Nutrition knowledge and barriers to good dietary practices among primary school children in a farming community

Abstract

This article examines the nutrition practices of black African children attending farm schools and looks at what they know about nutrition. The research was part of the Farm Labour and General Health (FLAGH) project of the North-West University (Potchefstroom Campus), South Africa. Two schools participated in the study, which involved 132 primary schoolchildren aged 8 to 16 years. A structured questionnaire revealed the children's knowledge about nutrition related issues, and focus group discussions brought to light attitudes and barriers to sound dietary practices. This study provided insight into the lives of children living on commercial farms in the North West Province. The findings provide strong support for the view that while nutrition education is important to children's development of nutrition knowledge, good dietary practices and overall nutritional status, so also are influences from the children's social, economic and psychological environment.

1. INTRODUCTION

Malnutrition among children is said to be one of South Africa's biggest problems, especially in the form of micronutrient deficiency disease (Labadarios, 2000). There are a number of initiatives in South Africa to address micronutrient malnutrition in children, such as food fortification, supplementary feeding, training of health workers and information and education about healthy diets and ways of preparing food and growing vegetables (Klugman, 2005). Despite all these efforts, and although the South African Constitution recognises the right of everyone to have access to sufficient food and the right of children to basic nutrition, many South African children still face the spectre of hunger and malnutrition.

The problem is particularly acute for previously disadvantaged groups. In the North West Province of South Africa, the Transition, Health and Urbanisation in South Africa (THUSA) study has identified commercial farm dwellers as an extremely vulnerable group because of their poor nutritional status and physical and mental health (Vorster et al., 2000). A report by UNICEF (1993) states that children living on farms were found to be especially vulnerable and more likely to be stunted and underweight than any other children, as was also confirmed in the National Food Consumption Survey (Labadarios, 2000). The current situation of people living and working on commercial farms originates from the South African history of racial and political inequities, resulting in farm workers and their families having very limited access to education and other opportunities (Ellis, 2001; National Department of Agriculture, 2003). A needs assessment survey conducted during 2001 as part of the Farm Labour and General Health (FLAGH) programme in a farming community in the North West Province revealed that the majority of adults have education levels of Grade 4 or less, and that farm schools provide education only up to Grade 7 level. This, in combination with several other factors, for instance distance to farm schools, intrahousehold issues and household food insecurity, impacts negatively on children in particular, with half of them being underweight, stunted or wasted (Kruger et al., in press). The UNICEF framework for causes of child malnutrition displays a complex set of underlying causes of malnutrition, death and disability: lack of information and education, poor household security, inadequate maternal and child care, insufficient health services and an unhealthy environment (UNICEF, 1997).

This article examines nutritional knowledge and barriers to good dietary practices among primary school children attending farming schools, with the aim of providing guidelines for nutrition education programmes specially designed for children with specific needs coming from farming communities in the North West Province of South Africa.

2. METHODS

2.1 Background

The study was part of the FLAGH programme of the North-West University (Potchefstroom Campus). This programme is a multi- and transdisciplinary and multisectorial intervention programme designed as a follow-up to the THUSA study in which farm dwellers on commercial farms were identified as the most vulnerable group in terms of their nutritional, physiological and psychological health (Vorster et al., 2000). The main aim of the FLAGH programme is to improve the quality of life of commercial farm dweller communities in the North West Province in South Africa through intervention programmes based on in-depth multi- and transdisciplinary research. After a thorough needs assessment in farming communities in the Ventersdorp and Potchefstroom districts during 2001 (Kruger et al., in press), the need for a project with the potential for improving nutrition knowledge and contributing to food security was determined.

2.2 The setting

This study took place during school hours in two farm schools in the Potchefstroom district of the North West Province. The schools were visited prior to collection of data to discuss the study protocol. The visits were also used to obtain informed consent from the children's parents or legal guardians.

2.3 Subjects

A convenience sample of scholars in Grades 2–6, aged eight to 16 years, in both schools, was the basis for the study. One hundred and forty-four children voluntarily participated: 86 from School 1 and 58 from School 2. Of these, ten left school and two migrated and enrolled in other farm schools. A total of 132 children (72 boys and 60 girls) completed the study protocol: 81 from School 1 and 51 from School 2.

2.4 Ethical considerations

The Ethics Committee of the North-West University (Potchefstroom Campus) approved the study (Approval number 00M21). Consent procedures were in Tswana, the first language of the subjects and their families. Letters and consent forms were sent to the parents/guardians via the children explaining the purpose of the study and requesting their consent on behalf of the children. Children with consent forms signed or marked with a cross (allowing the children to participate) were included in the study.

