Primary caregivers’s provision of a healthy diet in a resource constrained environment in South Africa.


 Background: Primary caregivers are frequently hearing mixed messages about healthy eating therefore, making it essential for these caregivers to have a clear understanding of what healthy eating is. The lack of understanding of what constituents healthy and nutritionally dense eating has not been investigated in low income families South Africa. Methods: A qualitative, cross-sectional study involving 10 in-depth interviews. Participants were purposefully selected. Data was analyzed manually using the thematic framework analysis method. The data was analyzed by means of thematic framework analysis Results: Primary caregivers struggled to provide daily access to food for their children, and at times would turn to family and friends for assistance in meal provision either through actual food or short-term financial assistance. For caregivers, limited resources impacted the ability of being able to provide a healthy diet. However, it was indicated that while shopping, caregivers looked for foods that were stated to be healthy and low in fat as well as for vitamins. These items were only accessible if they were cheap. Unemployment of fathers as well as absent fathers placed a great burden on mothers and grandmothers in the study group as this meant they needed to provide the nutritional, financial, emotional and physical care of the family. Conclusion: Primary caregivers’ food choices were based on the availability of resources, the cost, as well as access to quality food in the surrounding areas. It was also limited to what they were able to carry. Based on the reflection of primary caregivers, it was indicated that the consumption of processed foods and refined carbohydrates was high, while that of fruits and vegetables was low. Primary caregivers wanted the opportunity to learn about what a healthy diet is and how to be able to provide one for their family with their limited financial resources.

influenced by primary caregivers (1,2). The parental feeding practices which parents use to control how much and when their children eat, plays a significant role in the development of children's eating behaviours (3). This can also be done through parents' perceptions. According to Taylor and Medina (2013) (4), perceptions refer to an individual's truth which is obstructed by their worldview and influenced by their illusions, preferences and beliefs. The parental beliefs and knowledge parents have of 'child health' is often influenced by cultural and social norms, which on occasion, oppose official health recommendations (5). It appears that parents tend to be more concerned about the short-term health benefits than the long-term health consequences. For example, more focus is placed on getting the child to eat, sleep and stop crying, and less thought is given to the long-term outcomes such as disease and obesity (3). In addition, parental feeding practices may vary depending on numerous factors such as ethnicity and socioeconomic status (6). Studies have shown that children and adolescent of a low socioeconomic position (SEP), are more likely to consume poorer diets as their diets often consist of a higher intake of snacks, fast food and sweetened drinks, and very little fruits and vegetables are consumed (6). Thus, indicating that in developing countries, it seems that not much is known about what impact child-feeding practices, has on children's nutritional status (7).
South Africa is country regarded as food secure country however a large number of South Africans households are food and nutrition insecure (8). Research shows that 26% of South African households (approximately 13-15 million people), have inadequate or severely inadequate access to food (9).
Consequently, the South African government has employed numerous strategies and interventions which include support grants, feeding schemes at schools and free access to health services for children, pregnant and breastfeeding women as a means to alleviate poverty and food and nutritional related challenges such as extreme hunger, malnutrition, obesity, household food and nutrition insecurity (10). These programmes are continuing to address the need in several communities.
Examples of typical food choices in resource-constrained households, such as "a single staple, corn prepared in numerous ways, supplemented by dried beans, negligible amounts of milk and occasionally meat and wild greens, with seasonal additions of potatoes" (11). A 2017 General Household Survey, done by Stats SA reported that one in five South Africans reduce the size of their meals and/or skip meals at least five days each month (12). Herewith, since primary caregivers are key players in the child's health, it is important that their perceptions of healthy diet being provided to children needs to be studies in more detail. Thus, the examination of their actions and how they navigate food choices is necessary. The aim of the current study was to explore primary caregivers' perceptions of a healthy diet in a low-income community in Cape Town. Research was conducted through interviews.

Research Location
The study was conducted in Manenberg, Cape Town, South Africa. Manenberg is a predominantly coloured community which was created in 1966, when the apartheid government enforced the forced removal programmes. The community is located on the Cape Flats which is approximately 20km from the city center of Cape Town and is currently identified as a place where gang members roam freely and wield enormous power over the community. Drugs are readily available on the streets, and unemployment is high (13). Manenberg had a population of over 61 000 people in the last national census conducted. Of this population, 40 452 fell into the 'working age'  category. Amongst this group, 35% (13 962) were classified as employed, 20% (7 923) as unemployed and 46% (18 567) as 'not economically active'(14). The study site was initially aimed at three high schools in the area, which were purposefully selected based on the gangs in the environment and unemployment rates.
Primary caregivers were instructed to meet at one school in the area, as this was regarded as a safe zone. On the day of the interviews, caregivers from only one of the three schools were present as there was gang violence in the area. The primary caregivers indicated that they did not feel safe walking from one area of the community to the other in order to conduct the interviews.

