Linking Care and Support Systems to Improve Childhood Malnutrition: Early Childhood Development Practitioners’ Perceptions of Integrating Multisectoral Systems in South Africa

1. INTRODUCTION

Globally, 45% of children under five years’ old deaths are attributed to malnutrition. This represents nearly five million children dying in that age group. It goes without saying that this is a public health concern of global importance [1]. South Asia and sub-Saharan Africa account for 80% of these global under-five deaths [2, 3]. International efforts have been implemented to improve and strengthen multi-sectorial systems, including the Renewed Efforts Against Child Hunger in 2008, a UN-led inter-agency partnership with 13 countries taking part. This programme aimed to strengthen the coordination and facilitation of multisectoral nutrition programmes in various countries [4]. Other programmes, such as the Scaling Up Nutrition (SUN) Movement, which was established in 2010, aimed to end malnutrition in all its forms by uniting various government departments, businesses, researchers, civil society, and donors around the world. The SUN movement intended to have countries joining the movement committed to ending malnutrition through having multi-stakeholder partnerships and policymakers coordinating the effort to supports and scale up early childhood nutrition [5]. Up until today, 65 countries and 4 Indian states joined the SUN Movement, to focus on specific actions for nutrition. These include feeding practices, fortification of foods, micronutrient supplementation, and treatment of acute malnutrition. Furthermore, nutrition strategies such as agriculture, clean water and sanitation, education, social protection, health care, and resilience support were emphasized. The effectiveness of the programme was its ability to have political commitment from government states to prioritize nutrition on their national agenda [5, 6].

While the value of various sectors working together to improve nutrition is acknowledged, many countries face multiple challenges in coordination and implementation [7]. Therefore, in many cases, good programmes and policies are formulated at a higher level of government or international organizations [8]. However, practical implementation becomes a challenge due to multiple factors. These include corruption, lack of financial resources, unmotivated staff, lack of engagement with the people who require services the most, and lack of adequate coordination [9-11]. Therefore, the most vulnerable populations, such as children and people experiencing poverty, are the most affected. Coordinated efforts between individuals, households, government departments, Non-Government Organizations, and nonprofit organization are required to address the burden of malnutrition. This is critical because positive nutrition outcomes may have a positive impact on human development, human capital, and individuals' overall wellbeing [12, 13]. Wellbeing impacts individuals’ lives and that of their families, communities and society. The need to have different sectors working to resolve this challenge has been well recognized in the literature [14, 15].

In South Africa, evidence is sparse on how different sectors work together to reduce child malnutrition which dates back to 1994, when South Africa first became a democratic country [14]. In that year, the Integrated Nutrition Programme (INP) was first introduced and was intended to address children's nutritional needs at the population, household, community, and health facilities levels by the South African government [15]. The United Nations sustainable development goal 2 (SDG) target 2.2 aims to end all forms of malnutrition by 2020, including reducing stunting and wasting in children under five years' old. However, malnutrition is still very high in South Africa, with nearly 27% of children under five stunted, 17.1% overweight, 5.9% underweight, and 2.5% wasted [16, 17]. SDG Target 3.2 emphasizes the need to end all preventable deaths of children under-five and reduce under-five mortality to at least 25 per 1000 live births. However, South Africa has an under-five mortality rate of 32.2 per 1000 live births, and 30.9% of childhood mortalities are attributed to severe acute malnutrition [18, 19].

Little impact has been observed in programmes intended to reduce childhood malnutrition in South Africa. The country has government nutrition programmes designed to reduce child malnutrition, which have been strengthened since the emergence of democracy in 1994 [15]. They include introducing the INP, the National School Nutrition programme (NSNP), and feeding schemes. The INP was inclusive of three components, which are health, community, and nutrition promotion. However, these sectors were working in silos, and there is a paucity of evidence on whether they have successfully reduced child malnutrition [15]. The INP aimed to provide an intersectoral department collaboration with an approach to redress nutrition challenges. Therefore, multisectoral collaboration would address malnutrition’s determinants [20]. However, various scholars and members of civil society have critiqued the INP asserting that it lacked operation plans to make sure it would work across all sectors, including budgeting for staffing [21, 22]. Although programmes are in place to reduce child malnutrition, bottlenecks still hinder program implementation [23]. Previous studies have argued that nutrition programmes have long been available; however, their main focus was on food provision through the distribution of food parcels [8, 9, 24]. While these efforts directly dealt with the issue of food access, they ignored the role of the underlying factors associated with child malnutrition. These factors included poverty, illness, lack of maternal and child care, access and health service utilization, and access to clean, safe, and healthy environments.

