intake obtained by the 24-H-RQ and
the QFFQ are largely in good agreement and mutually supportive
of the respective findings.
Recommendations
- The
need to improve the dietary and nutrient intake of children
should be addressed within the current framework of the INP,
which is based on an integrated nutrition strategy for South
Africa. It is also strongly recommended that the Directorate:
Nutrition is provided with the necessary, additional and needed
resources to attain the aims and objectives of the INP
- Food
fortification is a trusted and tested solution to improve
the micronutrient status of children and the population at
large and should be implemented the soonest possible
- The
current menus of the Primary School Nutrition Programme, the
PEM scheme as well as those of crches should be reviewed with
a view to improving dietary variety and the quality of the
foods used
- The
data of the present survey should be used for the purpose
of targeting families for, in the short term at least, supplementing
the diet of preschool children. Specific weaning foods should
be made available to high risk families with young children
- The
introduction of a comprehensive nutrition education programme,
which together with socio-economic development will impart
practical knowledge and sustainable means of improving dietary
intake and quality of life, is considered mandatory. It is
also recommended that additional finance is made available
for this purpose
- Nutrition
education messages must be tailored to the currently prevailing
consumption patterns and the desired changes therein, including
the improvement of the nutrient density of childrens diets
as well as food hygiene and feeding practices, and, when appropriate,
home grown crops, and the use of foods of animal origin from
domestic animal production
- The
creation of preschool facilities for children in poor areas
is strongly recommended. State facilities for children from
low-income families should provide day-care including meals,
especially to children with working mothers in the rural areas
and high risk peri-urban areas of the country
- The
key findings of this survey need to be widely disseminated
to the public and health care workers in order to increase
awareness of the level and the nature of food and micronutrient
insecurity together with its effect on health and well being
of individuals and the economic, educational and health care
costs to the nation
- Within
the framework of health care services exclusive breastfeeding
for 4-6 months should be promoted and implemented. Furthermore,
the introduction of complementary feeding together with breastfeeding
for up to two years should form the corner stone in the nutrition
of young children. The factors responsible for the documented
tendency for younger children to be breastfed for periods
shorter than three months should be identified and addressed.
In South Africa, these goals should be achieved in close partnership
with all relevant role players and with due consideration
to and respect for the choice of an informed mother regarding
the feeding of her child. The prevalence of exclusive breastfeeding
for 4-6 months in the country is largely unknown and should
be defined. Breastfeeding practices, including exclusive breastfeeding,
should form part of the national surveillance system in order
to monitor progress and take corrective steps as appropriate
- Food
consumption surveys of the nature of the present survey should
be repeated every three/five years and be extended to cover
the whole population for the purpose of establishing baseline
data and for monitoring and evaluation.
FOOD
PROCUREMENT AND HUNGER
- The
findings of the survey on procurement patterns are substantially
supportive of maize and sugar being the two most frequently
and consistently consumed foods in the country, followed by
tea, whole milk and brown bread. It is equally important to
note that these same food items were also the ones that were
found most frequently in the HH
- Most
HHs procured these items by purchasing them primarily in supermarkets
and to a much lesser extent in small shops
- Subsistence
agriculture was not a major source of these foods in the country
- HH
income would appear to be a decisive factor in the consumption
and procurement of foods
- At
the national level, one out of two HHs experienced hunger,
one out of four were at risk of hunger and only one out of
four HHs appeared food secure
- In
the rural areas a significantly higher percentage of HHs experienced
hunger when compared with HHs in the urban areas
- There
was an overall consistent association between the hunger risk
classification and anthropometric status. A similar association
was found with energy intake and the intake of micronutrients
- HHs
at risk of hunger or experiencing hunger procured a smaller
number of food items and had a similarly smaller number of
food items in the HH inventory. Additionally, HHs at risk
of hunger or experiencing hunger tended to be of the informal
dwelling type, had the lowest monthly income and spent the
lowest amount of money weekly on food. The mothers of such
HHs also had a lower standard of education
- Food
insecurity was, on average, experienced nationally by two
out of three HHs, five out of ten individuals and four out
of ten children respectively at the HH, individual and at
the child hunger level
- It
would appear that women sacrifice the quality of their diets
and limit the amount of food eaten by the adults in a HH in
order to preserve the amount of food available to their children
- The
findings of the FPHIQ and the HSQ are largely supportive of
the poor nutrient intake as obtained by the 24-H-RQ and the
QFFQ.
