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Ecology of Food and Nutrition Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/gefn20
Household Food Security and Hunger in Rural and Urban Communities in the Free State Province, South Africa a
Corinna M. Walsh & Francois C. van Rooyen
b
a
Department of Nutrition and Dietetics, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa b
Department of Biostatistics, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa Published online: 31 Dec 2014.
Click for updates To cite this article: Corinna M. Walsh & Francois C. van Rooyen (2015) Household Food Security and Hunger in Rural and Urban Communities in the Free State Province, South Africa, Ecology of Food and Nutrition, 54:2, 118-137, DOI: 10.1080/03670244.2014.964230 To link to this article: http://dx.doi.org/10.1080/03670244.2014.964230
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &
Downloaded by [New York University] at 07:09 27 April 2015
Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Ecology of Food and Nutrition, 54:118–137, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0367-0244 print/1543-5237 online DOI: 10.1080/03670244.2014.964230
Household Food Security and Hunger in Rural and Urban Communities in the Free State Province, South Africa CORINNA M. WALSH Department of Nutrition and Dietetics, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
Downloaded by [New York University] at 07:09 27 April 2015
FRANCOIS C. VAN ROOYEN Department of Biostatistics, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
Household food security impacts heavily on quality of life. We determined factors associated with food insecurity in 886 households in rural and urban Free State Province, South Africa. Significantly more urban than rural households reported current food shortage (81% and 47%, respectively). Predictors of food security included vegetable production in rural areas and keeping food for future use in urban households. Microwave oven ownership was negatively associated with food insecurity in urban households and using a primus or paraffin stove positively associated with food insecurity in rural households. Interventions to improve food availability and access should be emphasized. KEYWORDS hunger, food security, food shortage Household food insecurity remains a major concern in developing countries. Although national food security is assured in South Africa (Du Toit et al. 2011), 26% of households are food insecure, while 28.3% are at risk of food insecurity (Shisana et al. 2013). Despite projections that food security will improve in most of the world in the next 10 years—based on food production and import capacity of countries—the International Food Security Assessment 2011–2021 by the United States Department of Agriculture (USDA 2011) estimates that the number of food-insecure people in sub-Saharan Africa will increase by 17 million between 2011 and 2021. Address correspondence to Corinna M. Walsh, Department of Nutrition and Dietetics, Faculty of Health Sciences, University of the Free State, 205 Nelson Mandela Dr., Bloemfontein 9300, South Africa. E-mail: [email protected] 118
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According to the Food and Agriculture Organization of the United Nations (FAO 2006), food security is assured when “all people at all times, have physical, social and economic access to sufficient, safe, and nutritious food that meets their dietary needs and food preferences for an active and healthy life”. Thus, household food security exists when food is available, accessible and affordable within the household (Coutsoudis et al. 2000). Food insecurity results in hunger and undernutrition (Rose and Charlton 2002a). Ironically, undernutrition, specifically stunting in children, often co-exists with adult overweight and diet-related chronic diseases and micronutrient malnutrition, called the double burden of malnutrition. Being overweight is not necessarily a result of eating too much, but eating food of a poor quality due to poverty (FAO 2012). Both under- and overnutrition can have serious consequences for health and well-being. A number of factors threaten food security. On a global scale these include population growth, climate change and environmental degradation (Lloyd, Kovats, and Chalabi 2011; Wheeler and von Braun 2013). In developing countries, human immunodeficiency virus (HIV) infection (Frega et al. 2010; Pelser 2004), poverty and unemployment (Aliber 2003; Hendriks 2005; Pelser 2004) and poor access to food at the household level (Rose and Charlton 2002a; Shisana et al. 2013) are major challenges. Poverty and food security are intrinsically associated. In the South African context information related to the incidence and causes of poverty is complicated by differences in definition of the concept of poverty (Aliber 2003). Historically, food poverty has been associated with rural communities in South Africa (Kepe and Tessaro 2014; Neves and Du Toit 2013), but urbanization has resulted in a marked shift in poverty from rural to urban areas in the country (Fayne et al. 2009). Aliber (2003) has suggested that communities with access to agricultural resources “are less likely to become destitute, even though those resources are rarely sufficient to escape poverty altogether”. Although a number of studies have been conducted in South Africa to determine the prevalence of food insecurity (Frayne et al. 2009; Kruger et al. 2006; Lemke 2005; Lemke et al. 2003; Oldewage-Theron and Kruger 2011; Oldewage-Theron et al. 2005; Oldewage-Theron et al. 2006; Rose and Charlton 2002a, 2002b; Shisana et al. 2013), information on the extent, degree and causes of the problem still remains limited (Frayne et al. 2009; Hendriks 2005). In addition, similarities and differences in food insecurity in urban and rural contexts have not been explored. The aim of this study was to determine sociodemographic status, household food security and hunger in the rural and urban southern Free State province of South Africa, and to examine the factors that overlap and are different in the two settings. Knowledge of the various predictors of rural and urban household food security could provide insights for relevant interventions.