2.5 The study

The structured questionnaire developed for the study population asked children what they knew about gardening, nutrition, hygiene, food-based dietary guidelines, and dietary issues and was used to obtain baseline and end data on the children's knowledge. The questionnaire was translated into Tswana and tested among children at another farm school. The researcher and three trained native Tswana-speaking assistants interviewed the subjects. Baseline data were obtained before the planting of vegetable gardens at both schools, followed by a nutrition education intervention in School 1. After five months, end measurements were obtained from both schools.

Focus group discussions were held to help the researchers understand the nature of and constraints on household nutrition practices and gain insight into beliefs and attitudes associated with knowledge and practices reported by the children. The focus group questions were set up in line with the recommendations laid out by Krueger (2000). Discussions were held with three groups of ten children each, boys and girls, recruited from each participating grade. One assistant monitored the tape recorder and noted any unforeseen occurrence during the discussions.

The focus group questions asked for information about factors that determine diet, barriers to sound dietary practices and beliefs and attitudes associated with dietary practices. From the transcribed tape-recorded discussions, themes and patterns of common ideas were noted. The main interest was in clusters of common concepts and ideas among the focus groups relating to perceived constraints in practising sound dietary practices.

2.6 Statistical analysis

The statistical analysis system (sas) version 8 was used to analyse the data. The data should be considered as small populations for which statistical inference and P-values are not relevant. Instead of reporting only descriptive statistics in these cases, effect sizes (a measure of practical significance) were determined. Practical significance (d-value) can be understood as a large enough difference to have an effect in practice and is described for differences in means, for the relationship in two-way frequency tables and also for a multiple regression fit. Effect sizes not only make the difference independent of units and sample size, but also relate it to the spread of the data (Steyn, 2000). Findings are considered to have a significant effect when d ≈ 0.8, a medium effect when d ≈ 0.5, and no practical significance when d ≈ 0.2 (Steyn, 2000).

2.7 Limitations of the study

Time was allocated to the researcher by the school headmaster; unfortunately this was usually towards the end of the day, when the children's concentration level may have been low. Another limitation of this study is that all data were self-reported. Nutritional knowledge may have been reported on the basis of practices associated with diet. There were also no other methods of food intake to verify the data from reported dietary practices (other methods are a 24-hour dietary intake recall, or a dietary diary combined with a food frequency questionnaire, or to analyse a blood sample and verify that against reported dietary intakes). However, the results are consistent with a study by MacIntyre et al. (2002) which reported deficient dietary intakes and practices among a South African farm population in transition.

3. RESULTS

3.1 Demographics

The subjects were children aged eight to16 and in Grades 2–6, from commercial farms surrounding their schools. The main products of these farms were dairy, poultry, game, maize, beans and wheat. Table 1 shows that men headed 68 per cent of the households of children in School 1. Of these, 61 per cent were fathers, 3 per cent uncles, 4 per cent brothers and 1 per cent grandfathers. The head was female in 32 per cent of the households. Of these, 27 per cent were mothers and 5 per cent grandmothers. Men headed 59 per cent of households of children in School 2. Of these, 57 per cent were fathers and 2 per cent brothers. The head was female in 41 per cent of the households. Of these, 30 per cent were mothers and 11 per cent grandmothers. Most of the children at these schools came from labouring families (farm workers, labourers in another industry, and domestic workers): 82 per cent of the children at School 1 and 84 per cent at School 2. The main languages spoken at home in both groups were Tswana, Afrikaans, Xhosa and Sotho, and the two groups had similar socio-economic and family circumstances.

Table 1: Characteristics of the subjects

Variable	School 1 (n = 81)		School 2 (n = 51)
	Mean (range)	SD	Mean (range)	SD
Age (years)	12.6 (8–16)	2.0	12.0 (8–16)	2.2
Size of household (no. of people)	5.6 (2–13)	2.1	5.0 (2–11)	1.7
Number of bedrooms	2.9 (1–7)	1.4	2.2 (1–7)	1.2
	Percentages
Gender
Boy	59		47
Girl	41		53
Gender of household head
Male	68		59
Female	32		41
Occupation of household head
Farm worker	46		43
Labourer in another industry	30		33
Housewife	10		6
Domestic service	6		8
Supervisory position (industry)	5		4
Unemployed	3		6
Main languages spoken at home
Tswana	42		71
Sotho	19		15
Afrikaans	14		8
Xhosa	11		6
Zulu	7		–
English	4		–
Sepedi	3		–

3.2 Baseline results

Table 2 shows no practical significant difference in nutrition knowledge between the two groups at baseline. The d-values of the questionnaire test items ranged from 0 to 0.3, indicating that the two groups appear to have similar nutrition knowledge.

