Socioeconomic and cultural factors influencing nutritional status of children in three sudanese villages

Socioeconomic and Cultural Factors Influencing Nutritional Status of Children in Three Sudanese Villages MARY

L.

DUNDAS 1 AND MARY F. FUTRELL 2

lCenter for Health Promotion, University of Tennessee, Memphis, Tennessee 38163; and 2Department of Food Science and Human Nutrition, Mississippi State University, Mississippi State, Mississippi 39762

Introduction. The drought and famine in Africa have received much publicity and attention, but the underlying causes of malnutrition also need to be examined. Sudan is the largest country in Africa, situated south of Egypt with the Red Sea and Ethiopia to the east; Kenya, Uganda, and Zaire on its southern border; and the Central African Republic, the Republic of Chad, and Libya to the west. The Nile River, which passes through the entire length of Sudan, is the principal means of transportation and livelihood of the people. Sudan is a land of contrast and diversity due to 'its great number of tribal groups, languages, customs, religions, climate, and terrain. Factors influencing the nutritional status of children in Sudan include customs and culture, income level of the family, location ofthe village, knowledge of the family member making food purchases, and the environmental conditions. It is extremely important that nutrition educators examine these factors before planning a program. Thus our objectives were to determine social, economic, and cultural factors that affected food consumption patterns; to determine which foods families consumed most frequently; to determine the methods of food preparation and storage; and to document the extent of malnutrition. We also wanted to draw some conclusions about the relationships among some of these factors. Villages. To achieve our objectives we surveyed three villages in the semi-arid central region of Sudan where whole-grain sorghum is a staple in the diet of the people. UmSagata, an Eritrean refugee village with a population of 25,000, is located 412 km southeast of Khartoum near the Sudan-Ethiopian border. The terrain is grassland with huge hills throughout the area. Nuba village, situated 45 km directly south of Khartoum on the White Nile River, has a population of 600. In spite of the desert climate, fruit trees and crops grow in this area because the village is near a good source of water. Nuba is near Khartoum and many people work and purchase their food there. Thus the residents of Nuba have access to a larger amount and a greater variety of food than do residents of the other two villages. Oliab village has 500 inhabitants and is VOLUME 19 NUMBER 2

1987

located 60 km north of Khartoum in the middle of tht desert, away from the Nile River and the main road 1£ Khartoum. It has few trees or other vegetation due t( the lack of water. None of the three villages has elec· tricity, running water in the homes, or a market wherE foods can be purchased. None of the villages receives food assistance from the government or relief agencies.

Lifestyle. The society in northern Sudan is familyoriented with the men having the dominant role. The people are extremely hospitable and friendly, and go to a great deal of effort to welcome visitors and make them feel at home. Because of the Arab cultural influence, men and women are segregated in both public and private activities. There are separate schools for girls and boys, and in the homes there are certain rooms designated for the women. Homes in these villages are made of readily available materials, such as mud, thatch, and straw. The houses in UmSagata, the Eritrean refugee village, are round with a conical thatch roof supported by mud and straw walls. The houses consist of one multipurpose room with an earth floor which is used for cooking, sleeping, entertaining guests, and sheltering the animals. The houses in Nuba and Oliab are made in the traditional Arab style with high mud walls surrounding the two- or three-room rectangular-shaped houses. Most homes are sparsely furnished with two or three rope beds and a small metal table; there are usually no chairs. Life in these villages is centered around the home and family. Since the villages do not have electricity, the work day begins at sumise and ends at sunset. The nuclear family is responsible for its members' daily needs such as food, clothing, and a place to sleep; but the extended family is very much a part of daily life. In some homes there is a constant flow of family and friends. Questionnaire. We developed a questionnaire that contained both open-ended and closed-choice questions. The questionnaire sought to identify the following descriptive data about household members: name, JOURNAL OF NUTRITION EDUCATION