The National Nutrition Security Plan of 2018- 2024 addresses food insecurity through a coordinated approach encompassing government departments such as social development, primary education, health, and agriculture [25]. Furthermore, the country has made provisions such as social grants and cash transfers to improve childhood malnutrition [26]. While the INP aims to facilitate cross-sectoral collaboration, effective planning and budgeting have not been observed in meeting nutrition goals. To improve child health, there is a need to strengthen and coordinate mechanisms such as interagency coordination, policy integration, data sharing and monitoring systems as well as community engagement across all government and non-government departments. The multifaceted nature of undernutrition necessitates multidimensional interventions that transcend sectoral lines. Therefore, eradicating malnutrition among children should remain a priority for government departments, and nutrition-related policies should receive significant attention. First, there is a need to understand the role of other sectors, such as health, social welfare, early childhood development centres (ECDs), and education. Secondly, there is a need for various sectors need to commit to using their resources and capabilities to help reduce child malnutrition. Therefore, this study aims to understand how different sectors can be linked to improving the nutritional outcomes of children under five.

2. CHILD MALNUTRITION AND MULTIFACETED INTERACTIONS OF FACTORS: SOME THEORETICAL PERSPECTIVES

The framework presented in Fig. (1) below is the adaptation of the 1990 United Children’s Fund (UNICEF) conceptual framework of the causes of malnutrition and the Nurturing Care Framework established in 2018. The UNICEF’s conceptual framework explains the multifaceted interaction of distal and proximal factors in understanding child malnutrition [27]. On the other hand, the Nurturing Care Framework provides a direction for childcare using evidence-based research. Furthermore, it explains how services and policies can help support parents, families, and communities in nurturing care [28]. Both these frameworks are relevant as they show that the child's nutritional status is beyond their food access. They also suggest that different systems can work together to improve nutrition and allow children to achieve optimum development. Fig. (1) depicts the complex interactions between the individual household and family, health, environment, and social systems. The dotted lines represent a moderation among these systems. Besides ensuring that children have adequate nutrition, linking various care systems will be essential to ensure good health, offer security and safety, and provide responsive caregiving. The broken arrows that point to optimum nutrition show that national responses to the different childcare structures may influence the children’s nutritional outcomes. The solid lines show direct pathways from the nutrition-enabling environment to the various systems that may influence child malnutrition. Based on the theoretical insights from the two adapted frameworks, this study hypothesized that for a child to grow and meet the optimum development, multiple systems must work together, including families, in providing nurturing and care to improve children’s nutritional outcomes, thus suggesting a need for a multisectoral approach in childcare and nutritional outcomes.

Fig. (2) below is a further illustration of Fig. (1) above. It depicts an expanded explanation of the underlying determinants of child malnutrition at the individual, household, and community levels. These determinants fall within the family, health, environmental and social systems.

3. MATERIALS AND METHODS

4. QUALITATIVE COMPONENT

The qualitative component of this study was completed next. It involved using a qualitative method. In-depth interviews using structured topic guides were used to explore The perception of ECD practitioners, perceptions about how they thought other care and support systems could be linked to improving childhood malnutrition. The aim of using semi-structured questionnaires was to ensure that the main themes the researcher was interested in were covered in the interviews while allowing for open-ended questions and flexibility in data collection. Table 2 below is an overview of primary data collection.

5. RESULTS

Table 3 describes the outcome variables and presents their mean and standard deviations. As presented in Table 3, stunting was the highest amongst children under 5 (22.16%) compared to the indicators of overweight (16.40%) and underweight (5.04%).

The summary statistics giving descriptive background information on the caregiver and the household are presented in Table 4 above. A total of 2 966 women aged 15-49 were surveyed. The majority were single or divorced (73.87%), had no medical aid (89.98%), had up to the secondary level of education (62.37%), were unemployed (57.78%), and just above a quarter (28.72%) lived in households that use pit-latrines as toilets.

Table 5 above, shows that most The majority of children were cared for at home during the day (67.22%), received the child support grant (80.59%), and had no medical aid (93.09%). Nearly a quarter of children were cared for at creches during the day (24.60%). Of the children who were ill, 30,79% caregivers did not seek health care. The highest cited reason for no care was that the child was not sick enough (62.15%).

Table 6 presents the bivariate analysis of selected caregiver and child level characteristics and the nutritional outcomes of stunting and child overweight. We find that the age of the child and where the child is cared for during the day is significantly associated with child stunting and overweight. However, variables such as the child support grant and medical aid were the only variables associated with child stunting.