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C. M. Walsh and F. C. Van Rooyen
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METHODS This study formed part of the baseline phase of the Assuring Health for All in the Free State (AHA-FS) study which aimed to determine how living in rural and urban communities can influence lifestyles and health. The rural study commenced in 2007 in three rural Free State areas, namely Trompsburg, Philippolis and Springfontein, and the urban study commenced in 2009 in Mangaung. In rural areas, all households in the black and coloured townships were eligible to participate. In urban Mangaung the number of plots in the Mangaung University Community Partnership Program (MUCPP) service area was counted on a municipal map and included Buffer, Freedom Square, Kagisanong, Chris Hani, Namibia and Turflaagte. An estimate was made of additional squatter households in open areas. A stratified proportional cluster sample was selected, stratified by area and formal plot/squatter households in open areas. Using randomly selected X and Y coordinates, 100 starting points were selected in this way. From each starting point five adjacent starting households were approached.
Study Design A cross-sectional descriptive study was undertaken, followed by logistic regression with forward selection to select significant independent factors associated with food insecurity. Pilot studies were undertaken in two samples of five persons each, similar to the target group before the main survey in order to determine whether questions included in the questionnaires could be easily understood and to determine the amount of time needed to complete the questionnaires.
Measurements VARIABLES
AND OPERATIONAL DEFINITIONS
Variables included sociodemographic status (i.e., employment status, type of dwelling, water and sanitary conditions, assets, household income, and the proportion of income spent on food) and household food security (i.e., agriculture, crop and livestock ownership, the distribution of food between household members, the degree of hunger in the household, and the coping strategies implemented by households in times when experiencing food insecurity). METHOD
AND TECHNIQUES
Hunger was determined by means of the widely used and validated Community Childhood Hunger Identification Project (CCHIP) index (Wehler,
Food Security in Rural and Urban South Africa
121
Downloaded by [New York University] at 07:09 27 April 2015
Scott, and Anderson 1992). It is based on eight questions that indicate whether adults or children in a household experience food shortages, perceive food insufficiency and alter food intake due to resource limitations or inadequate food resources. Two additional questions related to whether the household was experiencing food shortage at the time of the survey and to coping mechanisms employed, were added. Due to the fact that a large number of households included in this study did not have children living in them, the CCHIP scoring system was, however, not applied and a scoring system based on the questions relevant to households was compiled. A structured interviewing technique was used to complete the questionnaires with one adult member of each household. In very few cases, Sesotho, Setswana and isiXhosa interpreters assisted the researchers.
VALIDITY
AND RELIABILITY
To assure validity, all questions were related to the objectives of the study and were based on issues discussed in relevant literature. Random samples of 10% of the rural and urban participants were interviewed a second time to determine reliability of questions. Where answers to questions differed with more than 20%, the question was considered unreliable. Only the questions related to keeping food for future use were found to be unreliable in the urban sample and responses to this question are thus not reported.
