Outcome Analysis of the Botswana Government Food Rations on the Nutritional Status of HIV Infected Children under Five Years of Age in Mahalapye and Shoshong

Tables of Contents

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Abstract

Acknowledgements

Abbreviations

Abbreviations

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CHAPTER ONE: INTRODUCTION
1.1 Introduction
1.2 Motivation of the Research
1.3 Problem Statement
1.4 Significance of the Study
1.5 Aim of the Study
1.6 Objectives
1.7 Research Design
1.7.1 Data Collection and Analysis
1.7.2 Sampling
1.7.3 Inclusion Criteria
1.8 Limitations of the study
1.9 Organization of the study
1.10 Projected timeframe
1.11 Ethics
1.11.1 Informed Consent and Maleficence
1.11.2 Permission for Data Collection
1.11.3 Confidentiality
1.12 Conclusion

CHAPTER TWO: LITERATURE REVIEW
2.1 Introduction
2.2 HIV and AIDS Global Overview
2.3 Botswana National HIV and AIDS prevalence
2.4 Overview of the Paediatric immunity
2.5 Paediatric HIV and AIDS Epidemiology
2.6 Nutrition and HIV
2.7 Botswana Economic growth and poverty
2.8 Nutritional Appraisal of the diverse components
of food rations
2.8.1 Sorghum
2.8.2 Soybeans
2.8.3 Vegetable Oil
2.9 Conclusion

CHAPTER THREE: RESEARCH METHODOLOGY
3.1 Introduction
3.2 Research Setting
3.3 Methodological Approach
3.3.1 Research design
3.3.2 Data Collection
3.3.3 Study Population
3.3.4 Sampling
3.3.5 Type of Data
3.3.6 Data Analysis
3.3.7 Conclusion

CHAPTER FOUR: RESULTS, DISCUSSION AND INTERPRETATION OF FINDINGS
4.1 Introduction
4.2 Demography of Study Participants
4.3 Determining the default rate to child welfare clinics
4.4 Regularity of the food rations
4.5 Nutritional Assessment
4.5.1 Determining the pattern of the mid-upper arm circumference
4.5.2 Malnutrition rate amongst HIV infected under five children
4.5.3 Establishing the weight-for-age pattern of HIV infected children under five years old
4.6 Conclusion

CHAPTER FIVE: CONCLUSION AND RECOMMENDATIONS
5.1 Introduction
5.2 Research Problem Statement
5.3 Study objectives
5.4 Summary of the Study
5.5 Conclusion
5.6 Recommendations

REFEREENCES

ADDENDUM

List of Tables

Table 1.1: Projected time frame

Table 2.1: Adult HIV prevalence rate by year in Botswana

Table 2.2: Sorghum contents in macronutrients and micronutrients

Table 2.3: Soybeans contents in macronutrients and micronutrients

Table 4.1: Male weight-for-age means per visit with corresponding standard deviations

Table 4.2:Female weight-for-age means per visit with corresponding standard deviations

List of Figures

Figure 1.1: Adapted WHO Child Growth Standards 2006 for Boys

Figure 1.2: Adapted Child Growth Standards 2006 for Girls

Figure 2.1.Global HIV Prevalence (Million)

Figure 2.2. People living with HIV/AIDS in Botswana

Figure 2.3: An overview of the humoral immune response

Figure 2.4: Botswana-Population below poverty line (%)

Figure 4.1. Sex distribution of study Participants

Figure 4.2. Participants’ distribution per constituency

Figure 4.3 Sex distributions per site

Figure 4.4 CWC attendance and default rates

Figure 4.5 Food ration per visit

Figure 4.6: The highest malnutrition rate

Figure 4.7: The lowest malnutrition rate in relation to MUAC

Figure 4.8: Mid-upper-arm circumference at twelve month

Figure 4.9: The highest moderate malnutrition rate

Figure 4.10: the highest severe malnutrition rate

Figure 4.11: Weight-for-age means per sex

Figures 4.12. Weight-for-age means for both sexes

Abstract

Malnutrition might be the result of complex and interconnected factors, but the role poverty and HIV and AIDS epidemic played in underprivileged settings were determinant in the prevalence of a situation that accounted alone for more than one-third of infant mortality in the developing world. As a vulnerable group, the necessity of a balanced nutrition for children below five years of age to ensure growth and strengthen a developing immune system is paramount.

The research study assessed the outcome of the Botswana government food rations intervention through the analysis of the anthropometric parameters of 54 candidates in two constituencies of the central district (MAHALAPYE and SHOSHONG). Through a descriptive quantitative research design, the research study retrospectively reviewed anthropometric parameters of 54 HIV infected children below five years of age for their first year of attendance in respective child welfare clinics of the two constituencies. A customised data collection tool was designed for the purpose and aimed at recording the weights for each visit, the nutritional classifications per visit, the mid-upper-arm classifications, the default to child welfare clinics and the food packages study participants received per visit. Each study site visited availed the Nutritional Surveillance logbooks (MH3034) and the birth registers (MH3007) from 2010 to date. Only data from their first year under the food programme constituted the interest of the study.

However, it resulted from the analysis a lower malnutrition rate of study participants (13%) in comparison to the latest national prevalence. A significant annual default rate of 33% was noted with regard to children attendance to child welfare clinics. The food programme did not perform according to expectations in reference to a reduced coverage rate of food rations. The study further highlighted the concerning level of food shortage in health facilities. Study participants had a normal growth pattern when confronted to the WHO criteria despite a significant default rate and the shortage in food supply. Although the government nutritional supplemental programme has undoubtedly contributed to the nutritional status of HIV infected children below five years of age, it was hard to establish the cause-to-effect relationship between the variables, an endeavour outside the scope of this study.

Acknowledgements

Once again the opportunity is given to me to thank the Almighty God for guiding me through the long journey, for giving me the necessary strength and motivation to keep going in times of turbulence.

I personally acknowledge the invaluable contribution of Prof Johan Augustyn, my Supervisor for his time and advice.

My acknowledgements go to my lovely wife Bofaya Mireille, Bonkinga and my two children Kembo Eliane, Bakelana and Bonkinga Jesse, Bakelana for always standing by my side in the most difficult moment of this expedition.

I finally thank Prof Martin Kidd for helping with the statistics and the Health personnel of all health institutions visited for welcoming me in their workplaces.

I dedicate this work to my late father Ba-Kufimfutu Antoine, Bakelana and to my mother Ntoto Elizabeth, Bamanga

Chapter One INTRODUCTION

1.1.Introduction

Three decades ago, an unprecedented and decimating epidemic the world has never experienced during the modern time was declared. The epidemic was named the HIV and AIDS epidemic, for which the eradication hope has remained an uncertainty for years, in spite of the scientific and the technological advancement recorded in the biomedical field in recent years. As one of the most challenging epidemic humankinds have never faced, the epidemic turned out to be the prime responsible of millions of death worldwide.

Controversy exists as to where the HIV virus originated. The literature points out Kinshasa, in the Democratic Republic of Congo as the source of the virus, where it existed since the first half of the 1900s and from where it spread worldwide (AVERT 2016). However, the first case was isolated in 1983 among gay communities in the US (WHO, 2016).The epidemic kept getting momentum, spreading from homosexual individuals to their heterosexual counterparts. The epidemic became elusive such that nobody could have thought the world could still be struggling with this human catastrophe thirty years later. Here we are, several years later from the epidemic outset, persistently searching for means to mitigate its effects.

The latest development in the managerial perspective of HIV and AIDS epidemic supported a multidisciplinary approach proven to be effective in the mitigating endeavours of the epidemic effects. From the physiological point of view, AIDS is the resulting consequence of a compromised immune system caused by the virus which implicates beyond the broader concept of combination prevention, a balanced nutrition inclined to reasonably restore the deficits of macronutrients and micronutrients caused by the HIV virus and subsequently prevent further deterioration of the immunologic and clinical statuses.

Botswana has been listed amongst the rare Sub Saharan African countries that have developed a comprehensive and effective HIV programme regardless of the economic turmoil experienced. Through its social welfare and poverty eradication programmes, some needy have been able to access a certain variety of grants countrywide. Children under five years of age have accessed food rations in respective child welfare clinics for years now. In underprivileged and underdeveloped areas, food rations constituted the main source of protein not only for programme beneficiaries but for the entire families as well to the extent of jeopardising the required quantity children are expected to consume. In face of the disparity that exists in the energetic demands between HIV infected and HIV uninfected children, combined with the increased poverty in the remote settlements, the researcher had a particular interest to explore the outcome of such intervention to the nutritional status of HIV infected children.

