Environment & Health Research Unit

Executive summary

Introduction:
This report covers a 5 year period (1999 -2004) during which time a community-based nutrition programme (CBNP) was established in the Bloekombos community of the Cape Metropole. The report includes both the process of setting up the CBNP as well as its evaluation during this period. This is done against the background of the community being transformed from an informal settlement to predominantly formal housing.

Objectives:
The overall aim of the Project was to address malnutrition and its causes through the development of a sustainable and community-driven CBNP. Simultaneously, the implementation of the CBNP through its interaction with the health facility-based nutrition programme, a key component of the Integrated Nutrition Programme, was evaluated in Bloekombos.

Methods:
Four evaluative methods were used: 1) description, review and interpretation of the Project's implementation processes, 2) interviews with purposively-sampled key informants, 3) analyses of focus groups and in-depth interviews of mothers/caregivers as participants and non-participants respectively, and 4) quantitative evaluations of participant and non-participant's socio-demographic status and the nutritional status of the children enrolled.

Results:
1) The Project achieved its aim to develop a sustainable and community driven community-based nutrition programme to address the causes of malnutrition in children. 2) However it became clear that interaction and involvement of key stakeholders drawn from local structures is essential for sustainability. 3) Focus groups and in-depth interviews of mothers /caregivers revealed key reasons as to how participants understood the

Project in terms of alleviating malnutrition in their children, and the impact that it could have for them and the programme in the long term.

However non-participating mothers/caregivers (N=10 interviewed) did not fully understand the linkages between the Project and the nutritional status of their children, and identified the major constraints to participation as being lack of time, as well as lack of support from their partners. 4) Quantitative analyses of the socio -demo graphic and health status of the mothers/caregivers (N = 68) revealed that 75% had previously lived in a rural or peri-urban area of the Eastern Cape and that the mean length of stay in Bloekombos was 4.7 (SD 3) years. Mothers had a mean of 7.5 (SD 2.3) years of schooling, 38% were married, 35% were HIV positive and 34% previously had a child who had died. Their median monthly income was R300 (range 0-1600). No significant differences were detected in the socio-demographic status between participants and non-participants. Of the children enrolled into the project, 52% were underweight, 54% were stunted and 8% were wasted. Levels of underweight, wasting and stunting were similar for project (N=35) and non-project (N=33) children. At a mean follow-up of 8.5 (SD 4.4) months, the levels of underweight for the project and non-project children were 25% and 24%, respectively with a significant decline in the percentage of underweight for both groups (p< 0.05). Reasons for the positive impact on the growth of the children in both groups is discussed further in the report.

Conclusions:
The multidisciplinary participatory approach to the project and the evaluation of it was generally successful. The multifaceted approach and qualitative research methods were useful for the formative evaluation of this local health facility and community-based programme. Quantitative analyses proved to be positive for both project and non-project children with no significant differences being found between the two groups.

Recommendations:
Policy makers need to be aware of the difficulties that are encountered in developing and evaluating community- based nutrition programmes. Improvements in the growth status of the children enrolled should not constitute the sole criterion upon which success of these programmes are based. Attention must be given to addressing resource constraints such as staff shortages, while ensuring adequate support particularly with respect to social development, when replicating these programmes in other settings.