Data Collection The study protocol was approved by the Ethics Committee of the Faculty of Health Sciences, University of the Free State (ETOVS 21/07), the Free State Department of Health and local municipalities. Prior to data collection, information sessions for community leaders and members were arranged in each community. Trained fieldworkers from each community visited each household (in some cases on more than one occasion), explained the purpose of the study, and encouraged all eligible volunteers between 25 and 64 years of age to participate. Written informed consent was obtained from all participants in their language of choice. In addition to an information document, a participation letter was given to each selected household member to inform them of the date that they should be at the research venue to participate in the study, as well as the procedures that needed to be followed (for example, fasting on arrival). This letter could also be used to inform employers of the study and the reason for not being able to attend work on that particular day. On days of data collection, participants arrived at the research venue (community halls in rural areas and the MUCPP nutrition centre in the urban area) in a fasting state. The identity document of each respondent was
Downloaded by [New York University] at 07:09 27 April 2015
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screened to ensure that participants met the inclusion criteria for age and a data checklist was pinned to the clothing of each eligible participant. Each venue was arranged into stations where data were collected. These included stations for collection of blood and urine samples; a food station; medical examination; and anthropometric measurements. Results obtained from these assessments have been reported elsewhere (Groenewald et al. 2012; van Zyl et al. 2012). Thereafter, questionnaires related to the following aspects were completed: sociodemography (one per household); household food security (one per household); diet history (one for each participant); physical activity (one for each adult participant); reported health (one for every adult participant); and knowledge, attitudes and practices related to nutrition (one per household). After each station indicated on the data checklist had been completed, participants received a transport fee of R12 (approximately $1 USD at the time of writing the manuscript). No other remuneration was offerred. Participants with urgent medical conditions were referred to local clinics, local healthcare providers and healthcare centers directly after the medical examination. As soon as laboratory investigations were completed, communities were revisited by medical practitioners. During these follow-up visits, participants could obtain results of biochemical tests and referral letters, if necessary. If participants did not attend the individual feedback appointments, referral letters were delivered to participants by community workers.
Statistical Analysis Descriptive statistics, including frequencies and percentages for categorical data, and means and standard deviations or medians and percentiles for continuous data, were calculated. Differences between urban and rural groups were assessed by p values or 95% confidence intervals (CI) for the difference in rural and urban proportions. All analyses were performed by the Department of Biostatistics, University of the Free State, using SAS, version 9.4 (SAS Institute, 2012). For the purpose of this study, household food security was defined on the basis of the answers to four of the questions included in the hunger scale, namely (1) does the family currently experience food shortage? (2) does the household run out of money to buy food? (3) does the family cut the size of meals or skip meals because there is not enough food in the house? and (4) does the family eat less because there is not enough money for food? A score of > 2 out of the possible 4 classified the household as having a high risk for food insecurity. All other items on the hunger scale are only relevant to households with children and were therefore excluded. The following sociodemographic and food security variables related to households (and not to individuals) were considered for inclusion in the logistic regression model: type of dwelling (brick vs. other); has electricity
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(yes vs. no); water and sanitary conditions (own tap vs. other, and flush toilet vs. other); fuel used for cooking most of the time (electricity vs. other); household assets (yes vs. no for each asset); proportion of income spent on food (R100 [approximately $8 USD] or less vs. more than R100); and main source of income (wages and salaries or self-employment vs. other). Food security variables included: grow vegetables (yes vs. no); grow crops (yes vs. no); have fruit trees (yes vs. no); own livestock (yes vs. no); and keep food for future use (yes vs. no). The degree of hunger in the household at the time of the survey included whether the family was experiencing food shortage (yes vs. no); ran out of money to buy food (yes vs. no); cut the size of meals or skipped meals because of lack of food in the house (yes vs. no); and ate less because there was not enough money for food (yes vs. no). For all of these variables, a univariate analysis was applied to identify variables that could be included in the model (p < .15). In the rural sample, the following variables were identified: fuel used for cooking; electric, coal or gas stove in the household; primus/paraffin stove in the household; radio in the household; television in the household; money spent on food weekly; main source of income; growing own vegetables; and growing own crops. In the urban sample, the following variables were identified: the type of dwelling; microwave oven in the household; and keeping of food for future use. Logistic regression with forward selection (p < .05) was used to select significant independent factors associated with food insecurity.
RESULTS The median age of rural respondents was 48 years, which was slightly older than that of urban participants at 44 years. Most respondents were female (71.5% rural; 77.6% urban). A large percentage of participants had no schooling (27.4% rural; 20.9% urban) or only primary education (31.2% rural; 33.6% urban). The median period that participants had lived in a rural area was 45 years and in urban areas 15 years. In rural areas, respondents spoke Sesotho (33.5%), Afrikaans (31.7%) or isiXhosa, while in urban areas the majority spoke Sesotho (63.3%), most probably because urban households were almost completely black (98.7%), while 17.2% of rural households were of mixed ethnic origin, and 13.8% had more than one race living together in one household. In table 1 the sociodemographic status of households is described. In urban areas, significantly more respondents were unemployed (56.3%) than in rural areas, where 63.3% had a part-time or piece job (p < .0001).