1.2. Motivation of the Research

Although the remarkable economical success Botswana has experienced over the past 60 years, mostly owed to its good governance and policies, the country has persistently faced challenges pertaining to poverty eradication and HIV/AIDS epidemic. In 2012, the poverty rate was estimated at around 19.3% with an unemployment rate of 19.9% (UNDP, 2012) and the burden of HIV and AIDS epidemic has profoundly impacted negatively on human welfare, the fiscal and the country governance (UNDP,2012). Despite the economical success and the unprecedented HIV and AIDS programmes scale up, the nutritional aspect in the management of HIV and AIDS as recommended by several nutritional guides is yet to be scaled up. The role of HIV and AIDS on the individual welfare and in the household can never be overemphasised. In reducing the household income and increasing the expenses, HIV pushes families from disadvantaged settings into poverty, which is responsible for unenthusiastic health outcomes for children (AVERT, 2015). The government regards nutrition as a priority strategy for primary health care at districts level (UNICEF, 2007) but provision of nutritional supplement remained restricted to specific groups of the society and a significant portion of HIV infected individuals are nutritionally unassisted.

In 2005, a national plan of action for nutrition was launched, which plan consisted to embody the country’s efforts to improve multi sectoral collaboration concerning the food and nutrition situation (UNICEF, 2007). Destitute, orphans, vulnerable children have been all receiving food baskets through the social welfare services and community development offices (gov,2011).children below five years of age attending child welfare clinics have been receiving each a package of highly nutritious foods (Tsabana, Malutu, Beans, vegetable cooking oil) regardless of their HIV status. The food package they receive mostly constitutes the basic nutritional support for the livelihood of underprivileged communities (ohchr, 2010). The quantity both groups of children receive remains the same regardless of their HIV status, knowing the discrepancy that exists in terms of energetic demands between HIV infected and HIV uninfected children. In resource constrained settings, these grants have become the main source of protein and micro nutrients not only for the children, but for the entire family such that the total portion children are expected to have consumed until the next appointment is completely disrupted .It is not rare for families to sell a portion of the package received to purchase other valuable goods. Based on these multifaceted challenges, some directly affecting children’ wellbeing and others indirectly through the poverty impacts on the family organisation and structure, the researcher aimed to assess the nutritional outcome of HIV infected children below five years of age under the government food programme.

1.3. Problem Statement

HIV and AIDS have been reported to contribute in different ways to malnutrition. Through some direct or indirect mechanisms, there can be decrease in caloric intake, increase in loss and use of nutrients and energy (BIPAI, 2010). Other studies have noticed that insufficient macro and micronutrients intake were resulting from conditions such as anorexia, nausea, diarrhoea; vomiting and factors associated to malabsorption (ASSAF, 2007).Micronutrients are proved to be important for the immune system and for other bodily functions. There is no definitive evidence currently on the acceptable amount and the types of micronutrients PLHIV really need (WFP, 2014).

Based on the energetic loss PLHIV are subjected to because of their disease, a 10% energetic increase intake is recommended during their asymptomatic phase of the infection to make up for the increase resting energetic expenditure (WFP,2014). A reasonable amount of micronutrients and vitamins are found in TSABANA (iron, zinc, iodine, phosphorus, calcium, niacin, folacin pantothenic, Vitamin B12, Pyridoxin, Riboflavin, thiamine vitamin A,vitamin E,vitamin D, ,manganese, copper, chlorine and cobalt) and the energy produced is remarkable (agropedia,2009).The following is the research question: what is the nutritional outcome of the government food rations on HIV infected children below five years of age in MAHALAPYE and SHOSHONG ?

1.4. Significance of the Study

The role nutrition plays in the management of HIV infected clients can never be underestimated and efforts the Botswana government deploys in catering food rations for the children population merit encouragement and support. In evaluating the nutritional response of HIV infected clients after getting food rations, a number of recommendation can be tailored both for the local and the central level. Local facilities will be subjected to recommendations on service improvement, quantity adjustment when necessary, follow up visits to trace defaulters and referrals for further management in case of growth failure ,whereas the local government which represents the central level can be informed on the findings and recommendations made either to increase the quantity allocated to each facility, the emphasis on regularity and delivery time of food rations and suggestions regarding alternative means to palliate to product shortage.

1.5. Aim of the Study

The study’s aim was to assess the nutritional condition of HIV infected children below five years of age who enrolled under the government food programme within child welfare clinics.

1.6. Objectives

1. To establish the weight-for-age pattern of HIV infected children below five years of age a year after enrolling in the food programme in child welfare clinics.
2. To determine the pattern of the mid-upper-arm circumference a year after enrolling in the food programme.
3. To determine the proportion of undernourished HIV infected children within their first year under food programme.
4. To establish the regularity of food rations within the first year under the food programme
5. To determine the default rate to child welfare clinics of HIV infected children below five years of age within the first year of their enrolment in the food programme.

1.7. Research Design

Different definitions exist as regard to research design but a consensus prevails on the main focus which is summarised by answering the what, the where, the when, the how much, and by what means of a research question (Seema, 2008).Researchers have commonly made the mistake of beginning their investigation far too early prior to critically thinking about the kind of information that are needed to address a research question (USC,2016).A research design should therefore be associated with the entire strategy a devoted researcher select for the integration of various study components in a logical, coherent and unambiguous manner to ensure that a research problem is efficaciously addressed (USC,2016).

In the social sciences for instance, the mainstay of a research study is to test a theory, to evaluate a program or to accurately describe and assess significance related to an observable phenomenon by obtaining relevant information for a research problem (USC, 2016). In other words, a research design can be considered as the entire process of collecting and analysing data in a way aiming to associate relevance of the research purpose to the economy in procedure (Seema, 2008).

The most important elements of a research project include the basic approach (qualitative, quantitative or a combination of both); the sample, the interviews, the observations, the study location, the discussions outline, the questionnaires, and the materials to be introduced (AQR, 2013).The appropriate research design of this study would be a descriptive quantitative research design that analyses the nutritional outcome of the government intervention on the health of HIV infected children below five years of age attending child welfare clinics in both MAHALAPYE and SHOSHONG constituencies.

The descriptive quantitative component on one hand is explained by the use of multiple variables for analysis of medical and personal records from child welfare clinic registers. The use of numerical data to obtain information, the description of variables, the examination of relationships between variables presented in numerical patterns and analysed through statistical means are just a series of pivotal activities the research can refer to for answering the research question (Polit, Bernadette & Hungler, 1999). The purpose of the research would be to describe what already exists and help reveal new facts and significance.

The evaluation component of the design on the other hand is justifiable by the determination of the programme performance in alignment with expectations and population coverage. Polit et al (1999) stated that this type of research asses and/or evaluate the success of a particular practice or policy. The evaluation procedure resembles more or less of an audit or an outcome analysis of a change in a process, an impact analysis of certain measures put in place, a cost-benefit analysis for an introduction of new drugs for instance (Polit et al,1999).

1.7.1. Data Collection and Analysis.

Per definition, data collection can be seen as a process through which information are gathered and measured on variables of interest in a systematic way to allow or enable a researcher to answer the stated research questions and evaluate the outcomes (ORI,2005). The methodology selected for data collection depends on certain criteria such as the research problem, its design and the sort of information gathered about variables (Ludy, 2012).

The current research constitutes a retrospective study that proceeds through document review to assess the effects food rations had on the wellbeing of HIV infected children who attended or who are attending the child welfare clinics in the project’ s sites. Using a data collection tool for each research participant, the study intends to analyse the growth pattern of HIV infected children against the WHO criteria. With data collected, growth profile of HIV infected children will be compared with the WHO norms. Means of monthly anthropometric parameters such as weight-for-age for a year under the food programme are calculated and the average growth line determined to confront against the WHO criteria using the WHO child Growth standards graphs. The WHO acknowledges any value between -2SD and +2SD of the Z-score lines as normal. This helps to nutritionally classify children based of the following parameters: weight-for-age, height-for-age and weight-for-height (WHO, 2016). As a retrospective study, data are retrieved from current and registers, archived registers and where possible from the electronic database (IPMS, PIMS 2) for facilities that have gone through some upgrading in patient management system.

Each child welfare clinic disposes of a MH3007 register (the birth register and preschool health follow up calendar) and MH3034 forms (the Nutritional Surveillance Logbook). The MH3007 registers contains the following information:

-registration date
-date of birth
-place of birth
-sex
-Mother’s names and address
-child’s names
-Vaccination given
Whereas the MH3034 form contains information as follow:
-Birth registration number or the CWC card number
-Date of birth
-Sex
-Date of visit
-Weight
-Length for height (determined only twice a year in February and august)
-Weight for age
-MUAC (mid upper arm circumference).
-Growth failure
-Ration given the previous month
-Feeding method
-Illness code
-Vitamin A supplementation
-Immunization
-HIV status of the child

The data collection tools are designed to collect relevant monthly individual indicators such as weight, height, MUAC, growth failure to establish the monthly average that will be utilised for the determination of the average growth profile of the study population to confront against the WHO criteria using adapted WHO child growth standards graph. Below are WHO graph for boys and girls

Figure 1.1: Adapted WHO Child Growth Standards 2006 for Boys

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Source: Botswana Child Welfare Clinic Card

Figure 1.2: Adapted Child Growth Standards 2006 for Girls

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Source: Botswana Child Welfare Clinic Card

Here is an illustration on how the study intends to proceed in determining the growth pattern of the study population: Three HIV infected children A,B,C attending CWC have respectively weighed 5 kg,6kg,7 kg at their 6th visit(6th month of age) and 11kg,10kg,13kg at their 10th visit. Averages of their weights at different visits are calculated and the trend analysed and classified whether it falls under normal, undernourishment or over nourishment.

