Development of a workplace breastfeeding support practice model in South Africa.

BACKGROUND: Globally, mothers have identified work as one of the main obstacles to exclusive and continued breastfeeding. The support a woman receives in her workplace in terms of workplace arrangements can be critical to enable women to continue breastfeeding. This study aimed to develop and assess the face validity of a practice model to support exclusive and continued breastfeeding in workplaces in the Western Cape, South Africa. METHODS: An explanatory, sequential, mixed-method research design, was conducted (June 2017 to March 2019) in three distinct phases. Phase one employed a quantitative, descriptive, cross-sectional study design. Phase 2 used a qualitative, multiple case study. Phase three involved the development and face validity of a practice model to support exclusive breastfeeding in workplaces. The face validity included two Delphi rounds for experts to provide input on the draft practice model. This paper will only report on phase 3 of the study. The practice model was developed, drawing on the analysis of data from phases one and two and using programme theory approaches and a logic model. RESULTS: The practice model was positively perceived. Participants viewed it as informative, well designed and easy to follow, even for those not knowledgeable about the subject. It was viewed as an ideal tool, if accompanied by some training. Participants were positive that the model would be feasible and most commended the tiered approach to implementation. They felt that workplaces would be more open to a step-by-step approach to implementation and if only a few activities are implemented it would be a start to make the work environment more conducive for breastfeeding employees. There were mixed opinions regarding commitment; a few participants mentioned commitment as a challenge they anticipated in the male-dominant environments in which they worked. The provision of space for breastfeeding at the workplace was also highlighted as a potential challenge. CONCLUSIONS: Advocacy around creating an enabling workplace environment for breastfeeding is needed. The practice model has the potential to be internationally relevant, locally applied and may be of particular use to workplaces that want to initiate and/or strengthen breastfeeding support.

Development and Field-Testing of Proposed Food-Based Dietary Guideline Messages and Images amongst Consumers in Tanzania.

In this paper we report on the development and field-testing of proposed food-based dietary guideline (FBDG) messages among Tanzanian consumers. The messages were tested for cultural appropriateness, consumer understanding, acceptability, and feasibility. In addition, comprehension of the messages was assessed using culturally representative images for low literacy audiences. Focus group discussions were used as method for data collection. Results indicate that the core meaning of the proposed FBDG messages and images were understood and acceptable to the general population. However, participants felt that nutrition education would be required for improved comprehension. Feasibility was affected by some cultural differences, lack of nutrition knowledge, time constraints, and poverty. Suggestions were made for some rewording of certain messages and editing of certain images. It is recommended that the field-tested messages and images, incorporating the suggested changes, should be adopted. Once adopted, the FBDGs can be used to inform and engage various stakeholders, including parents, caregivers, healthcare providers and educators on appropriate nutritional practices for children and adults. They can also be used to guide implementation of relevant policies and programmes to contribute towards the achievement of sustainable healthy diets and healthy dietary patterns.

Perspectives from South African dietitians on infant and young child feeding regulations.

OBJECTIVE: This study aimed to determine the knowledge, perceptions and practices of dietitians in South Africa regarding the Regulations Relating to Foodstuffs for Infants and Young Children (R991). DESIGN: A mixed methods, cross-sectional design was used. SETTING: Quantitative data were collected using an online survey (n 282) and qualitative data by means of two focus group discussions (n 12). PARTICIPANTS: Participants were dietitians registered with the Health Professions Council of South Africa. RESULTS: Dietitians' average knowledge score was 64·8 % ± 12·5. Those working in infant and young child feeding had a 5 % higher knowledge score (95 % CI 1·4, 8·6, P = 0·01). Perceptions towards the Regulations were generally positive, and the majority of practices were compliant. Positive perceptions seemed to correlate with compliant practices. The most frequently selected enabler to the implementation of the Regulations was 'Increase in other initiatives which support, protect and promote breastfeeding', and the most frequently selected barrier was 'Lack of awareness of the Regulation among health care providers'. The major themes from the focus group discussions comprised: less knowledge among dietitians and mothers about products controlled under the Regulations, non-compliance of other health care providers, the dietitians' role in support and enforcement, the discrepancy between practice in private and public sectors and a lack of enforcement. CONCLUSIONS: South Africa has taken a bold step in legislating the International Code of Marketing of Breast-milk Substitutes and should upscale programmes to ensure consistent monitoring and enforcing of the Regulations.