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TABLE 1 Sociodemographic Status of Urban and Rural Households Included in the Study Rural
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n Employment status of respondent (R = 499; U = 387) Housewife by choice 13 Unemployed 127 Self-employed 9 Full-time wage earner (receive a salary) 34 Other (part-time job, piece job) 316 Husband/partner’s employment status (R = 499; U = 387) Retired by choice 9 Unemployed 47 Self-employed 1 Full-time wage earner (receive a salary) 53 Other (part-time job, piece job) 133 Not applicable (e.g. deceased) 256 Type of dwelling (R = 499; U = 387) Brick, concrete 417 Traditional mud 2 Corrugated iron 77 Plank, wood Other 3 Has electricity (R = 499; U = 387) 465 Drinking water from most of the time (R = 499; U = 387) Own tap 479 Communal tap 17 River, dam 1 Borehole, well 0 Other 2 Type of toilet household (R = 498; U = 387) Flush 468 Pit 2 Bucket, pot 16 Ventilated improved pit (VIP) 0 Other 12 Fuel used for cooking most of the time (R = 497; U = 387) Electricity 313 Gas 22 Paraffin 154 Wood, coal 8 Sun 0 Open fire 0 Home has a working: (R = 499; U = 387) Refrigerator and/or freezer 312 Stove (gas, coal, or electric) 387 Primus or paraffin stove 279 Microwave oven 101 Radio 381 Television 270
%
Urban n
%
p value for % difference
2.6 3 25.5 218 1.8 2 6.8 19 63.3 145
0.8 56.3 0.5 4.9 37.5
1.8 9.4 0.2 10.6 26.7 51.3
10 43 6 42 51 235
2.6 11.1 1.6 10.9 13.2 60.7
83.6 313 0.4 15.4 73
80.9
0.6 1 93.2 332
0.3 85.8
96.0 3.4 0.2 0 0.4
303 80 0 1 3
78.3 20.7 0 0.3 0.8
Ecology of Food and Nutrition Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/gefn20
Household Food Security and Hunger in Rural and Urban Communities in the Free State Province, South Africa a
Corinna M. Walsh & Francois C. van Rooyen
b
a
Department of Nutrition and Dietetics, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa b
Department of Biostatistics, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa Published online: 31 Dec 2014.
Click for updates To cite this article: Corinna M. Walsh & Francois C. van Rooyen (2015) Household Food Security and Hunger in Rural and Urban Communities in the Free State Province, South Africa, Ecology of Food and Nutrition, 54:2, 118-137, DOI: 10.1080/03670244.2014.964230 To link to this article: http://dx.doi.org/10.1080/03670244.2014.964230
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &
Downloaded by [New York University] at 07:09 27 April 2015
Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Ecology of Food and Nutrition, 54:118–137, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0367-0244 print/1543-5237 online DOI: 10.1080/03670244.2014.964230
Household Food Security and Hunger in Rural and Urban Communities in the Free State Province, South Africa CORINNA M. WALSH Department of Nutrition and Dietetics, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
Downloaded by [New York University] at 07:09 27 April 2015
FRANCOIS C. VAN ROOYEN Department of Biostatistics, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa
Household food security impacts heavily on quality of life. We determined factors associated with food insecurity in 886 households in rural and urban Free State Province, South Africa. Significantly more urban than rural households reported current food shortage (81% and 47%, respectively). Predictors of food security included vegetable production in rural areas and keeping food for future use in urban households. Microwave oven ownership was negatively associated with food insecurity in urban households and using a primus or paraffin stove positively associated with food insecurity in rural households. Interventions to improve food availability and access should be emphasized. KEYWORDS hunger, food security, food shortage Household food insecurity remains a major concern in developing countries. Although national food security is assured in South Africa (Du Toit et al. 2011), 26% of households are food insecure, while 28.3% are at risk of food insecurity (Shisana et al. 2013). Despite projections that food security will improve in most of the world in the next 10 years—based on food production and import capacity of countries—the International Food Security Assessment 2011–2021 by the United States Department of Agriculture (USDA 2011) estimates that the number of food-insecure people in sub-Saharan Africa will increase by 17 million between 2011 and 2021. Address correspondence to Corinna M. Walsh, Department of Nutrition and Dietetics, Faculty of Health Sciences, University of the Free State, 205 Nelson Mandela Dr., Bloemfontein 9300, South Africa. E-mail: [email protected] 118
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Food Security in Rural and Urban South Africa