1.7.2. Sampling

Owing to its tremendous HIV scale up programme, a result of one of the most comprehensive and effective HIV programme in the continent, Botswana has lately recorded a substantial reduction in its mother to child transmission rate. The success of Botswana’s PMTCT programme has significantly lowered the transmission rate to lesser than 2.49% (AVERT, 2015).Consequently the number of children currently living with the HIV virus has also decreased. The sampling method of the study will therefore be a purposive sampling technique using the entire population of HIV infected children who attended the child welfare clinic during the past 5 years, but can be extended further down the line in case of a small sample.

1.7.3. Inclusive criteria

Defined as attributes prospective participants must have if they are to be included in a research study (UNM, 2010)

Only data of the following children will be considered

-Known HIV positive
-Attending child welfare clinics
-Receiving food rations (Tsabana and/or cooking oil).

1.8 Limitations of the Study

The essential activity of the research study consists of documentation review of the records in CWC registers. For reasons associated to facility infrastructures such as lack of storage space, inadequacy of record keeping system, some registers might have been missed with relevant data. Another challenge pertains to the considerable number of children with pending HIV test results.

1.9 Organization of the Study

Chap 1. Introducing the problem statement relating to the necessity of nutrition for HIV infected people, the nutritional intervention in place for HIV infected children

Chap 2. A quick overview on available literature regarding HIV and nutrition

Chap 3.Discusses the research methodology and the study design based of the research question including the ethical considerations attached to data collection and related activities.

Chap 4.Data analysis and findings.

Chap5. Encourages positive achievement, lists challenges and intervention shortcomings. Make recommendations for intervention strengthening.

1.10. Projected time frame

Table 1.1: Projected time frame

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1.11. Ethics

Resnik has defined ethics as norms of conduct that distinguish between acceptable and non acceptable behaviour (Resnik, 2015). In the research field, Ethics remains a sensitive and complex matter to which a research application has to satisfy prior to being considered or funded. Adhesion to ethical norms promotes knowledge, truth and concomitantly prevents error by prohibiting against falsification, fabrication or misinterpretation of research data (Resnik, 2015).The Promotion of essential values such as trust, accountability, fairness and mutual respect constitutes non negligible aspect of research ethics.

Research designs and ethics are two interdependent concepts to always remember and consider when planning for a research. The consideration of a design in isolation, without accounting for ethical norms is a misunderstanding. One funder even underlined the existence of ethical norms for all sort of proposals regardless of the research methodology used (NEAC, 2012).

1.11.1. Informed Consent and Maleficence

As opposed to the majority of research studies in the social sciences that gather personal or health information from people or groups of people, the current research study represents a sort of evaluation in form of an audit because it analyses the activity outcome of the governmental food rations on HIV infected children attending CWCs. Generally, audits and related activities are characteristically of minimal harm risks comparatively to social researches. In most cases, they do not necessitate the explicit consent of the people or groups of people when the purpose of the audit is to protect and advance health.

The use of Health information without an additional consent in this study is ethical because prevents unnecessary anxiety from study participants and palliates for the non traceability of certain study participants (NEAC, 2012).Similarly, it is essential to be reminded that activities that are fundamental components of a high quality care delivery can be exempted from obtaining consent at data collection. In such cases, generally the public interest in the study far more outweighs the public interest in privacy (NEAC, 2012).

1.11.2 Permission for data collection

Prior to the submission of the final research proposal to the University Research Ethical Committee, permission were sought from the Local Ethical committee of the Health District and from the Head of the Health District and attached to the final research proposal at submission. Data collection was only effective upon the REC approval.

1.11.3. Confidentiality

In fact, the researcher engaged to protect the confidentiality of data by omitting information that might easily connect to the identification of participants, and when appropriate, to limit by any means the access of data. The researcher ensured to adequately safeguard data by using a computer with a password for electronic data and the use of a locked cabinet for hard copies with access essentially restricted to the researcher. Identity of participants would not be disclosed to a third party and hard copies were destroyed immediately after data have been analysed.

1.12. Conclusion

The magnitude of HIV and AIDS epidemic in the continent and most importantly in sub-Saharan Africa is alarming, and the multidisciplinary approach with a significant role ascribed to nutrition is indisputable. Several African countries including Botswana are still facing enormous challenges to accurately implement the nutritional aspect of the WHO recommendation about HIV and AIDS for economic reasons that are known to many. Despite the difficult moments the continent is undergoing, there is a necessity for African countries to learn from Botswana endeavours and political commitments to advance the fight against the epidemic in the sub-region. This chapter offers an overview on how the research study is organised and conducted from the motivation behind the current research project to the recommendations addressed to Health facilities visited by the researcher and relevant authorities regarding quality improvement of the nutritional intervention for HIV infected children.

Chapter 2 LITERATURE REVIEW

2.1. Introduction

Defined as the human immunodeficiency virus, HIV is microscopically subdivided into two main subtypes; the HIV-1 is the most predominant worldwide and represents the subtype people mostly refer to when there is no viral specification. The HIV-2 type, less common and less infectious is widely recognised as the low progress subtype that is essentially found in western Africa (AVERT, 2016).

Children below five years of age are particularly considered as a vulnerable group for HIV and AIDS because of the perceived immaturity of their immune system. In the setting of insufficient defence capacity, the cumulative viral effects on children immunity uphold devastating health consequences to the age group, immunity being defined as the defensive element triggered by the organism against exogenous aggression. Children below five years of age are therefore predisposed to health issues of diverse nature source of increased morbidity and mortality. The number of fatalities in developing countries has by far exceeded that of the developed world because of the defectiveness of public health systems unable to cater for the basic needs.

Failure of an undermined immune response by the HIV and AIDS virus adding up to extreme poverty that characterises the third world paves the way to the development of opportunistic infections responsible for ill health if untreated.

Through the macronutrients and the micronutrients provided, nutrition undoubtedly plays a crucial role in the energetic sustainability of vital functions of the organism and surfaces as a pillar in the disease containment process. Besides the organism resting metabolism, the viral replication process raises the energetic demands of an HIV positive individual and consequently entails an increase of the individual energetic supply. This piece of work intends to connect with existing evidences regarding the role of nutrition in children welfare and supports the evidence to which a good nutrition undermines the scale of HIV infected children’ malnutrition rate

2.2. HIV and AIDS Global Overview

Three decades from the inception of the epidemic, HIV and AIDS cure is yet to come. Historically proven to have existed long before the 1980s when the epidemic started to manifest through opportunist infections from the gay communities in the US and across the globe, scientific evidences pointed out Kinshasa, the capital city of the Democratic Republic of Congo as the cradle of the epidemic where the virus was spotted first (AVERT, 2016). The epidemic is believed to have started spreading around since the 1970s and a decade later 100,000 to 300,000 individuals were estimated to have probably been infected (AVERT, 2016).

In 1995 prior to the advent of ARVs, HIV and AIDS prevalence and incidence had exponentially increased before the down trending motion in response to the global commitment that implicated the treatment programme. The incidence skyrocketed between 1990 to 1996 from 1.8 million to 3.5 million, then reduced gradually to lower than 27 million in 2007. As per 2016, the incidence plummeted to 2.7 million, a 6% fall from the 2010 figures (UNAIDS, 2016).

The epidemic is unequally distributed; the majority of HIV infected individuals living in resource constrained countries where the sexual route is the main communicating channel. Sub-saharan Africa alone is home to two-thirds of the global burden of HIV infected individuals. Two-thirds of these individuals live in eastern and southern Africa. The total HIV and AIDS prevalence of Sub-saharan alone is estimated to 25 million whereas the Middle East and the North of Africa remain the least affected sub-regions with only 230,000 people (AVERT 2015).