A qualitative analysis of perceptions of various stakeholders on nutrition-sensitive agricultural interventions, including the taxation on sugar-sweetened beverages (SSBs), to improve overall health and nutrition in South Africa.

BACKGROUND: As a low-middle income country, South Africa has seen an upsurge in the double burden of malnutrition (DBM). Owing to the rising costs of obesity on healthcare in South Africa, the National Treasury implemented a fiscal policy for the taxation of SSBs, known as the Health Promotion Levy, in line with the WHO recommendation. Potential negative impacts of the policy on the sugar cane industry and economic and rural development have been voiced by different sectors. By including a subsection in the SSBs fiscal policy and aligning the goals with existing policies, government could have made provisions for sugar cane farms to substitute crops with alternatives, including nutritional alternatives where possible, while supporting existing small-scale farms to produce nutrient-dense, local and culturally acceptable crops. Thus, the purpose of the study is to understand the perceptions of the various stakeholders on combining nutrition-sensitive agricultural interventions with the taxation on sugar-sweetened beverages (SSBs) to improve overall health and nutrition in South Africa. METHODS: Semi-structured, in-depth interviews were conducted with each participant. The interviews were audio-recorded, transcribed intelligent verbatim, and cross-checked against the audio-recordings by the principal researcher. ATLAS.ti 8 software was used to navigate the data and assist with thematic analysis. RESULTS: Perceptions of combining SSB taxation with agricultural policies to improve food and nutrition security were positive. The participants found it to be an innovative idea in theory but questioned the feasibility of combining policies. Participants highlighted education as an essential element for successfully changing behaviour to ensure a positive impact of the combined policy approach. Participants believed that before government could scale up nutrition-sensitive agricultural interventions, basic services and government functions would first need to run optimally. CONCLUSION: Overall, perceptions with regard to combining the taxation on SSBs with nutrition-sensitive agricultural policies to improve overall health and nutrition in South Africa were positive. Although participants questioned the feasibility of combining these policies, it was viewed as a way to combat alleged collateral damage linked to the tax, with a specific focus on developing small-scale farmers. More research into these combined policy approaches in a South African context is required.

Anthropometric Parameters of HIV-Infected and HIV-Uninfected Mothers and their Premature Infants.

This study aimed to assess the maternal anthropometric parameters of human immunodeficiency virus (HIV)-infected and HIV-uninfected mothers as well as to assess the neonatal anthropometric parameters of premature infants in relation to maternal anthropometric parameters (weight, height and mid-upper-arm circumference), HIV status and anti-retroviral therapy (ART) regimen. Study participants included HIV-infected and HIV-uninfected mothers who gave birth to premature infants. All HIV-infected mothers received ART. The incidence of intra-uterine growth restriction (IUGR) among premature infants was high. Maternal anthropometric parameters, HIV status and ART exposure showed no association with IUGR in this study. Sufficient maternal ART exposure may positively influence head circumference at birth, which might determine the neurodevelopmental outcome of these infants.

Implementation of the Road-to-Health-Booklet health promotion messages at primary health care facilities, Western Cape Province, South Africa

Background: Age-specific health promotion messages appear in the Road-to-Health-Booklet, an assessment and monitoring tool for child health in South Africa. Healthcare workers should communicate health promotion messages to caregivers at each clinic visit.Objective: This investigation, part of a larger Road-to-Health-Booklet survey, assessed the implementation of health promotion messages and identified barriers to its successful implementation.Methods: A cross-sectional descriptive study with analytical components was conducted in the Western Cape Province. Knowledge and practices of caregivers and healthcare workers were assessed at 143 randomly selected primary health care facilities. Information was obtained through questionnaires; direct observation of consultations and recording of health promotion material in facilities.Results: In total, 2442 children (0-36 months; mean age 6.26 ± 6.24 months.); 2481 caregivers and 270 healthcare workers were included. Caregivers' educational level varied, with only 24.3% completing Grade 12. Healthcare workers had a median of five years (0.5 - 37.0 years) work experience in primary health care. All healthcare workers indicated that health promotion messages are important, however, messages were only conveyed in 51% of consultations observed. If communicated, health promotion messages were age-appropriate in 97% of cases. Barriers to the implementation of health promotion messages hinged on time and staff constraints, workload and language barriers.Various forms of health promotion material were available in facilities.Conclusions: Sub-optimal implementation of the health promotion messages in the Road-to-Health-Booklet are apparent despite healthcare workers realising the importance of health promotion.Barriers to optimal implementation must be urgently addressed by the National Department of Health and healthcare workers in partnership with caregivers and supported by society to promote child health and care

