This week researchers launched an innovative new training programme at Stellenbosch University's (SU) Faculty of Medicine and Health Sciences (FMHS) that aims to change the health status of young children in South Africa.

Development at a physical, intellectual, and emotional level occurs the fastest from the commencement of pregnancy until the child's second birthday (the first 1 000 days of life). For several reasons, many South African children are denied sufficient care during this period.

The Improving Early Nutrition and Health in South Africa (ImpENSA) Training Programme can provide healthcare professionals (HCPs) with the information, practical behaviour change tools, and communication skills needed to successfully address malnutrition in the first critical 1 000 days.

“We are thrilled to finally make this great learning opportunity available to healthcare workers all over Southern Africa, after three years of hard work by eight organisations in South Africa and Europe," says Prof Berthold Koletzko of Ludwig Maximilian University (LMU) in Munich, Germany, coordinator of the project.

“We are confident that this excellent investment of some €1 million will support both the health and development of the next generation of South Africans. The big difference between the ImpENSA programme and other training related to infant nutrition is that it enables HCPs to follow a practical, patient-centred approach to support patients to identify and deal with their unique circumstances that hinder optimal health and nutrition behaviours."

This is a very important initiative in a country that carries the triple burden of malnutrition, where micronutrient deficiencies, undernutrition and obesity co-exist within individuals, households and communities. This is evident from the high prevalence of maternal overweight and obesity, as well as of maternal anaemia and childhood stunting (a marker of chronic undernutrition).

“In addition, research shows we have various other micronutrient deficiencies that are prevalent, as well as an increasing prevalence of overweight in children under five," explains Prof Mieke Faber of the South African Medical Research Council (SAMRC).

A window of opportunity

There is strong evidence that investing in child health, especially during the first 1 000 days of life, can improve not only the current health outcomes of children, but also their future health status as adults, as well as their economic potential based on their health and developmental ability.

“This is a critical period when nutrition can affect growth and development," explains Prof Lize Havemann-Nel, the South African coordinator of the ImpENSA project. She works at North-West University's Centre of Excellence for Nutrition.

National and international guidelines recommend exclusive breastfeeding for the first six months of life to provide infants with complete nutrition and immune protection. However, only 24% of South African mothers exclusively breastfeed their children of that age.

Moreover, complementary feeding, which should ideally be introduced at six months along with continued breastfeeding up to two years and beyond, often lacks variety and nutritious value. “We know from research that South African children under five have low dietary diversity, especially among lower income groups. Because young children eat small amounts, it is necessary for them to eat micronutrient dense food to meet their dietary requirements," says Faber.

However, nutrient-poor food, such as sugar-sweetened foods and drinks, salty snacks, and highly processed foods, is an integral part of the diet fed to South African infants, and only approximately 23% of them have a minimally acceptable diet.

There are many reasons for this, including poverty, lack of workplace breastfeeding policies, ultra-processed foods that are cheaper than nutrient rich foods and water and food safety concerns that complicate the preparation of unprocessed foods.

“To successfully address malnutrition requires a systems approach, including change in the health system. One way in which this can be done is to improve the skills needed to maximise the support provided by HCPs, whether it's in antenatal care, to caregivers with babies or to adults with non-communicable diseases," Havemann-Nel says.

Early nutrition receives a great deal of attention in certain HCP curricula such as dietetics, but more emphasis is needed in the medical curriculum. “Very few structured programmes address the importance of micronutrients in health and preventing disease. The focus is more on the treatment of disease," says Prof Renée Blaauw from the FMHS' Department of Global Health.

A new approach

Guided by this knowledge and evidence, the ImpENSA Training Programme focusses on micronutrient nutrition in the first 1 000 days of life. Following in-depth analysis of the training landscape and focus group discussions with a wide range of HCPs, including nurses, midwives, dietitians, community healthcare workers (CHWs), pharmacists, doctors and nutritionists, the team identified the needs, challenges and preferences of these frontline workers for receiving training and for providing nutrition support to patients.

This data was used as the foundation for the design of a training programme by experts in their respective fields of nutrition, psychology and behaviour from nutrition organisations and higher education institutions in South Africa, Germany, the United Kingdom (UK), and Poland. The final product offers evidence-based nutrition education alongside behaviour change skills training.

Prof Etienne Nel from the FMHS' Department of Paediatrics and Child Health says another reason why the training programme can make an impact in low-resourced areas where it is most needed, is that the aim from the outset was to develop a programme that would be appropriate for the South African context. “Recommendations take the South African environment into account, for example the type of foods that are available and the diverse cultures in the country. We also ensured that the language used would be suitable for second-language English speakers. Providing the course online also makes it accessible to a larger audience."