Figure 2.1.Global HIV Prevalence (Million)

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Source: Avert (2015)

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The reduction in HIV and AIDS prevalence and incidence is the merit of HAART, highly active anti retroviral therapy that mainly acts in the replication phase of the virus to reduce the sero-conversion rate. It must be remembered that the FDA only approved the first protease inhibitor that paved the way to HAART in 1995 and the implementation only came into force in the aftermath of the presentation of researchers such as David Ho of the Aaron Diamond AIDS Research Center and George Shaw of the university of Alabama on the viral dynamic with antiretroviral drugs in the 11th international Conference on AIDS in Vancouver (Bartlett, 2006). The combination prevention strategy shifted the initial therapeutic role of HAART to prevention that is yielding significant result especially with the PMTCT programmes across the continent. The test and treat initiative initially adopted by the WHO in 2015 and only implemented in Botswana in 2016 should result in more satisfying outcome in terms of epidemic control because 21 million deaths and 28 million new infections are predicted to be averted by 2030 (WHO.2015).

2.3. Botswana National HIV and AIDS Prevalence

Botswana diagnosed its first HIV and AIDS case in 1985 and the country has since then relentlessly prioritized the fight against the epidemic through its diverse MDGs. Botswana features amongst the first African countries to have initiated the most comprehensive HIV and AIDS program and most importantly the very first country which set off universal antiretroviral drugs in the region. Its HIV and AIDS prevalence is currently the third highest in the world after Lesotho and Swaziland (AVERT, 2016).

The HIV and AIDS prevalence of younger age groups are besides that of the vulnerable groups amongst the highest in the country according to existing reports, endangering the hope of HIV and AIDS free generation the country strives for. A rapid peak of HIV incidence and prevalence was noticeable at the mid 1990s, evidenced by the steady upward trend up until mid 2000s before it’s plateaued and further reversed (GOV, 2005).

Figure 2.2. People living with HIV/AIDS in Botswana

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Whereas the prevalence of the general population currently stands at 18.5%, the prevalence of the female population has generally been higher than that of their male counterpart. Latest evidences estimate a higher female prevalence of 20.8% alongside the prevalence of their male counterpart of 15.6%.

Antiretroviral therapy program scale up has averted about 50,000 adult deaths by the end of 2007 and led to a three folds reduction of AIDS-related deaths from 2005 to 2013. Other evidences show the reduction of the death rate from 14,000 in 2005 to less than 5,800 in 2013 and the reduction of new infections within the same time frame from 15,000 down to 9,100 (AVERT,2016) .

Nonetheless, additional efforts are needed to save more lives especially from the vulnerable groups. The statistics regarding adolescents, youths and young adults are very discouraging despite the commitment and the resources availed to curb the epidemic. The prevalence data from BIAS 2004 to 2013 by the age cohort for instance has not showed any significant improvement in the prevalence statistics over a period of five years for the 15-19 years age group and question the prevention efforts for youth in Botswana (Agang, 2013). Table 2.1 provides a glimpse on adult HIV and AIDS prevalence within the past decades

Table 2.1: Adult HIV prevalence rate by year in Botswana

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Source: Index Mundi (2016)

2.4. Overview of the Paediatric Immunity.

The particularity of this age group is the inherited character of the HIV virus from the mother. These innocent individuals have either acquired the virus during pregnancy or while breastfeeding and yet have to face the ordeal of taking the drugs for the rest of their lives and the societal challenges beyond their coping capability. The vulnerability of newborns to HIV and AIDS as for other infectious diseases is mostly due to the insignificant immunologic memory and the developing immune system. Despite similarities of the newborns immune response to the adults’, researchers have demonstrated the divergence of respective immune responses in a number of circumstances (Marodi, 2006).

Newborns heavily rely on the innate immune response and the maternal antibodies passively acquired as a consequence of the relatively underdeveloped adaptive immune response resulting from a limited exposure to antigens during the intra-uterine life (Jaspan, Lawn, Safrit, Bekker,2006).Physiologically immunodeficient newborns are protected by the immunoglobulin A acquired from breast milk, an argument in favour of breastfeeding, and by the maternal antibodies generally protective up to 18 months (Jaspan, Lawn, Safrit ,Bekker,2006).

Figure 2.3: An overview of the humoral immune response

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2.5. Paediatric HIV and AIDS Epidemiology

In 1999, the estimated number of people who died by the HIV and AIDS epidemic was 14 million and HIV and AIDS were since then announced to be the number one killer in Africa and specifically in the Sub-saharan region. In 2015, there was an estimated 1.8 million children under 15 years of age living with HIV and AIDS. Nearly 150,000 individuals of this age group became infected in 2015 of which the majority was infected by their mothers and lived in Sub-saharan Africa (AIDS, 2016).

The good news out of the alarming statistics previously presented is about the dramatic fall in the transmission rate owing to the advent of ART and the aggressive implementation of PMTCT across the world. In 2010 for instance, there has been a 50% incidence decline amongst children and in countries such as Botswana, PMTCT interventions have the merit to have reduced the risk below 5% (AVERT, 2016).

2.6. Nutrition and HIV

According to available data, 5.1 million children have already been infected by HIV and AIDS since the epidemic outset. For being one of the sub-Saharan African countries with the highest HIV and AIDS prevalence, more than 25,000 children below fourteen years of age are infected in Botswana, and an average of 3,700 of these children are currently taking the antiretroviral drugs. A strong relationship exists between nutrition and HIV in a way that the immunity undermined by HIV and AIDS does benefit from external nutrients to optimise its function.

In 1994, the ministry of Health in Botswana, in partnership with UNICEF, conducted a large scale study which found that more than 13% of children under five years old were underweight, 23% of less than five years old were stunted and an estimated 5% had wasting syndrome (UNICEF, 2011).

There is a reciprocal cause-to-effect relationship between HIV and malnutrition, seen as a vicious cycle. HIV and malnutrition concomitantly impact negatively on the immunity of the individual by weakening the immunologic response to infection, an ideal situation to favour the emergence of a series of opportunistic infections. The limitation of nutrient intake, their absorption and their use are factors associated with further deterioration of HIV infected individuals’ health to the extent of altering the quality of life (WFP, 2014). Studies have established a similar importance of micro and macro nutrients for the wellbeing of HIV infected individuals. Of the 2 million people experiencing micronutrients deficiency, a huge number originates from countries known with considerable prevalence in HIV, tuberculosis and malnutrition (WFP,2014).The relationship between nutrition and immunity is more complex in infancy and childhood, owing to the relative immune immaturity of these age groups (ASSAF, 2007).Knowing the importance of micro and macro nutrients in an HIV infected child, a severe nutrient deficiency can only result in unprecedented devastating effects , since the HIV its self undermines the immune system by reducing CD4. Conditions such as kwashiorkor and marasmus have been reported to cause defect in the T cell maturation followed by loss of inducer T4 cell subsets (ASSAF, 2007).

The poor nutritional status in infancy and childhood of HIV infected individuals can be the result of a number of diverse mechanisms operating synergistically or simultaneously (ASSAF, 2007). Loss of appetite, commonly experienced by HIV infected children combined to the diminished dietary intake often lead to growth failure and to an increased nutritional needs (ASSAF, 2007).However, the conjunction of metabolic derangements, gastro intestinal illnesses, developmental or neurological challenges and infections have been considered as additional factors susceptible to cause substantial wasting syndrome and malnutrition in persons living with the HIV virus (BIPAI, 2010).

Challenges exist as to keeping people who have started antiretroviral drugs on treatment in low income countries. Food insecurity remains a major economic barrier for effective scale up of antiretroviral therapy. As a consequence, the nutritional aspect to the management of the epidemic is being seriously considered alongside the psychological, the legal and a variety of other components encompassed in a comprehensive set of HIV care (WFP, 2014). Depending on case to case basis in the food unsecured context, the provision of food to client taking ART as an additional package, allows compliance to treatment and retention to care as the food ameliorates their nutritional situation. There have been situations in which the food supplementation was extended to other members of the household to ensure their well being as well and ensure that the concerned HIV infected individual is getting the right portion (WFP, 2014).

In reference to the energetic demands of the virus in its replication process, it should be reminded that the nutritional needs of a HIV infected individual does differ from the needs of a HIV negative infant, similarly as the needs of a symptomatic individual does differ from that of an asymptomatic one. (WFP, 2014).

Although the HIV scale up in Botswana has been tremendous lately, being one of the successful HIV programme in the continent, there has not been a systematic nutritional support for every patient who enrols to the ART programme. The population groups benefiting for the government social safety net are only children attending child welfare clinics, orphans, some vulnerable groups, pregnant women, the disabled and the elderlies. In child welfare clinics, formula is exclusively reserved for HIV exposed neonates while Tsabana, Tsabotlhe, malutu, beans and cooking oil are all age specific rations destined for children attending child welfare clinics in Botswana.

2.7. Botswana economic growth and Poverty

Botswana’s remarkable recent economic performance has been globally appreciated. Some have referred to Botswana as one Africa’s veritable economic and human development success stories (UNDP, 2012). The country has enjoyed an unmatched political stability symbolised by 47 years of a strong democracy despite the geographical and climate unattractiveness and the country has been considered as one of the fast growing economy in the sub-region that swiftly transited from the least developed pool during independence to a middle income country in just three decades (UNDP, 2012).