Assessing the utilization of a child health monitoring tool

Objective: The study assessed the implementation of growth monitoring and promotion, immunisation, vitamin A supplementation, and deworming sections of the Road-to-Health Booklet. Caregivers and health care workers knowledge, attitudes and practices were investigated as well as health care workers perceptions of barriers undermining implementation.Methods: A cross-sectional descriptive study was conducted on a proportional sample of randomly selected Primary Health Care facilities across six health districts (35%; n=143) in the Western Cape Province. Health care workers involved in the implementation of the Road-to-Health Booklet, children (0-36 months) and CGs were included. Information was obtained through scrutiny of the Road-to-Health Booklet, observation of consultations and structured questionnaires.Results: A total of 2442 children, 2481 caregivers and 270 health care workers were recruited. Weight (94.7%) measurements were performed routinely. Less than half (40.2%) of caregivers reported that their child's growth was explained. Sixty-eight percent of health care workers correctly identified criteria for underweight, whereas only 55% and 39% could do so for stunting and wasting respectively. Road-to-Health Booklet sections were completed adequately for immunization (89.3%), vitamin A supplementation (94.6%) but not for deworming (48.8%). Most health care workers (94%) knew the correct regimes for vitamin A supplementation and deworming, but few caregivers knew when treatment was due for vitamin A supplementation (16.4%) and deworming (26.2%). Potential barriers identified related to inadequate training, staff shortages and limited time.Conclusion: Focussed effort and resources should be channelled towards health care workers training and monitoring regarding growth monitoring and promotion to optimize utilization of the Road-to-Health Booklet. Mobilisation of community health workers is needed to strengthen community awareness of preventative health interventions

Differences in Breast Milk Composition of HIV-Infected and HIV-Uninfected Mothers of Premature Infants: Effects of Antiretroviral Therapy.

INTRODUCTION: A key strategy to prevent mother-to-child transmission of the human immunodeficiency virus (HIV) and to reduce infant morbidity and mortality includes providing the HIV-exposed premature infant with breast milk accompanied by dual anti-retroviral therapy (ART). The effects of HIV and ART on premature breast milk composition are largely unknown. The aim of the study was to assess and compare the breast milk composition of HIV-infected mothers receiving ART and HIV-uninfected mothers who gave birth to premature infants. MATERIALS AND METHODS: Lactating HIV-infected women receiving ART (n = 38) and HIV-uninfected women (n = 36) with premature infants provided two breast milk samples on days 7 and 9, respectively, of lactation. Breast milk samples were analyzed for total energy, protein, carbohydrates, fat, phosphate, iron, zinc, and copper content. RESULTS: Breast milk of HIV-infected women contained higher protein (1.95 versus 1.78 g/100 g; p = 0.04), fat (4.42 versus 3.49 g/100 g; p = 0.01), and copper (0.64 versus 0.56 mg/L; p = 0.02) levels; whereas carbohydrate (5.37 versus 6.67 g/100 g; p = 0.002) and zinc (5.26 versus 5.78 mg/L; p = 0.04) levels were lower compared with those of HIV-uninfected women. Zinc levels were significantly lower in HIV-infected women with early gestation periods, and the lowest levels were observed in women who received ART for ≤4 weeks (0.58 mg/L; p = 0.03). Total energy (78.22 versus 61.48 kCal/100 mL) and fat levels (5.39 versus 3.00 g/100 mL) were significantly higher in the late gestation period HIV-infected women. Copper levels (0.61 mg/L) were higher in the late gestation period women who received >4 weeks of ART exposure (p = 0.05). CONCLUSION: Differences existed in the breast milk composition of HIV-infected women on ART compared with HIV-uninfected women. ART exposure period may influence breast milk composition.

Public health nutrition capacity: assuring the quality of workforce preparation for scaling up nutrition programmes.

