A total of 10 interviews were conducted, each between 45 - 60 minutes, allowing for an in-depth discussion. Table 1 below provides a breakdown of the socio-demographic and basic information of the study group. All the participants were female, with the lowest level of education being that of Grade 7 and the highest Grade 11. Nine out of ten mothers were working, and therefore earning an income. Additionally, all the participants were carrying out all the shopping and cooking for the family.
Table 1 Socio-demographic and basic information of qualitative study participants (all female participants)
The high levels of poverty in South Africa is linked to multiple factors such as high levels of unemployment, low levels of employment growth and also a seeming increase of inequality. Research conducted in 2016 shows that in a total population group of 55.9 million people, 29 733 210 lives below the Upper Bound Poverty Line of R1 036.07 (17). Thus, more than half of the population has insufficient income and as a result, they are unable to supply their basic needs such as food, education, transport and shelter. Furthermore, it is estimated that more that 12 million people live below the poverty line(17). The poverty line is an indication of the cost required for one person to meet their daily calorie requirement of 2,100 calories; In South Africa, this cost is R445.55 per month (17). None of the women in the current study earned more than the minimum wage in South Africa or had the total minimum wage in the household at the end of the month through another family members support. As the primary caregivers were not earning the monthly minimum wage, and this may have a significant impact on their family as it hinders their ability to provide a diet which is both healthy and nutritious. From the results of the data analysis, five themes emerged. These are daily access to food, unemployment hindering the provision of healthy nutritional meals, fast food meals as part of the family mealtime, changes in diet from the week to weekend, and understanding their children’s weight status. Findings regarding these five themes are presented below.
Daily access to food
This theme was important as it highlighted the preferences of food in families as well as the food choices that were made daily based on the available financial resources. Daily access to food was not chosen for its health benefits but rather to fill the hunger need experienced.
Results show that challenges exist in the families regarding the access to a healthy diet. These challenges are due to a limitation in resources, such as money, or that the mother is out working, and the father does the shopping and cooking in the house. This was prevalent in 7 of the 10 interviews. As reported by the mothers:
“There have been many times where there is no food or money in the house. We then need to ask friends to share with us and when we have we give to them.Money is split for everything and we have a monthly food budget. Sometimes it does not last the month as things are expensive so then we have to borrow and pay that money back again”.
(Caregiver—grandmother: age 57, Participant 5, seven children - ages 7, 10, 12, 14, 15, 17, and 21 years old.Different fathers who are drug addicts and only one mother of two of the children is present, but she is unemployed).
“The father makes sure that if there is no food in the house that he goes out and looks to borrow or ask somebody else so that the children as able to eat at least. We do get a grant for one of the children as they are disabled but it is not a lot. Things are so expensive, but I make sure that he eats everyday even if I must go without something”.
(Mother: age 39, Participant 2, seven children - ages 3, 6, 10, 13, 19, and 22 years old all living at home).
“As I am the one who is working but my husband, he is the one that goes to the shop though and decides what we can buy as I am at work. He is doing most of the cooking at the moment and it is just quick things as he is not a good cook, but he is trying. He likes to fry things or just a lot of tin food things with bread.”
(Mother: age 39, Participant 6, three children - ages 7, 10, and 16 years old, father unemployed but at home.)
“We make a lot of cooked food that will also stretch - rice food with potatoes and a little meat mixed with soy, so more people can eat with a gravy. So, it is like you have a full plate of food. And then there is a little food left for the next day. I do try and buy fruit but not every week - maybe just around the time of payday and frozen veg because then it lasts longer”.
(Mother - age 30, Participant 9, two children - ages 10 and16 years old.)
Not much focus was placed on the use of various vegetables in cooking other than potatoes, carrots, butternut which are then mashed in the food to make a gravy or used to add bulk to a stew that does not have many other vegetables in it. Many primary caregivers indicted that broccoli was not cooked often, if at all. Other green vegetables such as green pepper was used to start a pot of food, along with an onion. Avocados were bought in season from the corner shop as they were then cheap. However, they were never bought prepacked from a big supermarket as then they were too expensive.