119
According to the Food and Agriculture Organization of the United Nations (FAO 2006), food security is assured when “all people at all times, have physical, social and economic access to sufficient, safe, and nutritious food that meets their dietary needs and food preferences for an active and healthy life”. Thus, household food security exists when food is available, accessible and affordable within the household (Coutsoudis et al. 2000). Food insecurity results in hunger and undernutrition (Rose and Charlton 2002a). Ironically, undernutrition, specifically stunting in children, often co-exists with adult overweight and diet-related chronic diseases and micronutrient malnutrition, called the double burden of malnutrition. Being overweight is not necessarily a result of eating too much, but eating food of a poor quality due to poverty (FAO 2012). Both under- and overnutrition can have serious consequences for health and well-being. A number of factors threaten food security. On a global scale these include population growth, climate change and environmental degradation (Lloyd, Kovats, and Chalabi 2011; Wheeler and von Braun 2013). In developing countries, human immunodeficiency virus (HIV) infection (Frega et al. 2010; Pelser 2004), poverty and unemployment (Aliber 2003; Hendriks 2005; Pelser 2004) and poor access to food at the household level (Rose and Charlton 2002a; Shisana et al. 2013) are major challenges. Poverty and food security are intrinsically associated. In the South African context information related to the incidence and causes of poverty is complicated by differences in definition of the concept of poverty (Aliber 2003). Historically, food poverty has been associated with rural communities in South Africa (Kepe and Tessaro 2014; Neves and Du Toit 2013), but urbanization has resulted in a marked shift in poverty from rural to urban areas in the country (Fayne et al. 2009). Aliber (2003) has suggested that communities with access to agricultural resources “are less likely to become destitute, even though those resources are rarely sufficient to escape poverty altogether”. Although a number of studies have been conducted in South Africa to determine the prevalence of food insecurity (Frayne et al. 2009; Kruger et al. 2006; Lemke 2005; Lemke et al. 2003; Oldewage-Theron and Kruger 2011; Oldewage-Theron et al. 2005; Oldewage-Theron et al. 2006; Rose and Charlton 2002a, 2002b; Shisana et al. 2013), information on the extent, degree and causes of the problem still remains limited (Frayne et al. 2009; Hendriks 2005). In addition, similarities and differences in food insecurity in urban and rural contexts have not been explored. The aim of this study was to determine sociodemographic status, household food security and hunger in the rural and urban southern Free State province of South Africa, and to examine the factors that overlap and are different in the two settings. Knowledge of the various predictors of rural and urban household food security could provide insights for relevant interventions.
120
C. M. Walsh and F. C. Van Rooyen
Downloaded by [New York University] at 07:09 27 April 2015
METHODS This study formed part of the baseline phase of the Assuring Health for All in the Free State (AHA-FS) study which aimed to determine how living in rural and urban communities can influence lifestyles and health. The rural study commenced in 2007 in three rural Free State areas, namely Trompsburg, Philippolis and Springfontein, and the urban study commenced in 2009 in Mangaung. In rural areas, all households in the black and coloured townships were eligible to participate. In urban Mangaung the number of plots in the Mangaung University Community Partnership Program (MUCPP) service area was counted on a municipal map and included Buffer, Freedom Square, Kagisanong, Chris Hani, Namibia and Turflaagte. An estimate was made of additional squatter households in open areas. A stratified proportional cluster sample was selected, stratified by area and formal plot/squatter households in open areas. Using randomly selected X and Y coordinates, 100 starting points were selected in this way. From each starting point five adjacent starting households were approached.
Study Design A cross-sectional descriptive study was undertaken, followed by logistic regression with forward selection to select significant independent factors associated with food insecurity. Pilot studies were undertaken in two samples of five persons each, similar to the target group before the main survey in order to determine whether questions included in the questionnaires could be easily understood and to determine the amount of time needed to complete the questionnaires.