Recommendations
- Food
and micronutrient insecurity should be addressed within the
current framework of the INP 8
,
which is based on an integrated nutrition strategy for South
Africa. It is also strongly recommended that the Directorate:
Nutrition is provided with the necessary, additional and needed
resources to attain the aims and objectives of the INP
- The
creation of employment opportunities should rank among the
highest priorities of the government
- The
data of the present survey should be analysed more extensively
with a view to identifying parameters which can be used to
target HHs at the highest level of food insecurity
- The
data of the present survey should also be communicated to
other relevant sectors within government, especially the agricultural
sector, in order to highlight the importance and extent of
the food and micronutrient insecurity in the country.
FOOD
FORTIFICATION.
- Against
the outlined background of the findings of the present survey,
the following recommendations are made:
Recommendations
- Maize
(sifted, special, super), white and brown wheat flour and
white retail sugar should be the vehicles for fortification
on a mandatory basis, henceforth collectively referred to
as food vehicles
- The
micronutrients that should be used for fortification should
be:
- Vitamin
A
- Thiamin
- Riboflavin
- Niacin
- Folic
acid
- Vitamin
B6
- Iron
- Zinc,
and
- Calcium
- The
food vehicles should be fortified at the level designed to
deliver 33% of the current RDAs per serving at the point of
consumption, taking into account the inherent content of these
micronutrients in the food vehicles, the anticipated losses
of these micronutrients during production, distribution and
food preparation as well as the limitations that may arise
from organoleptic considerations of such additions, especially
with regard to riboflavin, folic acid, iron, zinc and calcium
- Sugar
should be fortified with vitamin A only at the level of 50
IU/g, and the portion size for calculation purposes for maize
and wheat flours should be 200g
- Encompassing
legislation, which must include all aspects of the necessary
monitoring and evaluation of a fortification programme, should
be enacted and implemented
- The
on-going discussions with the relevant sectors of the food
industry should be continued and expanded with a view to reaching
mutually acceptable solutions on issues relating to costs,
product quality and acceptability as well as any other related
issues likely to impact on the proposed fortification programme
- The
current food fortification task group within the Directorate
of Nutrition should be transformed into a permanent committee
on food fortification with a clear mandate to monitor and
coordinate all aspects of the proposed food fortification
programme
- Current
voluntary practices regarding the addition of fat soluble
vitamins to margarines should be retained
- The
current component of the INP regarding vitamin A supplementation
should be retained and should be targeted to children at the
highest risk for vitamin A deficiency
- The
current component of the INP regarding multi-micronutrient
supplementation (other than vitamin A) should be retained
and should be targeted to children at the highest risk for
such deficiencies. All such supplements should be reassessed
in terms of composition and posology
- Foods,
especially those consumed by children older than 6 months
of age, which are currently fortified on a voluntary basis,
should be reassessed with a view to harmonising the proposed
framework of fortification. The necessary negotiations with
the relevant manufacturers should be concluded prior to the
enacting of legislation on fortification. Additionally, any
fortified products currently used in the PSNP and PEM schemes
should be re-evaluated
- Any
future proposals by food manufacturers regarding the fortification
of additional food vehicles on a national basis with vitamin
A and/or iron should first be discussed with and agreed upon
by the Directorates of Nutrition and Food Control with a view
to assessing their impact and safety within the framework
of the proposed fortification programme
- With
regard to cows milk and in view of the findings of the present
survey, negotiations should be initiated with the relevant
sectors of the dairy industry in order to investigate the
feasibility of fortifying milk with selected fat soluble micronutrients
- The
inclusion of milk in the menus of the Primary School Nutrition
Programme and in crches should be seriously considered and
implemented
- No
health claims other than those approved by the Directorate
of Food Control should be allowed for any of the food fortification
vehicles
- With
regard to Trade considerations, negotiations should be initiated
with neighboring countries with a view to achieving regional
standards for fortified food items for import/export purposes
- The
impact of the proposed fortification programme on the countrys
population should be evaluated during the programmes third/fifth
year of implementation. Such an evaluation should form an
integral part of the regular evaluation of the monitoring
and evaluation component of the programme.