Population and Research Design
For this study, a cross-sectional qualitative research design was used. By using a qualitative research design, the researchers' main intention is to better understand a phenomenon by analyzing the firsthand experiences of individuals' and by understanding the importance of their unique viewpoints and experiences regarding the phenomenon studied (15). The qualitative techniques that were used for this study included in-depth individual interviews. A total of 10 interviews were conducted with primary caregivers who had children between the ages of 3 -18 years old. A description of the purpose of the research was provided to the participants. Time was allowed for the participants to read the information and decline the interview or sign the consent form, therefore agreeing to participation. Interviews were conducted by the first author and lasted 45-60 min. Open-ended questions set in an interview schedule was were used to guide the interviewer to collect relevant information. Information was also audio recorded and transcribed verbatim. Interviews took place in both English and Afrikaans (which was the main language of some of the participants). Questions focused on nutritional diet provision, fast food meals, challenges to a healthy diet, as well as the perceptions of primary caregivers' regarding their child's weight. The answers were not limited to the children in the target age range (3-18 years old); if children fell outside this range, questions centered on the child closest to it.

Data analyses
Each audio recorded interview was transcribed from Afrikaans and then translated to English by the interviewer who is bilingual. Each transcript was read at least twice, and core concepts were identified. A thematic analysis was then used to analyze data manually (16). This allowed the researcher to place focus on the interpretation of the numerous experiences, histories and beliefs of participants, thereafter, identifying thematic patterns from the data. The themes found in By extracting themes from the data, the researcher is able to obtain the essence of the phenomenon and with regard to the research aims and question (15).

Results
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. 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". "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". (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".
"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". "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." "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".
"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."  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." "She is normal weight, she also does dancing at school, so she does exercise."

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." "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.