Botswana is a landlocked territory without any direct access to sea and the semi-arid climate has not been very generous to the population because of the devastating effects of droughts which is quite frequent. A non negligible portion of the population depends on agriculture and farming for employment and subsistence. Climate change and environmental degradation have been potentially risky for the livelihood of the rural community as they affect agriculture, their main means of survival.

Although the achievement of most of the millennium development goals has contributed to the reduction of poverty gaps between urban and rural areas, a significant proportion of the population remains poor and vulnerable, the children under 15 years of age being the most affected (Worldbank,2015)

The national HIV and AIDS response might have been one of the best and more adapted to the population needs but the magnitude of the epidemic stretches the Government capability for sustainability to the limit. Poverty becomes a result of climate change, environmental degradation and the epidemic consequences.

Through vision 2016, Botswana Government was committed to poverty and inequality eradication through its eradication programmes that included water supply, energy distribution and adequate nutrition mostly for the rural areas (UNDP, 2012). Similarly, the country has been providing high rate coverage of social safety nets as a buffer against extreme hunger. Botswana dedicates annually 4.4% of its GDP to social spending and Guang Zhe Chen, the World Bank country director was impressed to notice that Botswana was one of the few African countries that fully fund their social programs out of their own resources (World Bank, 2015). Many citizens, especially the children remain poor despite poverty decline as a consequence of diverse government initiatives and actions, and the risks of falling back in poverty persist.

Figure 2.4: Botswana-Population below poverty line (%)

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2.8. Nutritional appraisal of the diverse components of food rations

TSABANA is a nutritional recipe developed in Botswana that consists of mixing Sorghum to Soybeans. Beyond being a weaning nutritional recipe that improves the nutritional quality of undernourished children, it is used as a nutritional support nationwide for children under five years of age attending child welfare clinics to curb the vulnerability of this age group to nutrient deficiencies and infectious diseases. TSABANA results from a preparation process that dehulls sorghum and soybeans prior to the mixing phase with a proportion of 3:1, meaning 75 percents of sorghum for a 25 percents of soybeans (Kopong, 2013). The mixed ingredients are hammer-milled and sifted to produce the mixture flour that is much appreciated across the country. Sorghum is extensively harvested in Botswana because of its climate adaptation, Botswana being a semi-arid land. The choice of soybeans in this preparation is based on it high concentration on proteins and amino acids.

2.8.1. Sorghum

Widely harvested in the United States of America, sorghum is after wheat, rice, corn, and barley the fifth most commonly grown grain crop in the globe (Blarowski, 2015). As a drought tolerant and environment friendly, the gluten free grain is somehow overlooked in the western world. Considered as a powerhouse in terms of nutrients, sorghum is primarily used to feed animals. It is furthermore utilised into secondary products in brewery for alcohol production (Blarowski, 2015).

One serving gram of sorghum is equivalent to 22 grams of protein which represents 47 percents of the daily recommendation of iron, 55 percents of phosphorous and 30 percents of the daily recommendation of vitamin (niacin, thiamine). The daily recommendation in protein for men and women are respectively 56 grams and 46 grams and Sorghum alone can provide 43 percents of that amount for an individual (Blarowski,2015).

Table 2.2: Sorghum contents in macronutrients and micronutrients

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Source: Organic facts (2016)

2.8.2. Soybeans

Harvested over thousands years in Eastern Asia as an indispensable source of protein, Soybeans are highly energetic legumes widely cultivated in North and south America for its diversified virtues (Arnarson,2012).

Soybeans potentially grow over a variety of soils and evidences exist that demonstrate the possibility to grow it even on snowy lands. The amount of protein a given area of soybeans can produce is unmatched comparatively to the same area planted with a different crop. It is broadly consumed and represents one of the very rare legumes that can be fully transformed. It is also utilised as ingredients in soups, sauces etc...

Soybeans are valuable foods for people on diet, for vegetarians and every one in general who needs to improve his health (Organicfacts, 2016).

Table 2.3: Soybeans contents in macronutrients and micronutrients

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Sources: Organic facts (2016)

2.8.3. Vegetable Oil

A vegetable oil is any triglyceride deriving from a plant after extraction. As opposed to vegetable fats that are solid oil, the term vegetable oil refers to plant oil that are liquid at room temperature and the most commonly known being Sunflower oil, Palm Oil, olive oil, corn oil, Soybean oil, peanut oil, canola oil. Nutritionally, 100 grams of vegetable oil basically produce 884 calories and a varied proportion of saturated and unsaturated fat. Other components such as vitamins and mineral are completely non-existent in vegetable oil.

2.9. Conclusion

From the most developed and advanced economies to the poorest, there has been unanimous perception on the potential effects of diet on the wellbeing of individuals. The place of nutrition has been rethought following the negative consequences recorded through the shift from the traditional lifestyle to the acquired western modern style. Metabolic diseases such as hypertension, diabetes and cancers initially found in the modern world, have now emerged in the developing world and have been linked to unprecedented morbidity and mortality. Prevention is becoming more and more the mainstay of tomorrow’s medicine with nutrition playing a critical role in comprehensive HIV and AIDS interventions. Although challenges still exist for the incorporation of nutrition as an integral part in HIV and AIDS strategies, significant steps have already been made in this regard in other parts of the African continent.

Nutrition does not only help HIV infected candidates build up energetic reserves to palliate the energetic deficits and strengthen the immune system but can be a valuable way of retention to care since lack of food and ARV side effects are reported as factors leading to adherence issues.

Chapter 3 RESEARCH METHODOLOGY

3.1 Introduction

The research problem investigated by the researcher relies on archived documents of health facilities encompassed within the study sites. The basis of this chapter is to delineate the methodology that guides the study and describe the relevance of explicit procedures to apply for the understanding of a research problem (Labaree, 2009). As a consequence, the methodical selection and description of the methodology within the work frame of this chapter entail a critical evaluation of the overall validity and reliability of the piece of work by readers (Labaree, 2009).

Researchers need methodology to illuminate where they are coming from and the necessity of a particular way to conduct their study. The problem solving process which is a very complex initiative with a wider range of methodology involves an outstanding understanding of the research problem and the nature of data to allow the selection of the more adapted methodology that elaborates on the design, the nature of data, the collection of data, the sample size and the sampling method including ethical considerations.

3.2 Research setting

A research setting can be defined as the site a study is conducted, the environment in which a research study is normally carried out. A variety of research setting exists depending on the problem that needs a solution and the type of data involved. Physical, social and cultural research settings represent just a sample of what has been described in the literature. Physical research settings for instance are geographical areas from which study participants are drawn.

MAHALAPYE and SHOSHONG health facilities constituted the sites of the current research study. HIV and AIDS services previously the monopoly of primary and district hospitals years ago in Botswana have been integrated in the package of primary health care provided by clinics and health posts following the scaling up initiatives of HIV and AIDS services.

Apart from MAHALAPYE district Hospital which is the biggest Health institution in the health district, other health facilities varies from small to medium size structures with a very restricted workforce. The outsourcing of certain basic services led to the reduction of government employees in most health facilities. Child welfare clinics were differently organised based on the available structures, the complexity of health services and the qualification of the human capital. In the district hospital for instance, Midwifes and nurses ensured the daily running of the service in child welfare clinics whereas the same duties were under the responsibility of health educator officers mostly assisted by interns on attachment in Health posts and Clinics. Facilities faced the challenge of space for documents keeping and the child welfare services were organised either in separated buildings or outside. The Hospital remained the only facility that faced fewer challenges in terms of space for archives and for food storage ,and remained the only facility were collection of data was quite comfortable.

3.3 Methodological Approach

This consists of the selection of a designated study approach more adapted to the nature of data that will answer the research problem. The current research study explicitly focused on document review of archived medical records of children who attended the child welfare clinic at a certain period of their childhood. The study will proceed by the determination of the population patterns by means of numerical data and a descriptive quantitative approach seem more plausible to answer the research question posed.

As previously stated, the choice of quantitative methodology is owed to the emphasis of objective measurements, the statistical analysis of patterns of the population under investigation and the numerical data used for analysis. Data collection is made possible in this particular study by the use of customised collection tools used for the manipulation of pre-existing numerical data intending to generalize across a group of people or explain a phenomenon justifiable by the descriptive characteristic of the design (Labaree, 2009).

3.3.1. Research Design

Problem solving is the essential outlook that motivates a researcher study and the adoption of a good design that minimises biases is core practice.

A research design thus represents the entire process of selecting the appropriate approach as regard to the data to be analysed and elaborate in details the step by step process from data collection to analysis of data. For Christensen, Johnson and Turner (2015), research design refers to the outline, plan or strategy that specifies the procedure to be used for seeking answers to your research question. It takes into consideration the primordial needs of a research in relation to the design, the ethical requirements and the feasibility of the study. While some authors refer to it as the master plan of conducting a research, others concede it as the framework of the study project that involves the entire machinery from the description of the approach to the analysis of data.