Measurements VARIABLES
AND OPERATIONAL DEFINITIONS
Variables included sociodemographic status (i.e., employment status, type of dwelling, water and sanitary conditions, assets, household income, and the proportion of income spent on food) and household food security (i.e., agriculture, crop and livestock ownership, the distribution of food between household members, the degree of hunger in the household, and the coping strategies implemented by households in times when experiencing food insecurity). METHOD
AND TECHNIQUES
Hunger was determined by means of the widely used and validated Community Childhood Hunger Identification Project (CCHIP) index (Wehler,
Food Security in Rural and Urban South Africa
121
Downloaded by [New York University] at 07:09 27 April 2015
Scott, and Anderson 1992). It is based on eight questions that indicate whether adults or children in a household experience food shortages, perceive food insufficiency and alter food intake due to resource limitations or inadequate food resources. Two additional questions related to whether the household was experiencing food shortage at the time of the survey and to coping mechanisms employed, were added. Due to the fact that a large number of households included in this study did not have children living in them, the CCHIP scoring system was, however, not applied and a scoring system based on the questions relevant to households was compiled. A structured interviewing technique was used to complete the questionnaires with one adult member of each household. In very few cases, Sesotho, Setswana and isiXhosa interpreters assisted the researchers.
VALIDITY
AND RELIABILITY
To assure validity, all questions were related to the objectives of the study and were based on issues discussed in relevant literature. Random samples of 10% of the rural and urban participants were interviewed a second time to determine reliability of questions. Where answers to questions differed with more than 20%, the question was considered unreliable. Only the questions related to keeping food for future use were found to be unreliable in the urban sample and responses to this question are thus not reported.
Data Collection The study protocol was approved by the Ethics Committee of the Faculty of Health Sciences, University of the Free State (ETOVS 21/07), the Free State Department of Health and local municipalities. Prior to data collection, information sessions for community leaders and members were arranged in each community. Trained fieldworkers from each community visited each household (in some cases on more than one occasion), explained the purpose of the study, and encouraged all eligible volunteers between 25 and 64 years of age to participate. Written informed consent was obtained from all participants in their language of choice. In addition to an information document, a participation letter was given to each selected household member to inform them of the date that they should be at the research venue to participate in the study, as well as the procedures that needed to be followed (for example, fasting on arrival). This letter could also be used to inform employers of the study and the reason for not being able to attend work on that particular day. On days of data collection, participants arrived at the research venue (community halls in rural areas and the MUCPP nutrition centre in the urban area) in a fasting state. The identity document of each respondent was
Downloaded by [New York University] at 07:09 27 April 2015
122
C. M. Walsh and F. C. Van Rooyen
screened to ensure that participants met the inclusion criteria for age and a data checklist was pinned to the clothing of each eligible participant. Each venue was arranged into stations where data were collected. These included stations for collection of blood and urine samples; a food station; medical examination; and anthropometric measurements. Results obtained from these assessments have been reported elsewhere (Groenewald et al. 2012; van Zyl et al. 2012). Thereafter, questionnaires related to the following aspects were completed: sociodemography (one per household); household food security (one per household); diet history (one for each participant); physical activity (one for each adult participant); reported health (one for every adult participant); and knowledge, attitudes and practices related to nutrition (one per household). After each station indicated on the data checklist had been completed, participants received a transport fee of R12 (approximately $1 USD at the time of writing the manuscript). No other remuneration was offerred. Participants with urgent medical conditions were referred to local clinics, local healthcare providers and healthcare centers directly after the medical examination. As soon as laboratory investigations were completed, communities were revisited by medical practitioners. During these follow-up visits, participants could obtain results of biochemical tests and referral letters, if necessary. If participants did not attend the individual feedback appointments, referral letters were delivered to participants by community workers.