Unemployment hinders the provision of healthy nutritional meals
It is important to understand how unemployment affects the nutritional needs of the family. Within this context, it is necessary to determine who is responsible for the nutritional needs of the family as well as how this affects the family. In the interviews with the primary caregivers, unemployment of one or more family members resulted in a large amount of stress when it comes to having to provide for the family as this responsibility then largely falls on one main member. This stress is amplified when it is a large family. In most cases, the mother or the grandmother was the main provider. Adding to the financial responsibility of caring for the family, the caregivers still need to continue the normal provision of care for the family e.g. washing, cleaning, cooking and walking children to school.
“Their father does not work now. And so, I am the only one who is working. I make about R750 a month which does not stretch very far into the month”.
(Mother: age 39, Participant 6, three children - ages 7, 10, and 16 years old. Father unemployed but at home).
“No child support from the father. There is no role of the father being fulfilled. He is not there where the son stays. The son lives with his grandmother, so I send money to her. He just left us all and I couldn’t have all the children, so I sent my son to live with his grandmother. But I still send money for his food”.
(Mother: age 30, Participant 9, two children - ages 5 and 10 years old.)
“I don’t even know where some of the children’s fathers are. So maybe they do not care.So we need to borrow money all the time to cover us for the month when we run out of money. My one grandchild and I are the only ones working. He is earning a weekly wage helping on a building site. So, it is just us providing money for 10 people in the house”.
(Caregiver—grandmother: age 57, diabetic, Participant 10, seven children - ages 7, 10, 12, 15, 17, and 21 years old. Different fathers who are drug addicts, only one mother of two of the children is present but she is unemployed and suffers from epilepsy.)
Discussion in general lead to the primary caregivers explaining the process they would follow when undertaking food shopping. The first step in the process was to check how much money they had for the month. This needed to be checked as often they had outstanding debts from having borrowed money for food the month before. Once this was completed, they would examine any sales that were being advertised from bigger food shops outside of their area. If more than 3—4 items were earmarked at shops that were near one another, they felt relief as this meant they would not have increased transportation costs. If their debts were too high from borrowing money the previous month, they would then conduct a much smaller shop from the corner community grocer. For a bigger shop, they would make sure that an older family member was able to join them who would then be able to assist with carrying the goods. The participants also indicated that they prevented taking the younger children with them as challenges would arise with their children requesting items that were not on the shopping list. When these challenges did arise, this then raised the irritation levels of all who were part of the shopping trip.
Questions that were specific to understanding what comprised a healthy diet was interpreted by some as understanding words to describe healthy foods. Some participants indicated that they had trouble understanding healthy words used on packaging, while others did not read food packaging at all. Results highlight that at times nutritional knowledge decisions are made when buying food and at other times the cost of food played a factor in food choice. An example being if the food was cheap and the packaging said anything along the lines of it being healthy, natural, good for you, high in fiber and enriched with vitamins they would buy the food; or if food was being sold in the bargain bin or fridge due to it expiring on the day of purchase.
“I check just for expiry dates, sometimes the food is cheaper because the next day it is expired. I do not know what all the information on the label means. I do look for things that say healthy, natural, added vitamin C, D or calcium as he needs that for his bones”.
(Mother: age 30, Participant 9, two children - ages 5 and 10 years old).
“I sometimes buy things that say they sugar free if it is cheap, sometimes they have specials on it. Look at food that say low fat, cholesterol free, or trans-fat free, I then buy those because fat is not healthy. Or packets that say good for children - cornflakes and oats, rice krispies”.
(Mother: age 39, Participant 6, three children - ages 7, 10, and 16 years old.)
“Expiry dates. Check for Halaal sticker, also if there is soya in the food as nobody in the house wants to eat soya. I try to buy what is on my husband’s diet sheet that he got from hospitals, but the food is expensive”.
(Caregiver—grandmother: age 57, diabetic, Participant 10, seven children - ages 7, 10, 12, 15, 17, and 21 years old. Different fathers who are drug addicts, only one mother of two of the children is present but she is unemployed and suffers from epilepsy.)
For one caregiver her husband did the shopping and she was not sure what he looked at when selecting food.