Discussion
Research suggests that the poor are exposed to an unhealthy diet as foods which are high in refined grains, added fats and sugars tend to cost less that healthy foods such as lean meats and fresh fruits and vegetables (18). This seems to be consistent with the findings in the current study as primary caregivers opted for meals which are high in refined white carbohydrates such as bread, white rice, and packets of soup to make gravy in order to feed a larger family. Studies have shown that in some countries, such as Brazil, there has been an increase in the involvement of processed foods in the availability of food in households. In addition, a study conducted by the Family Budget Survey reported that between 2002-2003 and 2008-2009, the consumption of cookies, ready-made meals and soft drinks increased by 10%, 40% and 16% respectively (19).
Brazil and South Africa, along with Russia, India, and China, are part of the BRICS countries which have been named as emerging economic countries. The BRICS alliance seeks to find a "new way" to attain progress and development for its approximately 3 billion people (20). South Africa is part of this group due to it being seen as the having large degrees of inequality (20). Despite the social, economic and cultural rights included in the 1996 South African constitution, the rate of inequality is still high (21). Figure 1 illustrates how social protection interventions can directly contribute to an ideal nutritional status which may be obtained by consuming a healthy diet for optimal health. Social protection is generally understood to be interventions which aim to reduce social and economic risks and vulnerability, and in turn, also lessen extreme poverty and deprivation in communities. This is a clear focus for the BRICS countries.  (22).
Families require both social and economic support for them to function adequately (22). This support may be especially challenging when families live in conditions which are not structurally conducive to a socially and economically supportive environment as the elimination of nutrition related health disparities remain a challenge. In addition to having insufficient funds to buy healthy and nutritious food, it is often found that people in low-income communities often live farther from grocery stores which may sell healthful foods, which also proves to be challenging. Moreover, evidence suggests that compared to those living in higher socioeconomic status (SES), people from lower socioeconomic status (SES) groups are more likely have diet which are high in fats, low in micronutrient density and evidently, they'll have a lower intake of fruits and vegetables (23).
Families in the current study did not place large emphasis on fruit and vegetable consumption because their children did not enjoy them. Vegetable preparation was mostly limited to potatoes.
Communities which have limited resources, will most likely choose food such as starchy vegetables, refined grains, added fats, fatty meats and sweets (24). This was indicated in the study group as their children preferred to not eat vegetables, that there was a preference for potatoes, and that it was expensive to buy a variety of fruit and vegetables for so many people in the household. Other factors which reduce dietary diversity, is the rising cost of living which includes an increase in prices of basic food items; thus more money will now be spent on staple foods such as bread and maze meal which leaves very little left to spend on other food groups (9). In addition, many families are also dependent on social grants. According to the 2012 StatsSA report (9), for poor families, social grants contribute 42% of household income and wages only contribute 32%; thus, social grants are an important source of income. All but one family in the current study had access to their own family vehicle. All other participants used public transport which limited the amount of food they could buy at a time.
Furthermore, access to transportation (public and private) is associated with access to healthy food choices, particularly in low-income communities.
In addition, there are still questions regarding whether an increase in access to healthy foods would in fact improve not only people's diets, but also their health (25). On the one hand, research shows that people who shopping at small convenience stores, is linked to higher rates of fruits and vegetables being consumed (26). For the current study this is true for some primary caregivers who opted to use public transport to leave the area and go to their preferred shops in order to bulk buy food items. This allowed them to have more control on spending as well as plan out meals for the month. On the contrary, numerous studies have found no correlation between fruit and vegetable consumption and supermarket proximity (27). This may need to be further explored through health behaviour analysis.
The impact socioeconomic status has on health behaviour is complex, as various factors coming into play. These factors can include economic resources, perceived stress, tastes/preferences, discounting of future value, knowledge, and personality factors which have been proposed to explain the relationship between SES and a variety of health behaviours (25). Moreover, primary caregivers' ability to accurately the weight status of their child is important. For example, a barrier to behavioural change is underestimation and the mother's ability to recognize when the child is becoming overweight is regarded as the key to childhood obesity prevention (26). When parents compare the weight of their child to that of other children, there may be a shift in social norms regarding body weight may occur (27). Studies have shown that between 50% and 95% of parents fail to identify that their child is overweight whereas 65% of parents of underweight children fail to identify their child as being underweight (28). In the current study, primary caregivers were not able to accurately provide their children's weight status as they did not know what it was, and instead based it on observation of how they physically compared to others in their school class, family or neighborhood street. Parents' perception of their child's weight status can influence their decision to have their child participate in a weight control program that focuses on exercise and correct eating (29). While parental support on healthy behavior can positively influence children's weight status, there is a dissonance between parental perceptions and the actual weight status of their children (30). A Canadian study which included 355 child-parent pairs found that a total of 38% of parents could not correctly determine their child's weight status (30).
In addition, many middle-and low-income countries, such as South Africa, are often faced with double burden of diseases where being overweight can contribute to the burden caused by undernutrition and communicable diseases. As a result, of undernutrition, children are often faced with stunted growth and underdevelopment whereas being overweight can lead non-communicable diseases including cardiovascular illnesses and problems (31). In some countries such as India, it is claimed that people link being overweight with wealth and happiness and also illustrates higher social mobility to a higher status, although there are no studies to support this (32). Therefore, supporting parents in increasing their nutritional knowledge and diet provision when they are in a resource constrained environment could lead to improved nutritional outcomes. The current study confirms that a disconnect between diet and health among low-income women calls for nutrition interventions that educate low-income families on inexpensive, healthful eating in a structured environment, and dietdisease relationships (25). Previous studies (33) also found like the current study participants clearly expressed the desire for information on food choices, and how to provide nutritional meals on a budget. Beliefs held by primary caregivers are also important to consider when attempting to modify caregivers' behaviours regarding food provision, specifically around how much food should be provided for the children's specific age and growth need as well as the types of food which should be eaten.
Several limitations were considered while interpreting the findings in the study namely while the primary caregivers were approached from the area, they may not represent the community fully.
Further questions could have focused on, the environment in which they live and how the environment affects the availability of food for the family and the degree to which they consider their diet, weight, and health status influenced by their socioeconomic status. Deeper exploration into shopping habits is recommended as this is a relatively new area within the public health arena. This should be conducted, with marketing research focus, which could provide detail as to the selection habits of primary caregivers when healthful options are available.

Conclusion
Primary caregivers' food choices were based on the availability of resources as well as the access to quality food in the surrounding areas. It was also limited to what they were able to physically carry when going to the bigger shops outside of the community in which they lived. Based on the reflection of the primary caregivers, consumption of processed foods such as sugary carbonated drinks and refined carbohydrates such as bread was high, while that of fruits and vegetables were low. The results are useful to identify the specific areas as to where interventions need to be focused in order to improve dietary choices and food preparation skills when primary caregivers are faced with limited resources. Further to this there needs to be an exploration the involvement of fathers in the selection and preparation of a healthy diet.  Figure 1 Conceptual framework of malnutrition and possible entry points for social protection interventions (22).