The burden of malnutrition
In 2016, the Toro Sub Region was put in the spotlight for its soaring burden of malnutrition and child stunting (UDHS, 2016). Anthropometric indicators for young children were collected to provide outcome measures of nutritional status. It was found that the region’s stunting rate for children under the age of five stood absurdly at 40.6 percent, above the national average of 39 percent. Since 2016, stunting rates in Uganda have continued to decline, but at a slow pace, to a prevalence of 28.9 percent (Global Nutrition Report, 2020). However, these figures are still unacceptably high. According to UNICEF, malnutrition threatens to destroy a generation of children in Uganda.
KRC’s evolving response to malnutrition
These shocking findings raised overwhelming concern for Kabarole Research and Resource Centre (KRC Uganda), the community, local government and development partners. KRC Uganda has since partnered with Kabarole District Local Government, Fort Portal Tourism City and non-state actors, including HIVOS, Health Food Africa, Broederlijk Delen and the Coalition of the Willing (CoW) to raise public awareness of the problem, aimed at stimulating proportionate response in fixing the underlying food systems challenges responsible for the burden of malnutrition and child stunting.
Community perceptions of malnutrition
Part of the Fort Portal Food Systems Lab work involves continuous engagement with food systems actors to situate the problem. Accordingly, KRC Uganda, alongside Kabarole District Nutrition Coordination Committee (DNCC) and Coalition of the Willing (CoW), a consumer advocacy group picked interest in understanding the community’s perceptions on the possible risk factors to the high burden of malnutrition in the communities.
A knowledge exchange with communities was conducted using radio magazines, where people’s views were gathered and recorded from the community conversations conducted in the Sub County of Rutete, Mugusu and Kasenda Town Councils. The study areas were selected based on the findings from the dietary diversity scores’ study conducted using food diaries by KRC in 2017. The study revealed that households in the selected areas had scored dismally low in dietary diversity a key risk factor to malnutrition.
Conversations were held with community leaders, Village Health Teams, Community Health Workers and community members through experience sharing, presentations of evidence-based information, brain storming on ideas, including questions and answers (QAs). The conversations were conducted as guided by two key objectives, namely: (1) To obtain community views on the risk and causal factors of the high burden of malnutrition, and (2) To map out key stakeholders and define their roles in ensuring improvement in the nutrition situation of the communities.
Following the community conversation, a nutrition themed radio magazine program was relayed on KRC FM Radio sponsored by Broederlijk Delen and HIVOS.
Risk factors in the spotlight of the malnutrition burden
Arising out of the community conversations, a number of risk factors attributed to malnutrition were raised by the community, including the major ones enlisted below:
- Income poverty: The low-income facet of poverty at household level was emphasized to be one of the leading causes of malnutrition in the region. Due to low incomes, there are households that are unable to afford more than a single meal every day and the end result is malnutrition.
- The time factor: Women noted that children are getting malnourished due to lack of ample time by women to care for them. They noted that men have left the family responsibilities to women and so they are doing all things possible to sustain their households. This has left women with no option but to rather leave their homes early in the morning and return late in the night in search for money, thus leaving the children without care.
- Limited or no knowledge on healthy food and nutrition: In the interactions with the community leaders and members, the knowledge gap on healthy diets was noted as a chief risk factor to all forms of malnutrition in the region. Other members noted that actually households produce diverse, safe, nutritious and healthy food in bulk but they sell it all to purchase unhealthy food such as junk foods, highly processed food and highly carbonated drinks. This results from knowledge gaps on healthy diets.
- Child neglect by parents or caretakers: It was noted that the trend of child neglect by parents and or caretakers is on a rise. The participants revealed that actually young children are left home under the supervision of their fellow children as parents go out to look for money in the markets. In this way, the children end up having days without meals since there is no body to prepare or plan for nutritious meals suitable for the children and other household members.
- In other instances, young mothers deliver children and hand them over to the elderly in villages to take care of them with little or no support towards children’s nutrition needs. The elderly people tend to feed the children on any available food since they do not move or they are too weak to fend for the children.
- Poor food choices and preferences: Food choices are undergoing constant change, from indigenous food to new varieties and highly processed foods. Many people prefer highly processed, fast food, carbonated drinks which are low in nutrients compared to locally processed indigenous foods that retain a higher nutrient content.
- It was also noted that currently, children in many households have taken on the role of decision making on food choices and thus, there is need to ensure that children have an understanding of the healthy and nutritious food. Choice of unhealthy and innutritious food could contribute to malnutrition
- Excessive selling of food: It was noted that many households are actually producers of nutrient dense foods. Nonetheless, the biggest proportion of the food is sold off to meet other important needs like education and health.