49

age, sex, and relationship within the family, as well as education, occupation, and income. The questionnaire also elicited family-based information such as number of children; infant-feeding practices; food purchasing, preparation, and consumption practices; food attitudes and beliefs; and an estimate of the amount and types of food consumed by the family over a 24-hour period. With the assistance of a resident of each village, we used the questionnaire to conduct interviews during February and March 1984. Thirty women in each of the three villages (a total of 90 women) were randomly selected for the interview. We also lived in participants' homes for approximately 7 days at each village. While residing in participants' homes, we observed household tasks performed by the women in the families as well as methods of food preparation and consumption. We had several discussions with family members to clarify Sudanese customs and dietary habits. Anthropometric measurements and statistical tests. In interviewees' homes in the three villages we measured children from 6 to 60 months in age. We used light-weight portable weighing and measuring equipment to obtain height, weight, and arm circumference measurements on a total of 116 children. We weighed and measured 44 children in UmSagata and 36 children in both Nuba and Oliab. A Salter portable scale was used to measure weight to the nearest 0.1 kg. A stationary tape measure was used to measure height of infants in the recumbant position; older children stood for the measurement. We used the Gomez et al. (1) and the Waterlow (2) classifications to determine the degree of malnutrition, and chi-square analyses to determine whether associations existed among the three villages. FINDINGS Household size. Sudanese families are large, and members of the extended family often live under the same roof. The families interviewed in the three villages ranged in size from 3 to 11 persons. The head of the family is always a man: if the father is absent, the oldest son or a brother of the mother takes on that role. Of the women that we interviewed in UmSagata and in Nuba, 71% and 67%, respectively, had families that ranged in size from 5 to 8 persons. In Oliab, 80% of the families had 4 to 8 persons in the household. None of the families interviewed in the three villages had fewer than 3 persons since it was not customary for single people or elderly people to live alone. Men's occupations. In the northern part of Sudan, women's and men's roles reflect the dominance of the 50

JOURNAL OF NUTRITION EDUCATION

Arabic culture. Women do not work outside the home except for those who are well educated and live in the city. The primary occupation of the men in UmSagata is farming; 70% of the families interviewed were engaged in this occupation. In UmSagata, the farmers grew only sorghum, but at the time of this study they were not doing so because of the drought. Fifty-three percent of the men in Oliab were employed shoveling sand into trucks that traveled to Khartoum, and 30% were drivers of sand trucks. In Nuba, the men's occupations were quite varied: carpenter, merchant, taxi driver, restaurant employee, policeman, school teacher, goldsmith, night guard, and grocer. Several of the men in this community had gone to Saudi Arabia and were working there because the salaries were much higher than in Sudan. Women's roles. The women that we interviewed in the three villages performed the typical tasks of homemakers, including preparing the food, washing clothes, caring for the children, and cleaning the house. However, women in this culture do not usually shop for food since it is the men's task to go to the market. Children help with the household tasks by hauling water and helping to care for the younger children; and some of the older girls are completely responsible for the meal preparation. Boys often help their fathers with their jobs, but those who go to school are not expected to help at home. Boys do not assist with what is considered women's work, but many do help care for younger siblings. Food preparation. Women squat on the earthen floor of their homes to prepare and cook food over an open fire. Cooking utensils consist of metal pots, a metal spoon, and a few dishes. Many homes have a saj-a square thick metal sheet that is placed over an open fire and used to cook kisra, the paper-thin bread made from whole-grain sorghum flour. The girls serve meals on large round metal trays containing several dishes of different foods. Family members do not use individual plates, utensils, or glasses. Instead, they gather around the food tray and sit on rope beds or wooden stools brought up close to the food. Kisra and pieces of wheat bread are placed around the outer edge of the tray so that all family members can reach them. Family members tear off pieces of kisra or bread and use them to scoop up some other food such as stew or vegetables. Soup is served with left-over bread in the soup bowl so that it can be consumed without using spoons and individual bowls. Only the right hand is used for eating. No beverage is served until after the meal. Then water or another beverage is poured into one glass and passed to all members of the family. After the meal, tea is served in a small glass which is passed around; everyone VOLUME 19