6. DISCUSSION

This study provided a mixed methods analysis of the linkages of different care systems and the ECD practitioners’ perceptions of how these systems can be linked together. We found that childhood malnutrition was staggeringly high, characterized by high stunting, overweight and underweight of children under five years’ old. Stunting and overweight results remain unchanged compared with the South African National Health and Nutrition Examination Survey conducted a decade ago [31]. Our qualitative assessment helped us to identify four critical childcare systems: the family, health, environmental and social systems. However, our study has found growing disintegration of childcare and support systems services. This disintegration is not only present in South Africa but also in many sub-Saharan countries. For example, a study conducted in Mozambique by Michaud-Létourneau and Pelletier supports our findings. It also found a lack of understanding of the meaning of “coordination” and the lack of understanding of roles and responsibilities in “coordinated” care among different sectors responsible for childcare service provision. The same study found this lack of integration in care services has resulted in children facing multiple adversities, including poverty, poor nutrition, and poor health outcomes (Michaud-Létourneau & Pelletier, 2017).

Regarding the health care systems, our findings show that some caregivers sought care when their children were ill. From the quantitative component, a small proportion of those who did not seek care cited “the child was not sick enough” as their main reason for lack of health care utilization (HCU) for their children. We also found that just over 90% of children had no medical aid access. Prior studies have indicated that children under-five morbidities and mortalities were due to preventable causes and the lack of timely HCU, which can contribute to these adverse health outcomes [19, 32, 33]. Similar to what has been found by other studies, the ECD practitioners also explained that sometimes they pick up health challenges with the child and refer the parents/caregivers for health care. However, they faced poor staff attitudes, lack of medication, long queues, and parents being turned away at local clinics [34,35]. The literature also supports our findings on the lack of HCU which, suggesting an overstretch in the health system, especially in South Africa, where over 80% of the population relies on the public healthcare provision [34]. According to Wendimagegn and Bezuidenhout, government healthcare services should provide promotive, preventative, curative, and rehabilitative services [36]. A global study conducted on low middle-income countries (LMICs) found that the quality of care for vulnerable populations such as the poor, less educated, and those with stigmatized conditions was worst compared to non-vulnerable populations. Mothers and children during preventative or curative clinic or hospital visits were given less than half of the recommended clinical interventions [37]. Therefore, service gaps at healthcare facilities due to under-resourcing and overcrowding highlight an urgent need to coordinate policies targeting service delivery issues in the health sector [38].

We also found a significant relationship between children being overweight and being cared for at home during the day. Children at ECD centers presented with better health outcomes than children cared for at home. In South Africa, registered ECD centres are regulated to ensure that children at least receive a healthy breakfast and lunch. Additionally, centres in-low income settings where children receive a CSG, can benefit from a nutrition government grant of R17 a day per child [40]. ECD centers can protect against childhood malnutrition, cognitive deficits, and academic underachievement resulting from poor nutrition [39]. However, the ECD practitioners expressed frustration with the bureaucracy of registering the ECD centers. For example, to qualify for the ECD permit and registration, centers must have enough area per child space indoors and outdoors, the class-to-teacher ratio should be 1:6 children, and a separate area for cooking and meal preparation. Unregistered centers do not qualify for the ECD nutrition grant of R17 per child per day. This means centers rely on the school fees they receive. Due to caregiver unemployment, the payment does not come on time or does not come at all. In South Africa, the Department of Education ECD census in 2021 found that only 42% of the ECD centers were registered, and only a third received the nutrition grant subsidy [40]. The restrictive laws and regulations in registering ECD centers make it challenging to deliver effective and quality childcare services They also serve as a barrier to the integration of the care system, thus making it difficult to improve children’s nutritional outcomes.

Although our data show that children in ECDs have better health outcomes, the family system is critical to improving child nutrition. The ECD practitioners reported challenges with parental involvement and partnerships, where the caregivers would not attend meetings when requested and would have older siblings collect their children. ECD practitioners perceived this as a lack of care for the child’s safety. According to the Epstein model of parental partnerships, parental involvement includes communication, school involvement, shared decision-making within the school, and community partnerships. This study found that children whose parents were involved in their care and education had better developmental outcomes, such as demonstrating social competence, communication, and extended development beyond education [41]. This study has proven that parental involvement is critical because it makes referrals easier, particularly when an ECD practitioner notes a child's problem with a child that needs attention. A study conducted in Ethiopia found that the mother’s low number of children ever born, high socioeconomic status, and level of education were associated with responsive caregiving [42]. In South Africa, a study conducted on the livelihood activities of informal traders found that mothers felt they had no choice but to look for more cost-effective ways to ensure their children are cared for. This includes the older sibling caring for the younger children. This is because caregivers are expected to make additional payments at the ECD centers after a particular number of hours, which can be expensive. Therefore, the next available childcare arrangement in the mother's absence is care by the older sibling [43, 45].