Table 2: Mean scores of correct nutrition knowledge answers at baseline

	School 1 (n = 86)		School 2 (n = 58)
	Mean score	SD	Mean score	SD	d-value
It is healthy to eat vegetables such as potatoes in their skin	0.10	0.29	0.12	0.33	0.1
Tea is a body building food	0.47	0.50	0.40	0.50	0.2
Morogo is an energy-giving food	0.13	0.34	0.14	0.35	0.0
When hungry between meals it is healthier to eat sweets than to eat an orange	0.50	0.50	0.47	0.50	0.1
A healthy meal could be pap, milk and an orange	0.62	0.49	0.72	0.45	0.2
It is healthy to eat fruit and vegetables every day	0.70	0.46	0.74	0.44	0.1
Exercise promotes health	0.67	0.47	0.74	0.44	0.2
It is necessary to wash your hands before you eat	0.93	0.25	0.80	0.41	0.3
It is healthy for your body to drink lots of water	0.50	0.50	0.47	0.50	0.1
A vegetable garden needs watering	0.90	0.31	0.95	0.22	0.2
Vegetables protect my body against illness better than pap	0.67	0.47	0.72	0.45	0.1
Vegetables cooked in lots of water are healthy	0.70	0.46	0.69	0.47	0.0
It is healthy for you to eat lots of fat or fatty foods	0.80	0.40	0.79	0.41	0.0
It is healthy to eat different kinds of food	0.47	0.50	0.45	0.50	0.1
It is necessary to eat dry beans, peas, lentils and soya regularly	0.24	0.43	0.33	0.47	0.2
What is the best way to eat
Carrots?	0.56	0.50	0.43	0.50	0.3
Potatoes?	1.00∗	0.00	0.97	0.18	0.2
Spinach?	0.01	0.10	0.10	0.00	0.1
Cabbage?	0.05	0.21	0.3	0.18	0.1
Tomatoes?	0.41	0.50	0.29	0.46	0.2
∗1.00 – all children knew that the best way to eat potatoes is when they are cooked.

3.3 Dietary practices

As indicated in Table 3, all children reported eating supper, but some did not eat breakfast and some did not eat lunch. The main breakfast meal was bread and tea or mealie meal (flour made from ground maize) and milk. A few of the children consumed mealie meal alone, mealie meal and meat or mealie meal and tea for breakfast. For lunch most of the children ate mealie meal and meat, or mealie meal and milk or mealie meal and vegetables. For supper, most children ate mealie meal and meat or mealie meal and milk.

Table 3: Children's dietary practices

	School 1 (n = 86)	(n = 81)	School 2 (n = 58)	(n = 51)
	Baseline (%)	End (%)	Baseline (%)	End (%)
Breakfast (main food items consumed)
No food taken	21	15	26	22
Bread and tea	36	42	21	24
Mealie meal and milk	13	11	21	31
Mealie meal	7	11	–	4
Mealie meal and meat	6	7	14	12
Mealie meal and tea	5	2	–	–
Lunch
No food taken	9	3	9	9
Mealie meal and meat	27	36	41	33
Mealie meal and milk	17	26	21	39
Mealie meal and vegetables∗	11	5	10	6
Mealie meal	–	–	7	2.0
Bread and milk	–	1	–	6
Supper
No meal taken	–	–	–	–
Mealie meal and meat	36	42	47	41
Mealie meal and milk	14	17	31	20
Mealie meal and vegetables∗	12	11	9	12
Mealie meal and beans	5	10	–	2.0
∗The examples of vegetables given were mainly potatoes, cabbage, onions and tomatoes.

3.4 Barriers to sound dietary practices

In both schools the children in the focus groups cited the main farm produce, payday and town visits by their parents as factors that determine their diets. Complex social issues such as the spending of meagre wages on alcoholic drinks were cited as the primary barrier to sound dietary practices. The groups identified financial and consumption related decision-making, domestic disputes, the use of alcohol, their guardians' entertainment, lack of care, cost, internalised beliefs and the physical appearance of some vegetables in the field (they are prickly so they cannot pick them) as barriers to their dietary practices.