NUMBER 2

1987

holds the glass at the very top to avoid burning their fingers. The tea, which is boiled, is extremely strong and very sweet because about 3 tablespoons of sugar are placed in the glass. Income and food expenditures. Family income had an effect on the diet and, consequently, the health of family when not enough money was available to purchase food. Fifty-seven percent of the respondents in Oliab and 70% in Nuba reported a yearly income of between $501 and $1250. Mean yearly income in Oliab and Nuba was $757 and $1162, respectively. In UmSagata, 83 % of the individuals we interviewed said they did not know their yearly income. However, the income in UmSagata was much less than in the other two villages. UmSagata residents had less money to buy food and little food was available for purchase. This was due in part to the fact that UrnS agata is a refugee village with sorghum farming as the primary source of income, and the area had suffered a severe drought during the previous growing season. No other crops were grown in this area. Mean food expenditure per week for families participating in the study was $4.50, $10.50, and $28.00 for UmSagata, Oliab, and Nuba, respectively. Ninety-seven percent of the respondents in Oliab, and 73% in UmSagata spent between $2.50 and $22.50 per week on food. In contrast, 93 % of the respondents in Nuba spent between $15.00 and $37.50 on food per week, which reflected the higher income level and standard of living in that village. The cost of some foods commonly eaten by Sudanese were $0.45 for a pound of tomatoes, $0.68 for a pound of beef, and $0.06 for a small loaf of wheat bread. Infant and child deaths. In the families interviewed, women typically had borne several children because many children die before reaching adulthood and living children are a form of old-age security. The number of children per woman ranged from one to twelve in both Oliab and Nuba. Of the women interviewed, 40% in Oliab, 43% in Nuba, and 47% in UmSagata had children die before 5 years of age (Table 1). The number of children per woman that died before 5 years of age ranged from one to four in Oliab, from one to three in Nuba, and from one to five in UmSagata. Food consumption. In all three villages the staple food in the diet of families is whole-grain sorghum. Sorghum is ground into flour and used to make kisra or cooked to make a thick porridge called aceda. In UmSagata kisra was the food eaten most frequently for breakfast, lunch, dinner, and snacks (Table 2). In contrast, in Oliab aceda was most frequently consumed for breakfast, kisra for lunch, and wheat bread for dinner. However, in Nuba, wheat bread was the most freVOLUME 19 NUMBER 2

1987

Table 1. Infant mortality expressed as the percentage of women in each village who had children die before age of 5 Percent of Women Number of Dead Children per Woman

UmSagata (n = 30)

Oliab (n = 30)

Nuba (n = 30)

0

53% 7 30 7 0 3

60% 27 7 3 3 0

57% 30 10 3 0 0

1

2 3 4 5

quently consumed food for all 3 meals. Wheat bread was much more readily available to Nuba residents because of their proximity to Khartoum. In Nuba, 50% of the respondents consumed kisra at lunch, which was the largest and most important meal of the day. In UmSagata 10 of 30 families interviewed consumed meat for dinner. In Oliab only 2 of 30 families ate meat for dinner, and in Nuba only 3 of 30 families ate meat for breakfast. Meat is expensive and is usually reserved for special Moslem holidays when a lamb is killed and the meat is roasted over a charcoal fire. UmSagata residents ate meat more frequently because they had several goats in the village. The amount of meat served to a family of 8 or more was about 1 pound, and therefore each family member would receive a very small portion. Young children, in fact, ate very little of the meat as their diet consisted mostly of kisra, lentils, and aceda. Fruits and vegetables were lacking in the diets of families in Oliab and UmSagata due to the distance of the villages from a market that sold these foods. Yousif and Khattab (3) also reported that people in Khartoum North did not have adequate fresh fruits and vegetables in their diet. Almost 50% of the respondents in Nuba ate salad for breakfast and over 83% ate salad for lunch. Salad consisted of leafy greens, tomatoes, cucumbers and onions. Fruit drinks were commonly consumed. Lemonade was particularly popular because lemons are inexpensive and readily available. In fact, in all three villages lemon was the only fruit mentioned by the respondents. Carbohydrates are the major source of calories in the Sudanese diet. In the three villages studied, the foods supplying the carbohydrates were kisra, lentils, aceda, bread, beans, potatoes, and rice. Cereals and sugar were the main sources of calories in the diet of people surveyed by Khattab and El Hadari (4) and contributed 84% of the total caloric intake. A food consumption survey (5) conducted in two residential areas of Khartoum reported that carbohydrates contributed 61 % of total calories and that the high consumption of sugar, 155 g. per day, was due to large amounts of sugar in tea and fruit drinks. High sugar JOURNAL OF NUTRITION EDUCATION

51

Table 2.