Statistical Analysis Descriptive statistics, including frequencies and percentages for categorical data, and means and standard deviations or medians and percentiles for continuous data, were calculated. Differences between urban and rural groups were assessed by p values or 95% confidence intervals (CI) for the difference in rural and urban proportions. All analyses were performed by the Department of Biostatistics, University of the Free State, using SAS, version 9.4 (SAS Institute, 2012). For the purpose of this study, household food security was defined on the basis of the answers to four of the questions included in the hunger scale, namely (1) does the family currently experience food shortage? (2) does the household run out of money to buy food? (3) does the family cut the size of meals or skip meals because there is not enough food in the house? and (4) does the family eat less because there is not enough money for food? A score of > 2 out of the possible 4 classified the household as having a high risk for food insecurity. All other items on the hunger scale are only relevant to households with children and were therefore excluded. The following sociodemographic and food security variables related to households (and not to individuals) were considered for inclusion in the logistic regression model: type of dwelling (brick vs. other); has electricity
Downloaded by [New York University] at 07:09 27 April 2015
Food Security in Rural and Urban South Africa
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(yes vs. no); water and sanitary conditions (own tap vs. other, and flush toilet vs. other); fuel used for cooking most of the time (electricity vs. other); household assets (yes vs. no for each asset); proportion of income spent on food (R100 [approximately $8 USD] or less vs. more than R100); and main source of income (wages and salaries or self-employment vs. other). Food security variables included: grow vegetables (yes vs. no); grow crops (yes vs. no); have fruit trees (yes vs. no); own livestock (yes vs. no); and keep food for future use (yes vs. no). The degree of hunger in the household at the time of the survey included whether the family was experiencing food shortage (yes vs. no); ran out of money to buy food (yes vs. no); cut the size of meals or skipped meals because of lack of food in the house (yes vs. no); and ate less because there was not enough money for food (yes vs. no). For all of these variables, a univariate analysis was applied to identify variables that could be included in the model (p < .15). In the rural sample, the following variables were identified: fuel used for cooking; electric, coal or gas stove in the household; primus/paraffin stove in the household; radio in the household; television in the household; money spent on food weekly; main source of income; growing own vegetables; and growing own crops. In the urban sample, the following variables were identified: the type of dwelling; microwave oven in the household; and keeping of food for future use. Logistic regression with forward selection (p < .05) was used to select significant independent factors associated with food insecurity.
RESULTS The median age of rural respondents was 48 years, which was slightly older than that of urban participants at 44 years. Most respondents were female (71.5% rural; 77.6% urban). A large percentage of participants had no schooling (27.4% rural; 20.9% urban) or only primary education (31.2% rural; 33.6% urban). The median period that participants had lived in a rural area was 45 years and in urban areas 15 years. In rural areas, respondents spoke Sesotho (33.5%), Afrikaans (31.7%) or isiXhosa, while in urban areas the majority spoke Sesotho (63.3%), most probably because urban households were almost completely black (98.7%), while 17.2% of rural households were of mixed ethnic origin, and 13.8% had more than one race living together in one household. In table 1 the sociodemographic status of households is described. In urban areas, significantly more respondents were unemployed (56.3%) than in rural areas, where 63.3% had a part-time or piece job (p < .0001).
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C. M. Walsh and F. C. Van Rooyen
TABLE 1 Sociodemographic Status of Urban and Rural Households Included in the Study Rural
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n Employment status of respondent (R = 499; U = 387) Housewife by choice 13 Unemployed 127 Self-employed 9 Full-time wage earner (receive a salary) 34 Other (part-time job, piece job) 316 Husband/partner’s employment status (R = 499; U = 387) Retired by choice 9 Unemployed 47 Self-employed 1 Full-time wage earner (receive a salary) 53 Other (part-time job, piece job) 133 Not applicable (e.g. deceased) 256 Type of dwelling (R = 499; U = 387) Brick, concrete 417 Traditional mud 2 Corrugated iron 77 Plank, wood Other 3 Has electricity (R = 499; U = 387) 465 Drinking water from most of the time (R = 499; U = 387) Own tap 479 Communal tap 17 River, dam 1 Borehole, well 0 Other 2 Type of toilet household (R = 498; U = 387) Flush 468 Pit 2 Bucket, pot 16 Ventilated improved pit (VIP) 0 Other 12 Fuel used for cooking most of the time (R = 497; U = 387) Electricity 313 Gas 22 Paraffin 154 Wood, coal 8 Sun 0 Open fire 0 Home has a working: (R = 499; U = 387) Refrigerator and/or freezer 312 Stove (gas, coal, or electric) 387 Primus or paraffin stove 279 Microwave oven 101 Radio 381 Television 270
%
Urban n
%
p value for % difference
2.6 3 25.5 218 1.8 2 6.8 19 63.3 145
0.8 56.3 0.5 4.9 37.5
1.8 9.4 0.2 10.6 26.7 51.3
10 43 6 42 51 235
2.6 11.1 1.6 10.9 13.2 60.7
83.6 313 0.4 15.4 73
80.9
0.6 1 93.2 332
0.3 85.8
96.0 3.4 0.2 0 0.4
303 80 0 1 3
78.3 20.7 0 0.3 0.8
