Addressing the study objectives

4.2.1 Risk factors associated with SAM

The first objective of this study was: to determine the risk factors and the degree to

which they are associated with severe acute malnutrition in children under five years old who reside in Region B and surrounding referral areas of the City of Johannesburg.

A chi2 test (or Fisher’s exact, where relevant) was used to determine if there was an association between nutritional status and the different variables. The variables that had an association with nutritional status were said to be a risk factor for SAM if their prevalence was significantly higher in the SAM group compared with the well- nourished group.

Based on this, the following were identified as risk factors for SAM: An age of 12–24 months; an HIV-positive diagnosis; previous malnutrition diagnosis; inappropriate choice of replacement feeds after early cessation of breastfeeding; acute gastroenteritis (AGE) diagnosis; diarrhoea in the past year; dehydration on

admission; immunisations not up-to-date; Vitamin A doses missed; no deworming in the past year; early or late introduction of solids; early introduction of starchy foods; the daily consumption of meat, spices and sweets; force-feeding when food was refused; having more than three children in the house; an unskilled working father; an outside water source; no electricity; and informal housing. The SAM participants also had the lowest rates of exclusive breastfeeding (4–6 months).

4.2.2 Risk factors associated with moderate malnutrition

The second objective was: to determine the risk factors and the degree to which they

are associated with moderate malnutrition and/or growth failure in children under five years old who reside in Region B and surrounding referral areas of the City of Johannesburg.

With respect to SAM, the variables that had an association with nutritional status were said to be a risk factor for moderate malnutrition if their prevalence was significantly higher in the moderately malnourished group compared with the well- nourished group.

Based on this, the following were identified as risk factors for moderate malnutrition: An age of 12–24 months; having more than three children in the house; an unskilled working father; an outside water source; no electricity; informal housing; early introduction to solids; daily consumption of meat, sweets and spices; force-feeding a child on refusal of food; a diagnosis of AGE; diarrhoea in the past year; dehydration on admission; a positive HIV diagnosis; and previous malnutrition diagnosis.

4.2.3 Comparison of risk factors associated with SAM and moderate malnutrition

The final objective was: to compare the risk factors associated with the following

groups: (i) severe acute malnutrition, (ii) moderate malnutrition and growth failure and (iii) well-nourished, in children under five years old who reside in Region B and surrounding referral areas of the City of Johannesburg.

As evident above, some risk factors were associated with both SAM and moderate malnutrition. These included: An age of 12–24 months; more than three children in the house; an unskilled working father; an outside water source; no electricity; informal housing; early introduction to solids; daily consumption of meat, sweets and

spices; force-feeding a child on refusal of food; a diagnosis of AGE; diarrhoea in the last year; dehydration on admission; a positive HIV diagnosis; and previous malnutrition diagnosis. All these factors (except for unskilled working father) had a higher prevalence in the SAM group than the moderately malnourished group.

When comparing the participants with SAM and the participants with moderate malnutrition, the SAM participants had more of the factors present that were significantly associated with nutritional status. This indicates that more factors occur in combination in participants with SAM than in participants with moderate malnutrition. This means that malnutrition was more likely to be more severe if an individual had more risk factors present, which highlights the fact that multiple factors need to be addressed to minimise the occurrence of SAM.

Some factors were associated with SAM but not with moderate malnutrition. These factors had a higher prevalence in the SAM group but similar prevalence in both the moderately malnourished group and the well-nourished group. These factors were: exclusive breastfeeding less than four months or more than six months; inappropriate replacement feeds after early breastfeeding cessation; the late introduction of solids; and immunisations, Vitamin A and deworming schedules that were not up-to-date.

4.3 Conclusion

The findings of this study provide insight into the risk factors associated with SAM. According to the UNICEF framework, many of the factors that are specific to children diagnosed with SAM are immediate causes of malnutrition. This emphasises the fact that an accumulation of underlying debilitating causes affect the wellbeing of a child over time. Since factors associated with SAM are diverse, there needs to be a focus on multiple interventions in order to reduce its prevalence.

This research showcases the importance of aiming these interventions at the first 1 000 days of a child’s life. Children’s health deteriorates with poor breastfeeding practices, insufficient dietary intake and suboptimal primary health care, which emphasises the importance of focusing on interventions relating to these areas. The information from this study can also be used to timeously identify vulnerable children in order to prevent development of SAM.