Frequency of consumption of foods in one day by 90 families in three villages Foods and Frequencies

Village

Breakfast

Snack and Beverage

Dinner

Lunch

Kisra 1 Lentils Aceda 2 Injera 3 Meat Tomato Dried okra Dried meat

11 9 8 7 6 5 5 3

Kisra Lentils Meat Injera Tomato Pumpkin Dried okra Aceda

18 12 10 9 5 5 4 2

Kisra Meat Aceda Injera Lentils Tomato Pumpkin Dried okra

13

Tea Coffee Milk Lemonade Kisra Injera Meat Bread Lentils

30 28 11 6 4 3 3 3 3

Oliab

Aceda Wayca 4 Kisra Stew Yogurt Tomatoes

21 17 6 3 3 2

Kisra Wayca Potato stew Aceda Lentils Stew Salad

24 11 9 5 3 2 2

Bread Aceda Kisra Salad Wayca Soup Stew Meat

12 8 3 3 2 2 2 2

Tea Milk Lemonade Tea + milk Kirsa + sugar Nasha 5 Bread Cookie Kisra

23 20 14 11 6 4 3 2 2

Nuba

Bread Salad Broad beans Kisra Fried eggs Meat Tamia 6 Soup Lentils Aceda

26

Bread Salad Kisra Potatoes Rice Okra Stew Macaroni Lentils Custard

26 25 15 14 11 7 3 3 2 2

Bread Broad beans Rice Potatoes Kisra Salad Okra

24 6 4 3 3 2 2

Tea 27 Milk 17 7 Lemonade Sesame sweet 6 Coffee 6 Bread 5 Pepsi 3 Tamia 2 Rice 2 Tea + Milk 2

UmSagata

13

12 5 3 3 3 3 3 2

9 7 7 7 6 3 3

1Kisra is a paper-thin bread made from fermented sorghum flour. 2Aceda is a thick porridge made from fermented sorghum flour. 31njera is an Ethiopian bread similar to kisra made from fermented sorghum flour. 4Wayca is a stew that contains powdered dried okra as a thickener. It is usually served with aceda. 5Nasha is a beverage made from fermented sorghum flour. 6Tamia is a ground chickpea patty fried in oil.

intake, which is typical of Sudanese food consumption patterns, was found in the present study as well. Food attitudes and beliefs. Factors other than food availability determine what a person eats, so it was important to determine food attitudes and beliefs of the mothers. In UmSagata and Oliab, milk was the food most frequently mentioned as being good for babies (Table 3); in Nuba, the most frequently mentioned food was custard made from milk. Foods not good for babies most often mentioned in UmSagata and Nuba were okra and in Oliab, kisra. In all three villages milk and nasha, a beverage made from fermented sorghum flour, were the foods most frequently mentioned as being good for lactating women. Milk was the food mentioned by the majority of women as a good weaning food; however, fresh milk was frequently not available and powdered canned milk was expensive. 52

JOURNAL OF NUTRITION EDUCATION

In addition to these reported beliefs and attitudes, some food practices reflect erroneous beliefs and food taboos. A food taboo that was widely observed in the three villages was that children should not eat fish and milk together because this combination of foods would delay their learning to talk. An erroneous belief in UmSagata was that food should be witheld from sick children. Bushara (6) reported that some mothers in Khartoum North erroneously believed that their children would be harmed if they ate milk, fish, and eggs. Other erroneous beliefs were that children who had diarrhea should not eat milk and other proteinrich foods, and that children with measles should not eat meat or milk (7). No special foods were prepared for Sudanese children (8, 9), and consequently they ate adult foods which are high in carbohydrate and lacking in complete protein. Sanhouri and Gabr (10) indicated that 95% of the children in their study in VOLUME 19