NUTRITION
EDUCATION
Against
the outlined background of the findings of the present survey
and in terms of nutrition education, the following recommendations
are made:
Recommendations
- An
in-depth analysis of the economic implications and needs for
a national nutrition education programme should be conducted
prior to finally selecting the most cost-effective and appropriate
nutrition education strategy on fortification and/or supplementation
- A
national consultative group on nutrition education should
be constituted in order to ensure that nutrition messages
and nutrition education/promotion campaigns are consistent
and globally supportive, that duplication is prevented and
that the targeting of such messages/campaigns is prioritised
in relation to the findings of the present survey. This consultative
group by necessity must include government (all sectors) as
well as industry and NGOs involved in providing nutrition
and nutrition related information to the public. Alternatively,
a smaller consultative group could coordinate activities in
the different sectors
- All
relevant role players (families, communities, health, social,
agricultural, educational workers, policy makers and politicians)
should be informed that the critical dietary inadequacies,
in terms of dietary variety and nutrient intake in general
and micronutrients in particular, affects the majority of
the children population in the country and impacts severely
and adversely on their growth and overall development
- A
government-food industry partnership must be established and
should work in unison in enhancing the already favourable
perception of the public at large regarding the benefits of
consuming fortified foods. The primary guide of such a crucial
partnership must be for the benefit of the people rather than
for market share
- Families
and communities, especially mothers/caregivers must be informed
that micronutrient deficiencies can be prevented by consuming
fortified foods as well as by consuming, within their financial
means, a variety of foods especially legumes, fruits, vegetables
and, when possible, foods of animal origin. In this regard,
the concept of budgeting for good nutrition should be introduced
and disseminated as should nutrition wise, good value for
money food choices
- In
conjunction with recommendation 9.6.5, Health- and Community-Based
Facility Programmes should become more specifically involved
in educating mothers/caregivers on the importance of micronutrients
and correct nutrition in the growth of their children. Health
Facility Based Programmes should also educate mothers/caregivers
on the importance of compliance when micronutrient supplements
are dispensed
- Families,
mothers/caregivers should be educated on the importance of
regular clinic visits to ensure that their children grow adequately
because of the subtle nature of stunting. The concept that
many children who look apparently healthy may not be growing
to their full potential needs to highlighted and emphasised
- Health
workers involved in feeding schemes should be educated on
the choice of micronutrient rich foods and should also be
made the conduit for strengthening the messages on the importance
of micronutrients. This should also be the case for all personnel
working in day care facilities especially in relation to purchasing
and preparation of food for young children
- The
importance of exclusive breastfeeding for the first 4
6 months of life in ensuring an adequate micronutrient intake
early in life, as well as the important contribution breast
milk can make up to two years of life in meeting micronutrient
requirements, should be included and be more emphasised as
part of the programme on promotion and protection of exclusive
breastfeeding. However, one should guard carefully against
creating a feeling of false security in the mother in relation
to breast milk being adequate to meet the nutrient requirements
of the older child, which is clearly NOT the case
- Families,
mothers/caregivers, health workers should be educated on the
importance of and need for younger children to have small
and frequent meals for adequate growth. Monitoring and evaluation
should specifically focus on the facilitating factors and
barriers to improving young child feeding with energy- and
nutrient-dense foods
- The
important slogan of clean hands, clean food and a clean home
protect children against diseases and ensures optimal child
growth should be promoted and disseminated to all individuals
concerned with the care of young children
- In
dealing with malnourished children (under- and over-weight),
their mothers/caregivers should be provided with nutrition
information relevant to the prevailing needs of their environment
and in relation to home based rehabilitation
- The
concept of child health begins before birth in relation to
planned parenthood (age, child spacing, nutritional and prenatal
care), the importance of micronutrient supplementation during
pregnancy (iron, folate) and preparation for choice of infant
feeding (breastfeeding promotion) should be promoted to all
women of child bearing age
- In
rural or other appropriate settings, the important role home
based crops and livestock can make to the childrens diet should
be strengthened and promoted as feasible and appropriate
- The
recommended Nutrition Education activities should, when applicable
to children older than five years of age, follow the FBDG
as follows:
- Enjoy
a variety of foods
- Be
active!
- Make
starchy foods the basis of most meals
- Eat
plenty of fruits and vegetables every day
- Eat
legumes regularly
- Foods
from animals can be eaten every day
- Use
fat sparingly
- Use
salt sparingly
- Drink
lots of clean, safe water
- If
you drink alcohol, drink sensibly
- ietary
guidelines for children younger than five years of age should
be developed
- The
proposed Nutrition Education Programme should be specific
and sensitive to provincial differences with regard to available
household appliances, prevailing circumstances and cultural
requirements. Equally, nutrition education materials on the
chosen topics should be relevant to prevailing environmental
circumstances. Such a programme should capitalise on existing
good practices
- The
primary target groups for the proposed Nutrition Education
Programme should not only be all the mothers/caregivers of
children and the children themselves (depending on age) but
also their grandparents, and specifically the poor (limited
financial and other resources) with relative low formal educational
levels in rural areas especially on commercial farms. Furthermore,
the same nutrition programme/messages need to be extended
to the urban areas in view of the high rates of urbanisation,
and also to pregnant women
- The
secondary target groups should include day care workers, the
food production and marketing sector, teachers and schools
(pre-primary, primary and secondary), as well as all health
workers including all private health practitioners. The low
schooling level of mothers also part of the regression analysis
suggests additional secondary targets for information i.e.