OBJECTIVE: To describe why and how capacity-building systems for scaling up nutrition programmes should be constructed in low- and middle-income countries (LMIC). DESIGN: Position paper with task force recommendations based on literature review and joint experience of global nutrition programmes, public health nutrition (PHN) workforce size, organization, and pre-service and in-service training. SETTING: The review is global but the recommendations are made for LMIC scaling up multisectoral nutrition programmes. SUBJECTS: The multitude of PHN workers, be they in the health, agriculture, education, social welfare, or water and sanitation sector, as well as the community workers who ensure outreach and coverage of nutrition-specific and -sensitive interventions. RESULTS: Overnutrition and undernutrition problems affect at least half of the global population, especially those in LMIC. Programme guidance exists for undernutrition and overnutrition, and priority for scaling up multisectoral programmes for tackling undernutrition in LMIC is growing. Guidance on how to organize and scale up such programmes is scarce however, and estimates of existing PHN workforce numbers - although poor - suggest they are also inadequate. Pre-service nutrition training for a PHN workforce is mostly clinical and/or food science oriented and in-service nutrition training is largely restricted to infant and young child nutrition. CONCLUSIONS: Unless increased priority and funding is given to building capacity for scaling up nutrition programmes in LMIC, maternal and child undernutrition rates are likely to remain high and nutrition-related non-communicable diseases to escalate. A hybrid distance learning model for PHN workforce managers' in-service training is urgently needed in LMIC.

Low intake of calcium and vitamin D, but not zinc, iron or vitamin A, is associated with stunting in 2- to 5-year-old children.

OBJECTIVES: This cross-sectional study examined the nutritional factors associated with the high levels of stunting in 2- to 5-y-old children in an impoverished South African setting where liver is frequently eaten and vitamin A deficiency known to be absent. METHODS: Children's dietary intake was assessed by a single 24-h recall. Heights and weights were measured and information was obtained on breast-feeding history, the child's habitual milk intake, as well as substance use by the mother during pregnancy (n = 150). RESULTS: The overall prevalence of stunting was 36.9% (CI 29.2, 44.6) and increased with age, being 49% in the 4- to 5-y-old age category. Birth weight correlated significantly with height-for-age z-scores (HAZ; r = 0.250, P = 0.003), and was lower in children whose mothers smoked and used alcohol during pregnancy than in children whose mothers abstained (P < 0.0001). Median intake of energy, carbohydrate and protein was adequate. Median intake for all micronutrients was at least 90% of the estimated average requirement, except for calcium, vitamin D and vitamin E, which was 21%, 15%, and 32%, respectively. Intake of fat, calcium, phosphorous, vitamin D, riboflavin, and vitamin B12 (nutrients that typically occur in milk) was significantly lower in stunted than in non-stunted children (P < 0.05). When excluding children with low birth weight, intake of calcium, vitamin D, and riboflavin were still significantly lower (P < 0.05). HAZ was higher in children who habitually drank milk compared to those who did not (P = 0.003). CONCLUSIONS: Inadequate calcium and vitamin D intake, presumably because of low intake of milk after weaning, may have contributed to stunting in this population.

Effects of agricultural biodiversity and seasonal rain on dietary adequacy and household food security in rural areas of Kenya.

BACKGROUND: Kenya has a high prevalence of underweight and stunting in children. It is believed that both agricultural biodiversity and seasonal rainfall influences household food security and dietary intake. In the present study we aimed to study the effects of agricultural biodiversity and seasonal rains on dietary adequacy and household food security of preschool Kenyan children, and to identify significant relationships between these variables. METHODS: Two cross-sectional studies were undertaken in resource-poor households in rural Kenya approximately 6 months apart. Interviews were done with mothers/caregivers to collect data from randomly selected households (N = 525). A repeated 24-hour recall was used to calculate dietary intake in each phase while household food security was measured using the Household Food Insecurity Access Scale (HFIAS). A nutrient adequacy ratio (NAR) was calculated for each nutrient as the percent of the nutrient meeting the recommended nutrient intake (RNI) for that nutrient. A mean adequacy ratio (MAR) was calculated as the mean of the NARs. Agricultural biodiversity was calculated for each household by counting the number of different crops and animals eaten either from domestic sources or from the wild. RESULTS: Dietary intake was low with the majority of households not meeting the RNIs for many nutrients. However intake of energy (p < 0.001), protein (p < 0.01), iron (p < 0.01), zinc (p < 0.05), calcium (p < 0.05), and folate (p < 0.01) improved significantly from the dry to the rainy season. Household food security also increased significantly (p < 0.001) from the dry (13.1 SD 6.91) to the rainy season (10.9 SD 7.42). Agricultural biodiversity was low with a total of 26 items; 23 domesticated and 3 from the natural habitat. Agricultural biodiversity was positively and significantly related to all NARs (Spearman, p < 0.05) and MAR (Spearman, p < 0.001) indicating a significant positive relationship between agricultural biodiversity of the household with dietary adequacy of the child's diet. CONCLUSION: Important significant relationships were found in this study: between agricultural biodiversity and dietary adequacy; between agricultural biodiversity and household food security and between dietary adequacy and household food security. Furthermore, the effect of seasonality on household food security and nutrient intake was illustrated.

