Impact assessment of the integrated nutrition programme on child malnutrition in South Africa.
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The Integrated Nutrition Programme (INP) was implemented in 1995 to target child malnutrition in South Africa. This study assessed the impact of the INP on child malnutrition by province and age group using secondary data. Data from three national nutrition surveys, conducted in 1994, 1999 and 2005, were used to describe trends in child stunting, underweight, wasting, vitamin A deficiency and iron deficiency. The relationship between the prevalence of the human immunodeficiency virus (HIV) in prenatal women and child nutritional status; challenges and constraints to implementing the INP at provincial level; and government responses to nutrition recommendations by lead experts in the 1994 and 1999 surveys were also investigated. Child nutritional status varied across provinces. In some provinces such as the Northern Cape, stunting, underweight and wasting remained consistently high. Stunting decreased in the Eastern Cape, but rates of wasting increased between 1994 and 2005. On the other hand, Gauteng and the Western Cape generally had lower rates of malnutrition compared to the other provinces. This may be due to these provinces being the most economically active in the country thus more opportunities for employment and higher purchasing power of foods rich in micronutrients. By 2005, vitamin A deficiency had doubled in most provinces despite mandatory food fortification being implemented in 2003. KwaZulu-Natal had the highest rates of vitamin A deficiency, while Limpopo had the highest rates of iron deficiency. By 2005, malnutrition had decreased in children aged seven to nine years, but had increased in those aged one to three years. There was a significant positive correlation (p<0.01) between the prevalence of HIV in prenatal women and vitamin A deficiency nationally. The prevalence of HIV in prenatal women was positively correlated (p<0.05) with rates of wasting in children aged one to three years. Limited skills, inadequate monitoring and evaluation, and limited infrastructure were common challenges and constraints to implementing the INP at provincial level. The effect of HIV on human resources and the higher demands of HIV infected patients also posed a challenge to provinces as they implemented the INP. Government responded to most recommendations made by nutrition experts. Supplementation,food fortification, growth monitoring and nutrition promotion programmes were implemented. Based on the data, it would appear that INP activities targeted at school-going children were more effective than those targeting children under-five. Although food fortification was implemented in 2003, the vitamin A content of fortified products might not have met legislative requirements. Additionally, because vitamin A is unstable to heat and light, if vitamin A fortified foods are cooked or stored this may also influence the bioavailability of vitamin A. Maternal HIV status might have attenuated child nutrition outcomes due to the negative effect of HIV on related health conditions such as child caring and feeding practices. Some of the challenges and constraints at provincial level might have negatively affected the implementation of the INP and consequently its impact. Although government responded to most recommendations made by nutrition experts, ongoing monitoring and evaluation of child nutritional status were not adequately done, which might have also negatively affected INP outcomes. In addition, factors in the macro-environment such as food inflation and access to basic sanitation, could have lessened the impact of the INP on child malnutrition. Interventions directed at malnutrition in children under-five need to be prioritised. There needs to be rigorous monitoring of micronutrient content, especially vitamin A, of fortified foods. Future studies need to include assessment of nutritional status in HIV affected and infected children to help identify specific needs and develop appropriate policies. Frequent nutrition surveillance to assess key child malnutrition indicators is required.
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