Based on the results of the current chapter, the following recommendations regarding the SFP policy in Botswana is recommended:
- There is a need to develop and implement nutrition education strategies targeting teachers, primary school learners and their caregivers regarding the importance of dietary diversity for optimal health and growth of primary school learners by utilizing more affordable, home-grown foods, especially in households of a low-socio economic status. This recommendation can be implemented by the promotion of school- and backyard gardens to improve the dietary diversity of the SFP as well as the household diet of primary school learners in urban and peri-urban areas.
Recommendations regarding future research opportunities that could be explored include the following:
- An investigation of learner attitude towards the SFP, - Plate waste studies of meals offered as part of the SFP, and
- Nutrition knowledge of primary school learners, their caregivers and school officials regarding dietary diversity.
It is recommended that the above studies should be conducted in districts characterised by a high prevalence of poverty.
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155 CHAPTER 5
ANTHROPOMETRIC STATUS OF PRIMARY SCHOOL FEEDING BENEFICIARIES (INTERVENTION) VERSUS NON-SCHOOL FEEDING BENEFICIARIES (CONTROL) Abstract
Background: Underweight and overweight is a major public health problem among children of school going age. This double burden of malnutrition is the result of the nutrition transition, as well as household food insecurity. However, SFP have been implemented in Botswana nearly five decades ago to address undernutrition among primary school learners.
Objective: To determine and compare the nutritional status of primary school learners who participated in the SFP (intervention) to non-participants (learners attending a private school) who served as the control group.
Methods: Weight and height was measured according to standard techniques. This was followed by the calculation of weight-for-age (WAZ), height-for-age (HAZ) and Body Mass Index-for-age (BAZ) using WHO AnthroPlus software version 1.0.4. For the calculation of WAZ, the Centre for Disease Control (CDC) tables were used to interpret weight-for-age for learners older than ten years, as WAZ is only available for children up ten years of age on the WHO growth standards.
Results: BAZ indicated that the majority of learners from both the intervention and control group had a normal weight. However, learners from the control group had a higher prevalence of being at risk for becoming overweight or being overweight (29.0% and 9.7%) compared to those in the intervention group (18.8% and 4.8%). While the WAZ categories of recipients versus non- recipients of the SFP differed significantly (p=0.005), BAZ categories between the two groups was not significant. A comparison of WAZ and BAZ categories between urban and peri-urban learners both differed significantly (p<0.000). As all private school learners were urban, these results should be interpreted with caution.
Conclusion: Despite the fact that the majority of learners had a normal WAZ and BAZ, two out of ten learners from government schools (intervention) were at risk of becoming overweight, while 5% were overweight. Three out of ten learners from the private school (control) were at risk of becoming overweight while 10% were overweight. Hence the risk of learners becoming overweight as well as those who were overweight at the time of the study, justifies further investigation. As the categories of BAZ did not differ significantly between the intervention and control group, it could be an indicator that the SFP has a positive impact on learner nutritional status in the South-east District of Botswana.
156 5.1 Introduction
The increasing prevalence of overweight and obesity among school going children in most African countries is becoming a public health problem (Adiele & Morgan, 2017; Pangani, Kiplamai, Kamau & Onywera, 2016; Kruger, 2014). As an upper middle income country (World Bank 2019), Botswana has not been spared the nutrition transition, resulting in a double burden of malnutrition, characterized by undernutrition and childhood obesity (Tapera, Merapelo, Tumoyagae, Maswabi, Erick, Letsholo & Mbongwe, 2017; Wrotniak, Malete, Maruapula, Jackson, Shaibu, Ratcliffe, Stettler & Compher, 2012). Urbanization is the main cause of the nutrition transition, associated with a sedentary lifestyle and changing dietary habits (Azuike, Emelamadu, Adinma, Ifeadike, Ebenebe & Adogu, 2011). A food insecurity assessment study conducted in Gaborone by Acquah, Kapunda, Gwebu, Modie-Moroka, Gobotswana & Mosha (2013) noted that in the surveyed households, although the majority of household diets were relatively balanced, children consumed mostly empty calorie foods and had an infrequent consumption of traditional meals (Shaibu, Holsten, Stettler, Maruapula, Jackson, Malete, Mokone, Wrotniak & Compher, 2012).
There is a correlation between place of residence and childhood growth parameters (Lardner, Giordano, Jung, Passafaro, Small, Haar & Beria, 2015). Previous studies have found disparities in nutritional status between children residing in urban versus rural or peri-urban areas, with a higher level of undernutrition in rural compared to urban areas (Majumder, Islam, Hossen, Uddin, Hasan, Talukder, Sarowar, Rahman & Sultana, 2017; Danquah, Amoah & Opare-Obisaw, 2013).
Other determinants of undernutrition among school going children are household food insecurity and a low dietary diversity (Wolde, Berhan & Chala, 2015). Several studies have examined the anthropometric status of primary school children in other African countries (Teblick, De Deken, Vanderbruggen, Vermeersch, Teblick, Ruymaekers, Andries, Colebunders & Mmbando, 2017;
Goon et. al, 2011) and found a relationship between socioeconomic status, gender, area of residence and nutritional status.