“I do not know if my husband reads the labels, I don’t go to the shop. But not really a big shop, not a monthly shop. Just when there is something that is needed at the corner shop. There is not really money for a big shop”.
(Mother: age 39, Participant 6, three children - ages 7, 10 and 16 years old.
Changes in diet from the week to weekend
In understanding food preferences and preparation styles it was important to ask primary caregivers if there was any difference or changes between their week and weekend meals, along with their consumption of nutrient dense foods such as fruit, vegetables, and meat. Participants were also asked if there was an increase in the consumption of less nutrient dense foods such as processed lunch meat, carbonated sugary drinks, and chips. However even with probing questions such as "how many fruit and vegetables are eaten per week?”, it was not always clear in the interview as to the actual fruit and vegetable consumption by the children. All families confused carbonated drinks with a preferred brand being sold in the area at a much cheaper price. Bulk chips were bought on the way to school if there was no time for breakfast. These chips had no brand name and were sold in clear packets at the corner shop.
“I do not always have breakfast for the children because it is a rush to get them all done. So, while we walk to school we stop at the shop and buy small freshly made pies, chips and a cooldrink to share. On the weekend, we will have bread and scrambled eggs if there is. I always try and cook a big meal on a Sunday like roast chicken and potatoes.”
(Caregiver—grandmother: age 55, Participant 10, two children - ages 7 and 10 years old).
“A weekday we try where everything is eaten - fish (frozen and crumbed box), chicken, but a lot of red meat it is very expensive. They have luxuries like chips and cooldrinks because they are children and they are very active. They don’t really like vegetables, so I do not buy it otherwise they waste it.They like potatoes and then I cut it into chips, on a Friday evening.”
(Mother: age 48, Participant 8, five children - ages 14, 19, 21, 25, and 28 years old).
“During the week the children love pasta, they will eat pasta every night if they could. I can mix the pasta with anything - cold meats or some chicken. They do love fruit, so it is bought as well. Luxuries are at home, so they buy for themselves and I also buy to keep in the house. Weekend they eat differently. She goes to friends, so she will eat take away - I do not buy a lot of takeaways as my husband did not like it. He wanted home food every day. But since he is gone, she just wants to eat pizza and different things. If she does not like what I make she will eat noodles and bread every day.”
(Mother: age 45, Participant 7, three children - ages 16, 18, and 22 years old.)
The above mother was the only one out of the sample that was able to highlight her children’s love for fruit. However, she was not able to quantify how many servings of fruit per day or week they have. It was indicated that it was likely one child would eat more fruit than the other children when coming home from school, or that it was being shared with friends.
Fast food meals as part of the family mealtime
It was important to note the behaviour of family from the week to weekend with respect to meal preparation and whether there was a difference in food choice based on their being more time for meal preparation, that the whole family was at home at various meal times, as well as if Sunday was seen as a special day for bigger meals to be shared. For some families, fast food meals were seen as a reward or brought into the household as part of a celebration. However, none of the families had fast food on a weekly basis as it was cited as being expensive for a large family and was not able to stretch into another meal for the next day.
“Maybe occasionally, not even per week. Maybe just once a month. Or when it is a child’s birthday. But then it is a parcel of fish and chips with rolls always close to payday.”
(Caregiver—grandmother: age 57, Participant 10, seven children - ages 7, 10, 12, 15, 17 and 21 years old.)
“Maybe 3 times a month - a Gatsby or a special occasion on a birthday”.
(Caregiver—grandmother: age 55, Participant 10, two children - ages 7 and 10 years old).
“No takeaway during the week maybe there is a special for KFC and then we buy it or we make a KFC kind of chicken.”
(Mother: age 48, Participant 8, five children - ages 14, 19, 21, 25, and 28 years old).
“There is no difference from the week and weekend food - we just have to eat what there is. Dahl, tin fish, curry anything that stretchers with rice to feed a lot of people. No takeaways there is no money for that”.
(Caregiver—grandmother: age 57, Participant 5, seven children - ages 7, 10, 12, 15, 17 and 21 years old.)