- Poor breasting practices: Poor breastfeeding practices are common amongst young mothers who lack the knowledge and experience. Poor breastfeeding is also common with working mothers who spend more time at their work stations leaving home their breastfeeding babies without alterative proper feeding options.
- Some young mothers on the other hand have a poor mentality of breastfeeding as they think breastfeeding will make their breasts floppy. All these deny children a right to breastfeeding and may result into malnutrition.
- Mind set and poor meal planning: The mind is key in making food choices, it was noted that many people have a poor mindset about indigenous nutrient dense foods like yam, sweet potatoes, cassava, pumpkin, millet, soy, beans, indigenous vegetables among others as they are considered local food for the poor. This deprived mind set has left many to consume unhealthy food that is considered modern and for the rich. This has grossly left many children micro nutrient deficient or over weight (obese).
- Meal planning on the other hand is linked to mind set and it has been noted that many households do not focus on healthy meal plans but rather consider consumption of unhealthy food due to the dietary paradigm shift.
- Diet monotony: One scholar, John A. Hannah, called it “Dietary Danger”. This was also highlighted as one of the major risk factors for malnutrition. It was noted that many families are dependent on the same type of food over and over especially matoke (banana) whose nutrient composition is majorly water and minute traces of proteins and carbohydrates.
- Poor cooking methods: It was revealed that some households have healthy and diverse food but they do not know right cooking procedures. As a result, some foods such as vegetables are over cooked and thus end up losing their valuable nutrients. The other risk factor is that foods are cooked with excessive fat, burnt onions and other spices which might be hazardous to human health.
- Increasing teenage pregnancies: Anecdotal data suggests that teenage pregnancies have been on the rise in the region. Leaders noted that young girls are giving birth to children with no or limited skills in child care. This has left many children at risk of malnutrition in due course as they receive limited care from their inexperienced and resource poor mothers.
- Population pressure: During the sessions, population rise was discussed to be a major risk factor to malnutrition. It was noted that due to increased population at both household and community level, there has been limited land for cultivation of food in some areas. On the same matter, community noted that some households are highly populated and with limited resources to purchase nutritious food thus leaving them at increased risk of malnutrition.
- Rural-urban youth migration: Following the increasing pace of urbanization of the region, many youths and energetic individuals have migrated to urban areas to look for jobs thus leaving the villages with limited man power for food production. This has certainly reduced on the food being produced to meet the increasing population food demands which may increase the risk of food insecurity.
- Poor sanitation and hygiene practices at household level: It was clearly indicated that some households have very poor sanitation and hygienic practices that always result into diarrheal illnesses especially in children.
- The illnesses are a great risk factor of malnutrition as it leads to loss of body nutrients, loss of children’s appetite for food. These could result into malnutrition in the long run.
Stakeholder mapping for an effective malnutrition response
In the second objective of the community debate on the burden of malnutrition in the Tooro Sub Region, a mapping of stakeholders was done to suggest the roles of each stakeholder in alleviating malnutrition. Five key stakeholders were enlisted, including; (1) parents/ caretakers, (2) Village Health Teams (VHTs) / community health workers, (3) community leaders (political, church and cultural leaders), (4) civil society organizations and (5) the private sector.
The following are the roles deserving of each of the stakeholders and affirmed by participants during the discussions.
- Parents/ Caretakers
- Create time and care for their children
- Make right dietary choices for their children
- Plan and prepare nutritious and safe food for their household members
- Ensure that they prioritize the health and nutrition status of their children
- Grow and or purchase nutritious food for their households
- Ensure optimal Infant and Young Child Feeding (IYCF) practices like breastfeeding and appropriate complementary feeding
- Village Health Teams (VHTs) / community health workers
- Conduct home visits and do nutrition and health surveillance at village level
- Make referrals of malnutrition to the health units
- Conduct health and nutrition education at the village level
- Timely report on the village health and nutrition situation
- Community leaders (political, church and cultural leaders)
- Regularly organize community health assemblies
- Enforce the health policies and regulations at community level
- Conduct home visits and guide the community on what to do to prevent malnutrition and ill health
- Participate in community sensitizations on nutrition, food security and health
- Civil society organizations
- Extend the health and nutrition sensitization sessions at village level.
- Participate in community health assemblies.
- Provide guidance to community members on health and nutrition practices.
- Train the community leaders and VHTs on community health and nutrition surveillance and community engagements.
- Support livelihood programs at community level to eradicate poverty and improve household incomes.
- Provide technical support to community leadership, VHTs and households on health, food production and nutrition matters.