Despite the high scores for hygiene knowledge in the quantitative measure, the children indicated that, to some extent, this knowledge does not imply practice. Concern was expressed by two focus groups about the standard of personal hygiene and hygiene practices during meal times at school and in the school toilets. The groups stressed that some of the children came to school dirty with ‘threads of blankets’ in their hair and in soiled clothes. They reported that some children do not wash their hands after visiting the toilet and before eating or serving food, and that in the school toilets they ‘poke their bottoms’ and use faeces to write on the walls: ‘they write about sex’. During discussions on hygiene the children also pointed out that ‘houses are more important than covering food’. They maintained that some children do not have houses. They indicated that their households do know about hygiene issues, but such stressors as lack of shelter are more important than hygiene and, as a result, what is known might not be practised.

Men were reported to prevent women from buying vegetables not only by mere disagreements about what food items to buy but by physically hindering them in the farm shops. When women attempt to buy food, let alone vegetables, they are ‘pulled’ and ‘shaken violently’. The women end up being physically abused. The children reported that when women who work get paid, men take the money from them and use it to buy alcohol. Phrases such as ‘Jou bliksem, waarmee gaan ek drink?’ [Afrikaans: ‘You rubbish, where will I find money to buy drinks?’ (Bliksem is a general term of insult)] were relayed as a typical response of the male partner. The scenario was seen as worse when the women drink as well. The use of alcohol was seen as one of the major barriers to sound dietary practices. The groups reported the abuse of alcoholic drinks, which leaves no money to supplement food items bought on credit or provided from the farms. The children maintained that ‘alcohol is number one’. ‘They [the parents] don't think. They don't buy children food, school shoes or pay school fees. All they do is drink, drink, and drink …’ The parents are also reported to play cartoons (slug, or slot machines) in the shop and waste a great deal of money in the process. This form of entertainment was seen as a wasteful way of spending money that could be used for food.

Lack of care and responsibility was also seen as a barrier to good dietary practices. Focus groups stated that ‘our parents do not care whether we have eaten or not. They leave children alone in the houses’ and ‘fall on us at night from the drinking sessions’. They emphasised that if parents cared and allocated the available resources, especially capital and time, to family needs as a whole, their dietary practices would be better. They also pointed out that some of the children in school are street children and ‘they are given bread in the farm shops when it has gone mouldy’.

Cost was also seen as one of the barriers to good dietary practices. They reported that farm shops are expensive and their families do not have enough money to buy the basics. This was associated with and exacerbated by poverty and mismanagement of resources. One group viewed the concept of balanced meals as a waste. It was seen as costly to have two relishes in the form of meat and morogo in one meal, as it was pointed out that there is need to stretch the relish for later use. One child remarked: ‘If I eat my mealie meal with morogo and meat what will I have with my mealie meal tomorrow?’ (morogo is a generic term in local African languages for a variety of traditional green leafy vegetables, some of which are cultivated for subsistence, while others grow as weedy plants in cultivated lands or occur naturally as members of the veldt flora (Van der Walt et al., 2005). Morogo here refers either to a vegetable growing wild and picked in the field or spinach bought from a shop. No one in this study grew their own vegetables at home).

Internalised beliefs and personal preferences also play a part: some children said they do not eat certain food items such as vegetables because they believe they are not good for their health. Remarks such as ‘I don't eat cabbage, it gives me a headache and makes me vomit’ were made during discussions.

4. DISCUSSION

The dietary practices described in this study indicate a monotonous diet with the same food items repeated with little variety. The children mainly consume bread, mealie meal and a protein in the form of either milk or meat daily. The meals mainly lack food items from the fruit and vegetable group. This finding is consistent with results obtained among farm dwellers in the THUSA study (MacIntyre et al., 2002).

In this study, children did not accept the concept of balanced meals as they thought it would be a waste to eat maize meal with both meat and vegetables. In addition, they knew little about the need to eat a variety of foods (as advised by the food based dietary guidelines accepted by Department of Health as the guidelines for South Africans to good dietary practices; Maunder et al., 2001). However, this is understandable considering their low economic status and the accessibility and availability of food. In their homes, food must be made to go a long way, or saved for other meal times. The level of food insecurity among them may prevent them from enjoying a variety of foods. Their meals have little variety of individual foods or food groups: they consist of the same few types of food present in their household and their farm environment. Unlike the children in the study by Owen et al. (1997) of pre-adolescent attitudes, knowledge and beliefs about food, children in this study do not have the option of food choice.