schoolchildren
- The
tertiary target groups should include decision-makers, administrators
and politicians at the national, provincial and community
level. This group needs to be involved in a number of alternative
strategies such as advocacy, regulation (food labelling, food
fortification, supplementation), organisational change (health
promoting schools and healthy cities), legislation (input
on minimum wages of farms workers from the nutrition sector)
- The
multiple causality of nutritional disorders demands that any
Nutrition Education Programme (like all other nutrition relevant
activities) must be of a multi-sectoral nature. The primary
target groups should be reached where they work, live and
play as well as through the education and health system, and
agriculture
- The
radio and/or television should be the primary communication
medium for the Nutrition Education Programme but not at the
exclusion of other means and modes of communication such as
printed material, the broader media, and, importantly, face-to-face
activities at every possible opportunity
- The
content of the education material must be sensitive to the
prevailing low level of education of the primary target groups
and cater for language and cultural prerequisites
- In
relation to 9.6.23, any education material must be developed
within the current framework and all components of the Integrated
Nutrition Programme of the Directorate: Nutrition of the Department
of Health
- The
overall monitoring and evaluation of the proposed Nutrition
Education Programme should form an integral component of the
programme. This should be achieved by establishing the level
of knowledge of the public at large on basic nutrition issues
in any future national surveys, and finally
- The
findings of the present survey should be made available to
all health workers, the media and the public at large in order
to increase awareness of the scale and nature of the most
prevalent nutritional disorders in the country.
RECOMMENDATIONS
OF A GENERAL NATURE
- Since
very significant delays were encountered and a considerable
time was spent on designing and drawing a national probability
sample of children, every effort should be made in future
health surveys to share sampling resources with other organisations
conducting national health surveys. An example of such an
organisation is the Central Statistical Service, which conducts
annually the October household survey. Given that the current
emphasis of the Directorate of Nutrition is correctly placed
on the improvement of child health, it is recommended that
the Directorate should investigate the feasibility of establishing
and maintaining a national valid sampling frame for children
- Socio-economic
upliftment is considered essential to sustainable reduction
of micronutrient deficiencies and undernutrition in general.
A detailed discussion of this subject falls outside the scope
of this report. Nevertheless, it is important to note that
these particular deficiencies, because of their intimate link
to socio-economic status, may be used as medium-term indicators
in assessing the success of the currently implemented national
nutrition programmes. Such findings should be incorporated
into the national Health Information System
- The
findings of the present survey indicate that the four most
seriously affected provinces were the Eastern Cape, the Northern
Cape, the Northern Province and Mpumalanga. The Directorate
of Nutrition should establish whether further assistance,
other than fund allocations, would be required in terms of
expertise to ensure the capability to implement the recommendations
in this report in these Provinces
- In
order to achieve a sustainable solution in the reduction of
micronutrient deficiencies and other dietary inadequacies,
it is essential to develop a comprehensive strategy that will
address such issues in the immediate- and medium-term, i.e.
until such time that socio-economic upliftment can achieve
sustained reduction. For an immediate- and medium-term solution
to be effective, several different aspects of adequate micronutrient
intake need to be addressed at a national level, which should
include campaigns to:
- Increase
consumer awareness of adequate micronutrient intake
- Increase
awareness of the importance of breastfeeding
- Improve
health worker training in respect of stunting, micronutrients,
and breastfeeding.
Finally,
the findings of the present survey are largely confirmatory
of those of the recently published report on poverty in country
in terms of the socio-economic determinant of malnutrition including
income. Importantly and in relation to HIV/AIDS, nutritional
status is considered of the utmost importance in delaying the
progression of the disease, reducing the incidence of complications
related to the disease, reducing overall health care costs and
improving quality of life. On these and other considerations,
therefore, it can be argued strongly that the nutritional rehabilitation
of those at risk must be given the highest priority.
In
conclusion, we believe that this has been a very successful
and much needed survey in both providing base line data for
future reference and also in formulating policy on a number
of aspects of food fortification in the country. The Directors
of the survey wish to express their sincere gratitude to all
those who made the study possible and successful. They are all
acknowledged in the appropriate chapter.
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