NUMBER 2

1987

Table 3. Responses to food attitude questions posed to 90 women in three villages Village

UmSagata

Foods Good for Babies

%

Foods not Good for Babies %

%

Good Weaning Foods

%

Uncooked food Kisra 4 Sorghum only Unboiled water Too much food Hot spices Powdered milk

33 20 17 13 13 13 13 10 7 7 7

Milk Nasha Soup Meat Tea Aceda Butter Grapefruit Rice Eggs Lemonade

90 80 44 50 13 10 10 10 7 7 7

Milk Nasha Meat Eggs Rice Tea Lemonade Liver Butter Biscuit Macaroni Powdered milk Custard

87 43 40 40 30 17 13 13 10 7 7 7 7

77 30 27 23 17 14 13 10 10 7 7

Kisra No response Okra stew Aceda Stew

50 23 20 17 13

Nasha Milk Meat Kisra + sugar Bread Grapefruit

93 73 20 17 13 7

Milk Cookie Kisra Nasha Lemonade Eggs Aceda Orange juice Bread Candy Oranges

80 33 27 27 27 20 20 13 13 10 7

57 53 47 47 33 27 27 23 7 7 7 7 7

Okra Fat-rich food Greens White beans Eggplant Aceda Squash

67 20 17 13 10 10 7

Nasha Milk Custard Meat Soup Sesame sweet Kisra Fruits

90 87 86 27 23 20 17 7

Milk Custard Potatoes Eggs Rice Fruit juice Kisra Cookie Broad beans Nasha Lemonade Sweet potatoes

77 63 47 40 37 13 13 10 7 7 7 7

Milk Eggs Meat Rice Butter Nasha' Liver Lemonade Grapefruit Bread Tea Lentils

80 57 40 37 23 23 17 10 10 10 7 7

Oliab

Milk Lemonade Bread Cookie Eggs Fruits Kisra Nasha Rice Candy Aceda

Nuba

Custard Potatoes Eggs Rice Lentils Milk Broad beans Kisra Meat Soup White beans Fruit juice Sweet potatoes

Dried okra Aceda 2 Unclean food Belila 3

Foods Good for Lactation

'Nasha is a beverage made from fermented sorghum flour. 2Aceda is a thick porridge made from fermented sorghum flour. 3Belila is cooked whole-grain sorghum with sugar added. 4Kisra is a paper-thin bread made from fermented sorghum flour.

Khartoum and Omdurman were given sugar water which provides calories but no other nutrients. Incidence of malnutrition. We used the criteria of Gomez et al. (1) and Waterlow (2) to classify the anthropometric data from the 116 children. First-, second-, and third-degree malnutrition, and wasting and stunting classifications were used. The Gomez classification based on weight as a percentage of that expected for age is particularly useful for infants under 1 year of age when length measurements may not be accurate, but it does not distinguish between present and long-term malnutrition (11). The Gomez criteria VOLUME 19 NUMBER 2

1987

indicated that 73% of the children in UmSagata, 42% in Nuba, and 75% in Oliab were in second- or thirddegree malnutrition, the most severe categories of malnutrition. The percentages of children in firstdegree malnutrition were as follows: 27% in UmSagata, 56% in Nuba, and 22% in Oliab. None of the children in UmSagata and 3 % in Nuba and Oliab were classified as normal (12). The Waterlow (2) revised criteria of weight-forheight and height-for-age were used to determine the severity of the deficit in the children measured. The weight-for-height index relates body mass to stature and is usually interpreted as an indicator of present JOURNAL OF NUTRITION EDUCAnON

53

nutritional status (11). Based on the Waterlow weightfor-height criteria, 95% of the children in UmSagata and 83 % of the children in Nuba and Oliab were malnourished to some degree (12). The height-far-age index is a measure of linear growth and is considered an indicator of past nutritional adequacy (11). The height-far-age criteria of Waterlow revealed that 84% of the children in UmSagata, 83% in Nuba, and 97% in Oliab were below the normal standard (12).