Social, psychological and economic problems were cited as constraints on sound dietary practices. These problems are evident in previous research among farm communities in South Africa (Davies, 1990; Waldman, 1994; London et al., 1998a, b; Robins et al., 1998; Vorster et al., 2000; Department of Labour, 2001; Kruger et al., in press). This study, however, shows not only the effect of these problems on the farm worker community but also their effect on children's knowledge of nutritional issues. These non-nutritional problems affect the diet of the farm children who depend on their environment for survival and also prevent them learning about good dietary practices.

The abuse of alcohol, domestic abuses, neglect of children and costs are seen by children as obstacles to sound dietary practices. There appears to be lack of financial management. The way the existing resources are allocated does not promote health; rather, it exacerbates the already poor situation. The meagre wages are spent mainly on alcohol and children see the male partners' physical control over financial issues as worsening their poverty. The problems they experience may impede their educational and social success. Children lack nurturing and care from parents, and it appears that they are left to raise themselves. This lack of parental attention, compassion and love may leave children ill prepared to learn. It also suggests that parents need to be taught about parenting in addition to family members' nutritional needs for optimum health. The home environment and a poor monotonous diet may negatively affect the pupils' learning.

The study findings provide strong support for the view that while nutrition education is important to children's development of nutrition knowledge and good dietary practices, so are influences from the children's social, economic and psychological environment. In agreement with this is a study on the association between improved sanitation and children's heights in Lesotho, which demonstrated that non-nutritional factors might influence nutritional issues. Improved sanitation positively correlated with improved anthropometric status of children under five years (Daniels et al., 1991). Similarly, our study indicates that the development of nutrition knowledge and sound dietary practices among this population may be hampered by the socio-economic problems of farm life.

It is argued that, irrespective of the duration of nutrition education and its intensity, if these psycho-socio-economic problems are not addressed among this population the requisite nutrition education will not be achieved and the quality of life among this group will not be improved. These problems appear to limit the benefits a nutrition education programme may confer on these children.

From this study, it appears that vegetable gardening and nutrition education alone do not seem to be a solution to the problem of deficits in the nutritional knowledge of children attending farm schools from communities where poverty, alcoholism, food-related domestic disputes, parental negligence and other adverse life circumstances prevail. If these perceived problems are addressed together with nutrition education, there may be a marked improvement in the quality of life for farm children. These conditions appear to mask the benefits that the nutrition education programme may have for this group of children. Future nutrition research should thus include aspects beyond nutrition education, such as psychological, social and economic intervention programmes: issues that cannot be addressed by a nutritionist alone. Therefore, a scientific trans- and/or multidisciplinary approach is needed, where nutritionists, teachers, social workers and psychologists work together in linked programmes to address these multifaceted perceived constraints farm dwellers experience. This is a holistic approach where solutions to complex and integrated many-factored socio-economic health problems (such as malnutrition in children) are defined as integrating all the disciplines involved. In other words, if a combination of psycho-social, economic and biological factors determines the nutritional status of children, the solution (in the form of interventions) should be multisectorial so that the psycho-social, economic and biological causes are addressed simultaneously in an integrated manner.

5. CONCLUSION

This study highlighted the challenges faced by everyone involved in education. An intervention, where a vegetable garden could be viewed as a food security project model where children study and grow their own vegetables to improve their overall quality of life, is proposed as a way in which malnutrition of farm children can be addressed through a multidisciplinary approach. In the school context, every aspect can be related to this garden: maths, physics, life skills, home economics, farming, health and exercise and so on. Future research should be aimed at answering questions such as: does education improve the development of nutrition knowledge and good dietary practices among farm workers if socio-cultural problems are reduced; what impact do government poverty alleviation programmes have on the nutrition knowledge and nutritional status of farm children; what role can the education curriculum play in addressing nutrition education so as to improve the quality of life for farm children?

Additional information

Notes on contributors

Hilda Van't Riet

Annamarie Kruger is Research Coordinator, Africa Unit for Transdisciplinary Health Research, Faculty of Health Sciences, North-West University (Potchefstroom Campus), South Africa; and Mars Phometsi is a former MSc Nutrition student at North-West University and is now a teacher in Botswana; and Hilda van't Riet is a former Post Doctoral student at North-West University and is now working at Helen Keller International, Indonesia. Financial support from the National Research Foundation of South Africa, the South African Sugar Association, and the South African Medical Research Council is gratefully acknowledged. The authors also wish to thank the children and the farm schools without whom this study would not have been possible.