3.3.2. Data collection methodology

The choice of data collection method is always influenced by a number of factors that can range from the types of variables, the accuracy required and the collection strategy. Data collection methodology can be defined as the gathering and the measuring process of information of the variables of interest in an organized fashion that enables the researcher to answer the stated research question and evaluate the outcomes (ORI, 2005).

Data collection instruments can be selected from the existing samples or customised in a more adapted fashion as long the instrument and the process provide accuracy and honesty to maintain the integrity of the research.

The research study which is a descriptive quantitative design with a retrospective character intends to use a customised data collection tool to record numerical data in relation to the anthropometric parameters of the study population and the nominal data that have to do with the attendance to child welfare clinics and the food rations allocated per visit.

3.3.3. Study Population

The study population can be defined as a group of people drawn from the general population that shares common characteristics. Christensen & all (2015) have defined the study population as the full set of people from which study participants are sampled.

HIV infected children under five years of age from both MAHALAPYE and SHOSHONG constituencies who attended child welfare clinics at an early stage of their existence constituted the study population of the research study. Only data of the first year under the food programme interested the study.

3.3.4. Sampling

Sampling refers to the technique that consists of selecting a section of individuals from a larger population to make up for the study participants. The methodological sampling technique mainly used depends on the type of analysis performed .For the purpose of the study, the estimate regarding the sample size only came into light after total document review of different study sites since no record keeping mechanism existed to update the HIV status of children under five years of age attending child welfare clinics. From the research outset, the researcher anticipated a small number of study participants not exceeding a hundred individuals based on the latest national statistics on mother-to-child HIV transmission. PMTCT programme in Botswana has been amongst the most effective in the sub-region due to the substantial reduction in the transmission rate to lesser than 2%. The scarcity of HIV infected children less than five years of age across all the sites prompted for a purposive sampling technique using the data of the entire population of HIV infected children under five years of age within a specified period of 6 years(since 2010).

3.3.5 Type of data

The research study employed data collection tools that primarily targeted subsequent study participants’ weights from their first visit into the food programme to the twelfth visit. Different classifications of the nutritional status were recorded as well alongside the frequency of visits and the nature of food package provided at each visit. Indeed the research used numerical data for weights and classifications whereas data for clinic attendance and the rations provided were nominal. The codified data collection tools were designed in a de-identified format omitting every identifier that could link data to candidates to ensure unanimity and confidentiality.

3.3.6 Data Analysis

A descriptive statistics was opted to understand the set of data collected in our various sites because of its attributes of describing phenomenon, situations and events and specifically the growth profile of study participants enrolled under the programme within a certain period of time.

To ensure an adequate communication and optimize understanding of the findings by a broader range of readers, the research study intended to summarize collected data representing key characteristics of study participants in form of frequency distributions, trends using graphic representation of weight means, the nutritional status, clinic attendance and food ration allocation for both genders.

3.3.7 Conclusion

At this point, the research methodology through the approach and the descriptive design highlighted the study framework and the parameters of interest in the conduct of the project.

With regards to the numerical and nominal nature of data, activities were channelled through a designated pattern corresponding with the roadmap of a descriptive quantitative research that reached out for statistical expectations translated in graphic representation of important characteristics of the study population.

Chapter 4 RESULTS, DISCUSSION AND INTERPRETATION OF FINDINGS

4.1 Introduction

The ultimate of a descriptive quantitative research data is the determination of events or phenomena patterns that describe most the population under investigation and data collected are of no benefit if they cannot be compiled, organized and graphically represented to serve the purpose.

The mainstay of the chapter is the elaboration of an organized response to the research problem raised by the investigator following a societal phenomenon observed. This chapter emphasises on the organisation of data, describes or interprets the trends and patterns that have emerged for the data in connection with the population studied and link the findings to perceived causes. The aim of data collected from MAHALAPYE and SHOSHONG constituencies is to shed light on the nutritional condition of HIV infected children under five years old receiving food rations in their respective clinic. The research objectives are stated as follow:

- To establish the weight-for-age pattern of HIV infected under five years old children attending child welfare clinics a year after enrolling in the food programme.
- To determine the pattern of the mid-upper-arm circumference a year after enrolment in the programme
- To determine the proportion of undernourished HIV infected children within their first year in the food programme.
- To establish the regularity of food rations within the first year in the programme
- To determine the default rate to child welfare clinics of HIV infected children within the first year following their enrolment in the programme.

4.2 Demography of study Participants

In total 54 candidates were estimated eligible after documents review of different sites and 38 candidates (70%) represented the male population and 16 candidates (30%) the female population as depicted by Figure 4.1. The proportion of male participants from the study sites was slightly more than the double of the female participants. The research study has surprisingly demonstrated the opposite of what has generally been the case in terms of sex distribution of HIV infected people of other age groups. There has been a female predominance of new infection within adolescents and the adult groups as per available literature (AVERT 2016).

Figure 4.1. Sex distribution of study Participants

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Another critical aspect of the demography is the participants’ distribution per constituency as demonstrated by the following graph.

Figure 4.2. Participants’ distribution per constituency

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Figure 4.2.Showed that MAHALAPYE recorded more participants (59%) of eligible candidates that attended child welfare clinic, a number which was slightly above that of SHOSHONG constituency with 41% of study participants. The district hospital is located in MAHALAPYE, an urban rural area with more infrastructures and a transport system much more organised than in SHOSHONG. These factors could have contributed to the bigger number of participants identified in MAHALAPYE than SHOSHONG.

Figure 4.3 Sex distributions per site

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Figure 4.3 which represented sex distribution per constituency clearly highlighted the equal rate of female participants between MAHALAPYE and SHOSHONG at 50 %( 8 participants each).

4.3 Determining the default rate to child welfare clinics

It is evident that after birth, children should be weighed at least once monthly if less than one year of age and less frequently for children aged a year and above for monitoring of the development. Weight gain is crucial for children and a regular weighing strategy can assist professionals for the detection of an early faltering growth that can necessitate appropriate actions. Child welfare clinic attendance warrants children with food rations in Botswana as a nutritional supplement under the accelerated child survival and development strategy beyond the routine practices of weighing and immunization.

Figure 4.4 illustrates frequency distribution between clinic attendance and the default rate for the entire investigation period.

Figure 4.4 CWC attendance and default rates

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Figure 4.4 clearly showed that the attendance rate surpassed the default rate in each visit apart from the ninth visit where the two rates equalled. Considering the importance of regular monthly visits for children regarding the assessment of their nutritional and development statuses, the default rate as demonstrated by the figure was inextricably worrisome. In the majority of cases, the default rate represented either the third of the attendance rate and in few instances almost half the attendance rate such as at visit 10 (39%), visit 2 and visit 4 (35%). The annual average of the default rate stood at 33% which is half the annual average of the attendance rate (67%). The first visit under the food programme corresponded with the lowest default rate (24%) probably for the enrolment purpose. The large default rate recorded throughout the year posed a question of reachability of the population target. The findings aligned with a different study that demonstrated that default rate to clinics were somehow connected to socio economic factors. Age of caregivers and their literacy rate accounted the most (UNICEF, 2012:12). During collection of data in rural areas specifically, shortage of food rations in Health facilities during certain periods of time was associated with default to CWC. A fact that highlighted the high reliability of the rural population to the food rations and which rations constituted the primary motivation to attend child welfare clinic for children weighing. An observation was made that in the absence of food rations, carers preferred to attend to their agricultural activities than going to the clinics.

4.4 Regularity of food rations

In 2010, more than 3 million children died in Sub-saharan Africa for condition deemed preventable, a reason that motivated the Government of Botswana in partnership with UNICEF to develop the accelerated child survival and development strategy (ACSD) to rapidly achieve the MDGs and the vision 2016. Supplement of vitamin A and of TSABANA, a cost-effective and locally manufactured food were critical parts of the project to improve the nutritional situation of children aged 6 to 59 months. Although the implementation impacts of such strategy in hunger reduction and child mortality is still to be documented, the strategy intended to improve the coverage and quality of interventions such as food supplementation for the wellbeing of children (UNICEF, 2012:6). The supplementation of TSABANA is monthly based countrywide and has been facing challenges as that of vitamin A supplementation in terms of reaching out for the target population (UNICEF, 2012:12).

Below is the figure that demonstrated the pattern of food packages study participants received within the first year under the food programme.

Figure 4.5 Food ration per visit

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Figure 4.5 showed the frequency distribution of different packages study participants received per visit. Complete food rations within this age group was the combination of TSABANA (Sorghum, Soybean)and vegetable oil whereas incomplete package was identified as a single component of the complete package combination.