IMPLICATIONS Malnutrition cannot be considered without taking into account the lifestyle of the family and the environment in which the family lives. Other researchers reported that lack of health and nutrition education, poor sanitary conditions, and the ignorance of mothers (6, 9) contributed to the development of malnutrition. We observed some cultural factors that may deprive children of much needed food: Children eat after the guests, father, older siblings, and the mother. Foods that are not nutrient dense, such as sweet tea and lemonade, are served to children daily. Food is withheld from sick children and those with diarrhea because it is believed that feeding th?ffi would make them worse. Other factors including the drought and lack of adequate water also contributed to malnutrition in UmSagata and Oliab by making it impossible to raise crops. The income level of a family affected its ability to make food purchases. This was evident in UmSagata and Oliab. In addition to efforts directed at major problems in the areas of transportation, inflation, desertification, migration of the poor into the cities, and reoccurring drought and famine, nutrition education should be an important component of development strategies for Sudan. Since the men in the family do the grocery shopping, nutrition education efforts should focus on men as well as women. And mothers need to learn how to combine sorghum grain with other grains or legumes to provide their children with a complete protein in their diet. 0

54

JOURNAL OF NUTRITION EDUCAnON

ACKNOWLEDGMENTS This study was supported in part by a Fulbright Research Grant for Sudan in 1983. The authors thank Ahfad University, Foster Parents Plan International, and the Sudan Council of Churches for helping to make this study possible.

UTERATURE CITED 1 Gomez, F., R. Ramos, S. Frenk, J. Cravioto, F. Chavez, and J. Vasquez. Mortality in second and third degree malnutrition. Journal of Tropical Pediatrics 2:77-82, 1956. 2 Waterlow, J. C. Classification and definition of protein calorie malnutrition. British Medical Journal 3:566, 1972. 3 Yousif, M., and A. H. Khattab. Sudan Medical Journal 5:76,1967. 4 Khattab, A. G. H., and A. M. EI Hadari. Sudan Notes and Records 1:160, 1969. 5 Nutrition Division, Ministry of Health. Quarterly report on the period Oct.-Dec. 1969, Khartoum, Sudan, 11 pp. 6 Bushara, Y. M. Child malnutrition in the Sudan. In: Food and nutrition in the Sudan, Y. B. Yousif, K. Bagchi, and A. G. Khattab, eds. Khartoum: Tamaddon Press, 1973, 236 pp. 7 Orner, M. I. A. Infant malnutrition and weaning practices in the Sudan. In: Food and nutrition in the Sudan, Y. B. Yousif, K. Bagchi, and A. G. Khattab, eds. Khartoum: Tamaddon Press, 1973, 236 pp. 8 Taha, S. A. R. A. Society, food and nutrition in the gezira: A social and medical study. Khartoum: Khartoum University Press, 1977, 155 pp. 9 Shazali, H. Home-made weaning foods for Sudanese children. In: Food and nutrition in the Sudan, Y. B. Yousif, K. Bagchi, and A. G. Khattab, eds. Khartoum: Tamaddon Press, 1973, 236 pp. 10 Sanhouri, N. Y., and E. H. A. Gabr. Nutritional status and dietary pattern of infants and preschool children in Khartoum. In: Food and nutrition in the Sudan, Y. B. Yousif, K. Bagchi, and A. G. Khattab, eds. Khartoum: Tamaddon Press, 1973, 236 pp. 11 Simko, M. D., C. Cowell, and J. A. Gilbride. Nutrition assessment. Rockville, MD: Aspen Systems Corporation, 1984, 182 pp. 12 Dundas, M. L., and M. F. Futrell. Socioeconomic influence on the use of sorghum products and nutritional status of children in Sudan. Nutrition Reports International 33:793-802, 1986.

VOLUME 19

NUMBER 2

1987