School feeding has been shown to have a positive effect on the nutritional status of primary school children in a study which was conducted in Kenya (Neervort, Rosenstiel, Bongers, Demetriades,
157
Shacola & Wolffers 2013). In this particular study, the learners who were participating in the School Feeding Programme (SFP) were less likely to be nutrition related problems than children in the control group. A previous cross-sectional study which was conducted India, which highlighted dual nutritional problems of learners from private schools and government schools found that most of the learners who were malnourished were from government schools and those that were obese were from private schools (Ashok, Kavitha & Kulkarni, 2014). In the majority of studies conducted in India and Nigeria (Kar, Pradhan, Samal, 2018; Nwoke, Nkoro, Ibe, Nwufo
& Nwokor, 2017; Sehgal, Shankar, Singh, Alvi & Jain, 2017), the prevalence of underweight was usually higher in government schools compared to private primary schools, while the prevalence of overweight was usually higher in private schools. Stunting has also been found to be higher in government (non-paying) compared to fee paying (private schools) (El-Sabely, Tok & Hussien, 2013).
In studies that investigated the nutritional status of learners from urban and peri-urban areas, there is a coexistence of overweight and undernutrition with results being somewhat conflicting, as Dabone, Delisle & Receveur (2011) found that undernutrition was more prevalent in urban areas.
Gender also seems to have an impact on the type of malnutrition (Ogheneruese & Joy, 2016), as a study conducted by Audain, Veldman & Kassier (2015) found that prevalence of overweight and obesity was higher among peri-urban girls with a higher prevalence of stunting among boys from peri-urban areas. Undernutrition in urban areas is also not uncommon. A study conducted in Nigeria, found a 31.3% prevalence of severe malnutrition that was higher among boys (Goon, Toriola, Shaw, Amusa, Monyeki, Akinyemi & Alabi, 2011).
This present study also assessed the level of physical activity among primary school learners in relation to their nutritional status. Although the benefits of physical activity is well-researched, very few studies have been conducted in Botswana among school-aged children (Tladi, Monnaatsie, Shaibu, Sinombe, Mokone, Gabaitiri, Malete & Omphile, 2018). School aged children spend the greater part of the day at school and the school environment with physical activity related extracurricular activities being recognized to reduce the risk of children becoming overweight (Ip, Ho, Louie, Chung, Cheung, Lee, Hui, Ho, Ho, Wong, Jiang, 2017). There is a great disparity in type of physical activity being conducted in urban versus rural areas. In rural
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areas, the children of a low socioeconomic status tend to be more physically active through walking as a means of transport (Micklesfield, Pedro, Kahn, Kinsman, Pettifor, Tollman & Norris, 2014).
Monyeki (2014) recommends that governments should promote and encourage active lifestyles among children by creating a conducive environment. Cape Town is one of the first few cities in South Africa to provide free outdoor gym access to the community (van Biljon, McKune, DuBose, Kolanisi & Semple, 2018).
The purpose of this study was to determine and compare the nutritional status of recipients of school feeding to that of non-recipients during the school term (baseline), as well between urban and peri-urban learners during the school term. In addition, a comparison was drawn between the nutritional status of recipients of school feeding during the school term to that of their nutritional status after the school holiday (period of no school feeding), as well as between urban and peri- urban recipients of school feeding during the school term versus after the school holiday (period of no school feeding). As recipients of school feeding were sampled from government schools while all non-recipients were from a private school, school feeding could serve as a proxy of socio- economic status in the current study which was conducted in the South-east district, Botswana.
The resultant null hypotheses were that:
(i) there will not be a significant difference of the anthropometric status of recipients versus non-recipients of school feeding at baseline (during the school term);
(ii) there will not be a difference of the anthropometric status of urban versus peri-urban recipients of school feeding at baseline (during the school term);
(iii) there will not be a difference of the anthropometric status of recipients of school feeding at baseline (during the school term) versus after the school holiday at end line (period of no school feeding);
(iv) there will not be a difference of the anthropometric status of urban versus peri-urban recipients of school feeding at baseline (during the school term) versus after the school holiday at end line (period of no school feeding).
159 5.2 Methodology
5.2.1 Study design
A cross-sectional descriptive study was conducted to determine the baseline anthropometric status of recipients of the SFP versus non-recipients of the SFP. To determine whether the absence of school feeding during the school holiday had an impact on the nutritional status of learners, SFP recipients were followed up directly after the school holiday. Hence the latter aspect of the study formed the longitudinal component.
5.2.2 Study sample
The study sample consisted of primary school learners, aged 8 to 13 years, from 12 government schools and one private school from urban (Gaborone) and peri-urban areas (Tlokweng, Otse and Mogobane). The majority of learners were classified as early adolescents. This age group is considered to be nutritionally vulnerable due to increased nutritional requirements as a result of rapid growth and development (Danquah et. al, 2013). Nearly four hundred (N=392) primary school learners participated in the anthropometric component of this study during the school term (period of school feeding for government schools). Of the study sample, 330 were from government schools, while 62 were from private schools and therefore non-recipients of the SFP.
Following the school holidays (period of no school feeding), it was only possible to follow up 93 learners, representing a drop out of 71.8% of recipients of school feeding as the majority of learners from government schools were lost to follow up due the following reasons: (i) transfer to other schools; (ii) participation in independence celebration; and (iii) writing of exams for standard seven learners (iv) Absence from school
5.2.3 Anthropometric measurements
For the assessment of learner nutritional status, the following anthropometric measurements were taken.
Weight
To measure the weight of study participants, standard weight measurement protocols were followed as described in Chapter 3 and according to WHO (2014) standards. Weight measurements were used to calculate weight-for-age (WAZ) using WHO AnthroPlus version 1.0.4. For the calculation of WAZ, the Centre for Disease Control (CDC) tables were used to