The first visit which had the highest attendance rate (76%) as illustrated earlier on was for unknown reasons embodied with the highest proportion of children (69%) not receiving any food ration. We tend to believe that the observed gaps might be explained by the inadequacy in programme implementation from Health professionals, knowledge gaps concerning programme eligibility, caregivers’ reluctance or food shortage that happened to be more significant at the first visit. The first visit was marked by the smallest rate of incomplete package (3%) as well.

However, apart from few visits (visit 1, visit 2, visit 7) the number of children who received complete package remained higher throughout the year of investigation with an annual average of 40%, an evidence of political commitment to nutritionally support the children despite the economic recession. The annual averages of both incomplete and lack of ration were respectively 21% and 33%.

The underperformance of the nutritional coverage was multi factorial. Away from the government capability to sustain the programme and technical issues pertaining to the supply chain beyond of Health facilities’ control, the lower coverage of food rations as evidenced by figure 4.5 aligned with findings from a similar study that pointed out socio economic factors, literacy rate and age of caregivers as factors explaining the supplemental programme underperformance (UNICEF,2012:12).

4.5 Nutritional Assessment

4.5.1 Determining the pattern of the mid-upper arm circumference

The upper-arm circumference abbreviated MUAC is the arm circumference measured between the tip of the left shoulder and the ipsilateral elbow of children. Reasonably easy for Health providers and used at different contact points, the determination of mid-upper arm circumference found its significance in the nutritional assessment of children under five years old. Several studies have associated measurement of mid-upper arm circumference to the detection of malnutrition and the identification of children in need of treatment (WHO, 2012).

Whereas the determination of the mid-upper arm circumference is mostly numerical in centimetres or millimetres, the nutritional surveillance logbook used in Botswana offered two possibilities and the nutritional classification option seemed to have been the mostly opted by professionals in the study sites visited.

The MUAC nutritional classification as per the nutritional surveillance logbook used the number 0 to represent well nourished children, the number 1 for moderate malnutrition and the number 2 for severe malnutrition.

Figure 4.6: The highest malnutrition rate

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The tenth CWC visit had the highest malnutrition rate in relation to the mid-upper arm circumference as illustrated but figure 4.6 above, reaching the 13% for a total number of 32 participants who attended their 10th visit under the programme.

Figure 4.7: The lowest malnutrition rate in relation to MUAC

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Figure 4.7 which represents the sixth visit is only a sample of visits (visit 2, visit 3, visit 5) with the lowest malnutrition rates averaging the 3% in relation to MUAC.

Figure 4.8: Mid-upper-arm circumference at twelve month

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Nonetheless, at the twelfth month of the food rations programme which corresponded to the end of the investigating period, no malnutrition rate has been identified and the twelfth visit was similar to visit 1and visit 4. In conclusion, study participants had their mid-upper arm circumference within normal after the completion of twelve months under the programme.

4.5.2 Malnutrition rate amongst HIV infected under five children

Malnutrition is responsible of over one third of children deaths in the world and the prevalence seems more exacerbated in developing countries because of excessive poverty. Malnutrition and HIV and AIDS represent in Sub-Saharan Africa two of the leading causes of infant mortality. Botswana malnutrition rate is considered amongst the highest in consideration with the recent economic achievements and the national income. Although the national malnutrition prevalence has reduced by 10% for the past ten years, the latest statistics were characteristic of a stagnant pattern. In 2004, the prevalence rate was at 34% before it dropped down to 24.8% ten years later and remained the same in 2015 despite the political commitment and the funding efforts (FACTFISH, 2016). Figures below demonstrated the general malnutrition pattern of the study population the first year of the food programme.

Figure 4.9: The highest moderate malnutrition rate

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Figure 4.9 showed the highest moderate malnutrition rate which occurred at the 11th visit under the programme. Four children (10%) during this visit were identified as presenting moderate malnutrition out of a total number of 39 attendees. And figure 4.10 below identified the visits with the highest prevalence rate for severe malnutrition observed at the 4th visit and the 5th visit.

Figure 4.10: the highest severe malnutrition rate

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The above figure which represented simultaneously the situation of the fourth and the fifth visit identified the highest severe malnutrition rate of the study population. Three children (8%) out of a total number of 36 attendees had severe malnutrition.

More than one-third of children deaths have been nutrition related in Botswana despite the latest economic achievements. Malnutrition eradication might remain the priority of every national programme and implicates more than what is already done in terms of commitment and interventions, but the prevalence rate of the study participants remained below the recent national statistics which was already encouraging considering the positive HIV status of the participants. Very few children were malnourished within the first year of the food programme and by the end the study period, three candidates (7%) only out of 38 attendees presented with moderate malnutrition at twelfth month. The causes of malnutrition were not established but the urban rural setting of the study made it believe that socio economic factors such as poverty, the unfavourable semi-deserted climate that prevented agriculture of subsistence might be the explanation, entailing the higher reliability of the entire family to the food rations allocated to children.

4.5.3 Establishing the weight-for-age pattern of HIV infected children under five years old

The growth patterns of both male and female are determined by establishing the trends from weight means obtained in each visit. Generally a normal trend of a healthy child follows a tract that is parallel to the median and to the Z-score lines. A healthy tract will be between the Z-score lines above or below the median (WHO, 2008). The Z-score lines on the weight-for-age graphs are identified as lines above the median corresponding to a standard deviation of +2 and below the median corresponding to a standard deviation of -2. The growth line of a growing child will generally be comprised between -2 SD and +2 SD Z-scores of the weight for age indicator. An overweighed child will have his growth line crossing the +2 SD Z score line above the median and an underweighted child in contrary will have his growth line that crosses the -2 SD Z score line below the median (WHO,2008).

Tables 4.1 and 4.2 summarise successive means of both groups (male and female) for the entire follow up period with their respective standard deviations.

Table 4.1: Male weight-for-age means per visit with corresponding standard deviations

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Table 4.2: Female weight-for-age means per visit with corresponding standard deviations

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The above tables have evidenced that none of the standard deviation per visit was > +2 and < -2 Z-score meaning that every mean fell between Z score lines indicative of normal values. While prominent discrepancies were observed between standard deviations of the female group, standard deviations of the male group remained nearly constant with slim differences.

Figure 4.11 below contained weight-for-age means for both genders representing the average growth lines of both genders during their follow up period. Study participants were six months old at the first visit of the investigation period which corresponded with the enrolment age under the food programme.

The average attendance rate was 67.7% for a total population of 54 individuals. The lowest attendance rate (53.7%) was observed at the 9th visit and the highest attendance rate (75.9%).

Figure 4.11: Weight-for-age means per sex

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Both growth lines representing the patterns of both genders were encompassed in a tract between the Z score lines, parallel to the median with the males’ growth line slightly above their female counterparts.

The males’ growth line progressed steadily along the median from the first visit (sixth months of age) without significant decline nor incline till the twelfth visit (eighteen months of age).

The average of females’ growth line was marked by a sudden decline at the third visit but remained between the two Z score lines and immediately regained it steady progression at the fourth visit. The growth line did not cross the Z-score lines above nor below.

The female group presented the highest standard deviation of SD=1.79 at the fifth visit and the lowest SD=0.61 at the second visit.

Figures 4.12. Weight-for-age means for both sexes

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Figure 4.12 showed a healthy growth line, parallel to the median and encompassed between the Z score lines. It represented the average growth line of both genders. The standard deviations of weight means which are not represented here were all comprised between -2 SD and +2 SD. All the means obtained were within the normal range according to the WHO standards of healthy children.

4.6. Conclusion

The analysis of data collected by the research answered all the research objectives and demonstrated the normal growth patterns of HIV infected children under five years of age benefiting from the Government food rations during their first year on the programme. The graphic representation of growth profiles that needed to be confronted against the WHO child growth standards median showed normal means encompassed between the Z score lines. Important figures and proportions have been unearthed as to the malnutrition levels of HIV infected children under five year of age. The analysis of data further provided a broad insight on child welfare clinic default rates which seemed to be non negligible and the rate of distribution of different packages associated with the coverage of food rations.

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Chapter 5 CONCLUSIONS AND RECOMMENDATIONS

5.1. Introduction

The vulnerability of children under five years of age has been sufficiently demonstrated in the literature due to their potential for malnutrition and because of their deficient immune system preventing this age group from an effective protective mechanism against infectious diseases.

The number of children currently dying before reaching their fifth birthdays is unprecedented in the developing world. Evidences showed that in spite of a dramatic drop in child mortality, the most vulnerable and disadvantaged children across the globe continued dying from preventable diseases. Malnutrition which is the resultant of extreme poverty prevented the population in general and children in particular to access the necessary nutrients their organism needed for a healthy physical and mental development. One billion people less has been estimated to be living in extreme poverty than two decades ago but children roughly accounted for half of the world’s extreme poor (Garcia,2015). Understanding the importance of nutrition in the integral growing process of children is a crucial step for the development of interventions that are susceptible to alleviate the suffering of many, knowing that only one in three children of the poorest benefit from social protection.