Understanding the child’s weight status
The above theme was important to highlight as it allowed the researcher to understand if primary caregivers were able to notice physical differences in their children due to their dietary needs not being met or over met due to available food sources. During questioning, the primary caregivers were willing to share their understanding of their children’s weight status, with a few caregivers stating that they thought of themselves as fat, while their children were not. However, this perception was based on the other children in their class or home street and therefore was not necessarily a true reflection. None of the primary caregivers were able to share the weight of their children in kilograms or when last they had a weigh in at the clinic or school nurse.
“Normal weight. He is tall for his height. Taller than the other children his age in his class.
(Mother: age 30, Participant 9, two children—ages 5 and 10 years old.)
“My daughter is overweight, we went to the doctor when her father died, and they did some tests and they told her she is big for her age and needs to start watching what she is eating. I do not know what her weight is, but you can see she is bigger than the other children who are 16 years old. She is bigger than I am.”
(Mother: age 45, Participant 7, three children - ages 16, 18, and 22 years old.)
“Just the 6-year-old she is very thin and tall based on the build of the other children. She also does not want to eat a lot. So, one has to beg her to eat food at times.”
(Mother: age 39, Participant 2, seven children - ages 3, 6, 10, 13, 19, and 22 years old, all living at home).
“She is normal weight, she also does dancing at school, so she does exercise.”
(Mother: age 48, Participant 8, five children - ages 8, 10, 12, 16, and 19 years old.)
“They all normal weight they are not fat children, they can wear each other’s clothes.”(Caregiver—grandmother: age 57, Participant 5, seven children - ages 7, 10, 12, 15, 17 and 21 years old.)
Nutritional skills and understanding of mothers and primary caregivers
The children’s weight, based on the descriptions of primary caregivers, seems to be normal at their relevant stages of development. However, the caregivers themselves are suffering from diseases and obesity. Most of the women interviewed claimed that they were responsible for managing the family’s diet which includes budgeting meals, shopping, preparing as well as serving meals. While questioning the mothers and grandmothers on what they provide for their children in relation to food selection, many indicated that there was a need to understand what is healthy, what is a healthy food (a carbohydrate was indicated), and how to cook on a limited budget but still make sure they as a family are all getting enough nutrients.
“How to feed children, because you can make the food but then they do not want to eat what is healthy. I am diabetic and the hospital they gave me a list of what to eat. I cannot buy all those things. It will be too expensive, so I try to buy some of the things, then we can all eat healthy, but they do not want to eat a lot of veg. They say it doesn’t taste nice. Maybe I need to know how to make it differently. Classes where you learn, not just pieces of paper that you throw away. How do I as a diabetic buy good food if it is so expensive?”
(Caregiver—grandmother: age 57, Participant 5, seven children - ages 7, 10, 12, 14, 15, 17, and 21 years old. Different fathers who are drug addicts and only one mother of two of the children is present, but she is unemployed).
“How to make good healthy food choices and why. They tell you sometimes you must eat less salt but there is salt in everything. Maybe a course for everyone in the family so the children also understand why they are being given the food they are given. It is maybe important to know when to buy foods in season and the quantity of food to buy for a family and how then to make sure they are eating enough or too little.”
(Mother: age 30, Participant 9, two children - ages 5 and 10 years old.)
“Yes, I dish the food and say they can have a little first and if they finish it and want more, they can have so that we do not waste. I eat whatever there is left or just a lot of white bread and coffee, but I take my medication for my diabetes. But how do I make the food with a little money?”
(Mother: age 39, diabetic, Participant 2, seven children - ages 3, 6, 10, 13, 19, and 22 years old, all living at home.)
“I shop, one of the boys will take me to the shop with a car. I will then cook all the food. I love cooking, so I sometimes read in magazines what I can make for us all.”
(Mother: age 48, Participant 8, five children - ages 14, 19, 21, 25, and 28 years old).
“I prepare all the food and dish for them in the evening, if you do not want to eat what is made there is no replacement, so they know this. I am teaching them how to make food also as they help me in the kitchen. If I get older one of them must then take over the cooking.
(Caregiver—grandmother: age 57, Participant 5, seven children - ages 7, 10, 12, 15, 17 and 21 years old.)