Evaluation of selected aspects of the Nutrition Therapeutic Programme offered to HIV-positive women of child-bearing age in Western Cape Province, South Africa.

BACKGROUND: The Nutrition Therapeutic Programme (NTP) involves the provision of food supplements at primary health clinics (PHCs) to correct nutritional deficiencies in vulnerable groups. Although previous studies have identified problems with implementing the programme at PHCs, assessments of its efficiency have been scarce. OBJECTIVE: To evaluate implementation of the NTP at PHCs that provide antiretroviral therapy. METHODS: A cross-sectional, descriptive study was conducted at 17 PHCs located within 3 districts of Western Cape Province. Two target groups were chosen: 32 staff members working at the sites and 21 women of child-bearing age enrolled in the NTP. Questionnaires were used to obtain data. RESULTS: Only 2 women (10%) lived in food-secure households; the rest were either at risk of hunger (29%) or classified as hungry (61%). Most of the women knew they had to take the supplements to improve their nutritional status, but the majority only recalled receiving basic nutritional advice, and the information was mainly given verbally. Ten of the women had shared their supplements with others, mostly with their children. The study identified lack of clearly defined NTP responsibilities at the PHCs, causing confusion amongst the staff. Although many staff members expressed problems with the NTP, only 38% of them reported having routine evaluations regarding the programme. CONCLUSION: Several aspects compromised the effectiveness of the NTP, including socio-economic factors leading to clients' non-compliance. The strategic organisation and implementation of the NTP varied between different PHCs offering antiretroviral therapy, and staff experienced difficulties with the logistics of the programme.

Liver intake in 24-59-month-old children from an impoverished South African community provides enough vitamin A to meet requirements.

OBJECTIVE: To assess the contribution of liver to the vitamin A intake of 24-59-month-old children from an impoverished South African community where liver is frequently consumed and vitamin A deficiency previously shown to be absent. DESIGN: Cross-sectional. SETTING: Northern Cape Province, South Africa. SUBJECTS: Children aged 24-59 months (n 150). Vitamin A intake from liver was assessed using a single 24 h recall and a quantified liver frequency questionnaire. In addition, information on vitamin A intake via the national fortification programme was obtained from the 24 h recall and information on vitamin A supplementation from the Road-to-Health Chart. Height, weight and socio-economic data were also collected. RESULTS: Stunting, underweight and wasting were prevalent in 36·9 %, 25·5 % and 12·1 % of children. Mean daily vitamin A intake from liver was 537 and 325 µg retinol equivalents measured by the 24 h recall and liver frequency questionnaire, respectively. Liver was consumed in 92·7 % of households and by 84·7 % of children; liver intake was inversely related to socio-economic status (P < 0·05). The food fortification programme contributed 80 µg retinol equivalents and the vitamin A supplementation programme 122 µg retinol equivalents to daily vitamin A intake. CONCLUSIONS: The study showed that liver alone provided more than 100 % of the Estimated Average Requirement of the pre-school children in this impoverished community. The results also challenge the notion generally held by international health bodies that vitamin A deficiency, poor anthropometric status and poverty go together, and reinforces the fact that South Africa is a culturally diverse society for which targeted interventions are required.

The rationale for adopting current international breastfeeding guidelines in South Africa.

Current international breastfeeding guidelines recommend exclusive breastfeeding for 6 months, followed by the appropriate and adequate introduction of complementary foods at 6 months, with continued breastfeeding for 2 years and beyond. This guideline is based on evidence to support exclusive and extended breastfeeding as the optimal method of feeding infants and young children. Not only do these breastfeeding practices meet the nutrition needs of infants and children for optimal growth and development, but they also offer a host of other health and socio-economic benefits at all levels of society. The poor breastfeeding rates and increase in infant and child morbidity and mortality in South Africa have led to increased prioritized attention towards the promotion, protection and support of breastfeeding. In 2000, the National Department of Health formally adopted the international breastfeeding guidelines for exclusive and extended breastfeeding practices. Therefore, it remains a priority to implement these guidelines in all current and future breastfeeding programmes and interventions, including the South African paediatric food-based dietary guidelines.