The HIV and AIDS economic burden in Botswana and the unfavourable climate for agriculture of subsistence have certainly contributed to the development of a national poverty eradication strategy that aimed at alleviating the torment of vulnerable groups such as children. Through its Accelerated Child Survival and Development Strategy (ACSD), Botswana featured amongst the rare countries in the Sub-region that provided a social safety nets to children and the food rations allocated to this age group constitute a comprehensive buffer against hunger countrywide (UNDP,2012).

5.2. Research problem statement

HIV and AIDS epidemic effects in Botswana in a background of poverty might have specifically increased reliance of the rural communities to government food rations not only for children and the vulnerable groups but also the physically fit portion of the population. The research study aimed to understand the outcome of the government food programme on the nutritional status of HIV infected children under five years of age in MAHALAPYE and SHOSHONG constituencies.

5.3. Study Objectives

- To establish the weight-for-age pattern of HIV infected under five years old children attending child welfare clinics a year after enrolling in the food programme.
- To determine the pattern of the mid-upper-arm circumference a year after enrolment in the programme
- To determine the proportion of undernourished HIV infected children within their first year under food programme.
- To establish the regularity of the food rations within their first year under the programme
- To determine the default rate to child welfare clinic attendance of HIV infected children within the first year following their enrolment in the programme.

5.4. Summary of the study

The study was marked by an unequal demographic distribution of the study participants and the number of participants drawn from each constituency had no relation with the size of the constituency. A total number of 54 candidates had medical records that were compatible with the research problem after systematic document reviews of each facility within the concerned constituencies, and these children the medical records belonged to were estimated eligible to participate in the study.

The study sample which equalled the study population was made up of 54 candidates unequally distributed within the two constituencies and MAHALAPYE had more participants than SHOSHONG. The male predominance of the study sample was evident and the sex distribution showed 38 male participants (70%) and 16 female participants (30%). The size of constituencies did not matter in terms of the female sex distribution because both constituencies presented the same number of female participants that were eligible for the study (eight female participants each).

The analysis of the data collected revealed an important default rate of children under five years old to child welfare clinics and the annual average rate of the default was estimated at 33%. Reasons for the defaults are yet to be investigated but a similar study of UNICEF that mostly focused on the coverage of TSABANA listed a number of elements considered as factors susceptible to affect the coverage of TSABANA and consequently affected the attendance to child welfare clinics as well. Factors such as the level of urbanization, the level of wealth, the level of literacy and the age of the caretakers had all contributed. The poverty rate being quite significant in the urban rural setting of the study, transportation to health facilities, inability of older caretakers to read the children medical records for the appointment dates due to insignificant literacy level could have played a major role in defaulting child welfare clinics. Most interestingly, an observation emerged at the data collection process that revealing the connection between food shortage in Health facilities and increased default rate to child welfare clinics. This situation was almost obvious in rural areas and could be explained by the allocation of caretakers’ time to other activities. In the rainy season for instance, agricultural activities such as ploughing takes precedence over other aspects of life and the attendance of child welfare clinic loses it intrinsic meaning in the absence of food rations. The default rate to health facilities was not only limited to children during the rainy season but extended to their adult counterpart with regard to HIV and AIDS services.

The underperformance of food programme was also uncovered with only an annual average rate of complete food rations at 40%. The first visit under the food programme was characterised by a large number of children not receiving food package and it is not clear whether food shortage was the main reason or whether it had to do with inadequacy in the implementation of the programme from health professionals.

Nevertheless, the determination of the mid-upper arm circumference which is another way of assessing the nutritional status of children under five years of age alongside the nutritional classification of children under five years of age according to the weight-for-age criterion had all converged to the determination of a maximum malnutrition rate per visit of 13% at the tenth visit, by far lesser than the national children malnutrition rate of 24.8% in 2014. Despite the irregularity of food ration to the proportion of 60% (incomplete package and no package), the Government of Botswana managed to reduce the national malnutrition rate by 10% within a decade. A reduction from 34% in 2004 to 24.8% in 2014 over a period of 10 years is proof enough that political commitment and effective planning in a setting of financial constraints can result to malnutrition alleviation.

Finally, the determination of the growth patterns of both genders using the WHO standard of weight-for-age has showed healthy patterns of the two study population groups. Weight means from the first visits to the last visits during the investigation period for both genders were within normal. They complied with the WHO standard deviations of healthy children and the average trends obtained were between SD>-2 and SD<+2.

5.5. Conclusion

Through the generations, foods played the role of critical ingredient in the existence of humankinds. It represented the major motivation that explained the nomadic lifestyle pattern of our ancestors in the ancient time who were relentlessly in search of vital source of proteins. Our ancestors perfectly knew the role of macronutrients and micronutrients provided by a balanced diet as the rational for individual welfare. The incontestable virtues of a balanced diet as regards to disease prevention have contributed to the scientific advancement of nutrition as one of the fast developing disciplines across the globe.

Besides the unequal distribution of resources in the world, the emergence of HIV and AIDS epidemic considered as a global threat has constantly threaten population of the developing world already harmed by poverty and malnutrition. The magnitude of the epidemic and malnutrition impact is so severe in Sub-saharan Africa such that policy makers and policy implementers’ efforts in the elaboration of strategies to simultaneously overcome the epidemic and eradicate malnutrition have been highly appreciated and encouraged. In its positive strategy thinking, the Government of Botswana in partnership with relevant stakeholders took further steps in HIV and malnutrition burden alleviation initiatives specifically for the most vulnerable population groups including children under five years of age.

The family enthusiasm that surrounded children’ rations every month motivated the research study to answer the questions that were raised on whether the beneficiaries of the food programme really benefited from their donation. The assessment of the food programme and the nutritional status of children below five years of age enrolled in the programme were then made possible by evaluating the growth profile of study participants through answering the diverse study objectives. It surfaced from the analysis of data from the 54 study participants a higher default rate to child welfare clinics within the two constituencies under investigation. And the irregularity of food rations did not prevent the study participants to present normal growth patterns as per the WHO criteria for healthy children. The research study described main nutritional characteristics of the study population without determining the cause and effects relationship between food rations and resulting nutritional status which was not the scope of the project. Indeed the study concurred with facts that the food ration programme might have not been the only reason explaining the healthy growth pattern of the study population, but definitely accounted as a major contributor to the welfare of children below five years of age in MAHALAPYE and SHOSHONG.

5.6. Recommendations

The conduct of the research study has not been without challenges. Data collection appeared to be the most complex step owing to the differences in site structures, personnel and most importantly issues ascribed to records keeping.

On one hand, recommendations are addressed to diverse institutions visited by the researcher and to a broader extent to every health facility within the national framework pertaining to service improvement in child welfare clinics. Emphasis should be placed on efficient and reliable recording of anthropometric values of clients who attend child welfare clinics in relevant registers. Readable handwritings are determinant for the future utilization of medical records and should not stand as a major obstacle for a third party that embarks in document review. Ensuring timely HIV testing especially for HIV exposed children and the tracing of results are necessary steps to envisage since polymerase chain reaction, the required diagnostic test for this age group is only done at the national laboratory in the capital city of GABORONE and the long turnaround time can sometimes be inconceivable. It is imperative to try by all means, depending on the available human capital and the resources in place to follow up children who are defaulting child welfare clinics.

On the other hand, the research study uncovered areas for potential further investigations susceptible to enlighten the gaps and shortcomings found in the government food programme.

Whereas the current study described the growth patterns of the programme beneficiaries, further studies can focus on the determination of the cause to affect relationship that existed between food rations and the nutritional status of HIV infected children under five years of age. The research study evidenced a significant annual default rate to child welfare clinics of about 33% and if socio-economic elements have been identified as some of the contributing factors, further studies to identify personal reasons behind the significant default rate in MAHALAPYE and SHOSHONG constituencies will be welcome. The study showed that the annual rate of incomplete package and no package within the period of investigation were high and the study could not explain the food shortage because it had to do with the supply chain, a situation which was completely beyond the control of health facilities. Further investigations to understand the supply chain of food rations from TSABANA production to health facilities would be very informative. The poverty context of the study setting raised the possibility of shared food rations between beneficiaries and the entire family, a situation that questioned the exact portion of the food rations the programme beneficiaries actually consumed. A research study on this aspect to determine the portion of food rations HIV infected children under five years of age eat from their donation would be very much appreciated and despite the nutritional status of HIV infected children benefiting from the programme, policy makers and implementers are hereby suggested to consider the expansion of the initiative to family members of HIV infected children to alleviate the disease burden the entire family faces. It requires a lot of political commitment and resource mobilization to effect such an initiative which might pose questions on programme sustainability as for other HIV and AIDS services. Further researches might be needed to evaluate the cost of such interventions locally and within the national framework.

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ADDENDUM

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