Both Soweto and Gamasemola areas were characterized by high poverty and unemployment rates. This study found unemployment among caregivers to be heightened by nearly 60%. Families and caregivers cannot meet their children’s basic needs because of the lack of income. All ECD practitioners spoke of the importance of increasing opportunities for employment and argued that this also would decrease the rising crime rates observed in their communities. Furthermore, environmental systems, such as access to water and electricity, affect hygienic food preparation and nutritional diet. A study conducted in South Africa found that lack of electricity affected how food was stored. Studies have found that inadequate food storage may result in infections, such as diarrhea, a low immune system, and child malnutrition [44,45]. The significant concerns reported in the rural ECD centers were the issue of water and sanitation. In Limpopo, the primary concern was the lack of water. At the time of this research, the ECD practitioners reported that they had no water provision, the communal taps were dry, and they received no announcement from the municipality about providing water, which is part of our Bill of rights. Water was only accessible from the river, which was also running dry due to the shortage of rain. Lack of water affects Children and staff's sanitation and hygienic food preparation, because the water needs to be reused to ensure that it lasts longer. Soweto occasionally gets water shortages, but the challenge is not as severe because the municipality provides water tanks, even though they do not always come as scheduled. Some ECD practitioners reported that they are forced to close the ECD centre for hygiene protocol on the days when there is no water. This may put the children at risk of being at home and not receiving the care they need.

7. STRENGTHS AND LIMITATIONS

Our study’s primary strength was the mixed-methods approach and design, which thoroughly evaluated the factors contributing to child malnutrition and the caregivers views on how different care systems can work together. The rural-urban communities’ inclusion gave insight into the different contexts in which children are brought up and the services they need. These two settings are geographically diverse regarding their availability and access to services, such as (health, education, environmental, and social development services). The limitation of the study is that the qualitative component was only conducted in the Gauteng and Limpopo province. Although the NIDS data was intended to be nationally representative, it was not designed to be provincially representative. Therefore, the results cannot be generalized. Another observed limitation of using qualitative methods was the discussion of delicate subjects such as childcare practices, nutrition, and ECD financing.

To some extent, the researcher’s presence contributed to participant bias, influenced by the respondent’s knowledge of the “right” answer. This bias resulted in ECD practitioners over reporting on the nutrition given to children in ECD centres. A limitation observed from the quantitative analysis was the absence of information on birth spacing and mother’s health information. This information would have been useful to understand these factors’ influence on children’s nutritional outcomes.

CONCLUSIONS AND RECOMMENDATIONS

The coordination of different sectors of care for children is urgently needed. Understanding the challenges and opportunities for collaboration in different sectors from ECD practitioners’ perspectives is critical because they provide secondary care to children without primary caregivers. This understanding will enable efficient and effective service referral and service delivery to improve childhood malnutrition in South Africa. This study highlights the need for continuity and coordination of food, family, and health, systems. While there is a need for systems strengthening, there is also a need for triangulation using the available data to understand the various functions of childcare systems. The evidence-based nurturing care framework builds on the knowledge of how child development unfolds and the int erventions and policies that can improve child malnutrition [28]. When these systems work together, they have the potential to meet the physical, emotional, social, and educational needs of children. Multiple shifts in government departments, such as as providing administrative support to ECD centres to get registered should be implemented to ensure ECD centres are accessible to all children, in the same way that education is prioritized. This is more important given that ECD centers are protectors of adverse child health outcomes, as this study has shown. Some strategic pathways for priority investments and me development to improve child malnutrition include: 1) Improving access to healthy foods - in rural areas and encouraging food gardens in urban areas; 2) developing nutrition education programmes and training health workers to deliver adequate nutrition services to address nutritional needs in both urban and rural areas; 3) investing in water and sanitation infrastructure, particularly in rural areas, to ensure access to clean water and sanitation facilities; and 4) encourage cooperation between government, non-governmental, civil society, and the corporate sectors to make use of resources, and available information for the successful implementation of nutrition programme, as well as engaging communities in the planning, implementation, and monitoring of interventions to ensure their sustainability.

REFERENCES