The training programme offers two self-paced knowledge-based online modules and one skills-based online module. The first module covers the optimisation of micronutrient nutrition during the first 1 000 days of life, and module two deals with communication to support behaviour change. The third module provides practical Healthy Conversation Skills (HCS) to support behaviour change.

Changing the world, one conversation at a time

The HCS module aims to increase the confidence and ability of HCPs to have patient-centred conversations, encouraging patients to take first steps towards healthy behaviour.

It has four aims: 1) to support HCPs to have empowering, exploratory discussions with patients; 2) to listen rather than just provide information or suggestions; 3) to develop skills to reflect on conversations; and 4) to support goal-setting that is specific, measurable, action-orientated and realistic.

“In a resource-strapped environment, emphasis of HCS is to do things differently, not to do more," emphasises Dr Wendy Lawrence, Associate Professor of health psychology at the University of Southampton.

Learners can expect evidence-based information, guided by national and international guidelines, practical recommendations, interactive media elements, self-assessment quizzes, in-lesson activities, animation videos, scenario-based videos and colour graphics to support their learning.

Lawrence believes the programme will have a much wider impact thanks to the inclusion of HCS. “It has the ability to change the world one conversation at a time. Once people have learnt the skills, they can use them in their personal and work lives. Whether they are talking to family, friends, patients, colleagues, managers or students, they will have more effective, non-confrontational conversations that can lead to improved relationships and outcomes. What's not to be excited about?"

Roll-out and expansion

The next step is to roll out the programme to a widening spectrum of healthcare workers such as medical professionals, nurses and CHWs. “To achieve this, the cooperation of the Department of Health, provincial governments and academic institutions is important," says Nel.

Adapting the programme, to for instance face-to-face delivery to HCS, may be necessary to reach frontline workers in low-resourced rural areas.

The programme will be offered free of charge during the initial roll-out phase until January 2023. For more information visit www.early-nutrition.org/impensa or send an email to [email protected].

FAQs

Who is the ImpENSA training programme aimed at?

The target audience is dietitians, nutritionists, nurses, midwives, doctors (paediatricians, GPs, gynaecologists) and any other HCP working in antenatal care or with infants and young children.

What does the programme entail?

Module 1 consists of:

• Unit 1: The importance of nutrition in the first 1 000 days of life
• Unit 2: Optimisation of micronutrient nutrition during pregnancy
• Unit 3: Optimisation of micronutrition nutrition during breastfeeding and complementary feeding

Module 2 consists of:

• Unit 1: An empowering, person-centred approach to support behaviour change
• Unit 2: Factors that affect health and influence change
• Unit 3: Principles of behaviour change
• Unit 4: Supporting behaviour change using the Healthy Conversation Skills (HCS) approach

Module 3 consists of two structured, live facilitated virtual practical sessions for implementing HCS.

How much will the programme cost, and how can I enrol?

The programme will be offered free of charge until January 2023. The steering committee members are still finalising the next steps to offer the programme in a sustainable manner when the project ends, when a modest fee may possibly have to be charged. Send an email to [email protected] to find out more.

Will it be integrated with national and provincial level HCP training?

Integration into such programmes is currently being explored. It is also envisioned that the ImpENSA Training Programme can be embedded in existing higher education institution programmes and qualifications in the future.

Why should HCPs enrol?

HCPs will gain key skills to support caregivers, mothers, and pregnant women to provide their children with the micronutrient requirements for the first 1 000 days. A further incentive is that a significant amount of the 30 Continuous Professional Development (CPD) points required by the Health Professions Council of South Africa (HPCSA) can be earned through this course.

What are the SA statistics related to the triple burden of malnutrition?

• For women 15-49 years old, the latest data indicated 62% are overweight or obese, 33% are anaemic, 22% are vitamin A deficient and 20% are iodine deficient.
• For children under five, chronic malnutrition manifests in 27% being stunted (short for age), while 13% are overweight, 32% are anaemic and 35% are vitamin A deficient.

About the ImpENSA Project:

The overall aim of the ImpENSA project is to strengthen the relations between higher education institutions (HEI) and the wider economic and social environment. They hope to achieve this through the exchange of state-of-the-art practices to culminate in the co-creation of an innovative training course that can facilitate continuous professional development among South African HCPs. The ImpENSA Training Programme is the result of this work. The team further plans to establish infrastructure in South Africa for the programme's efficient and sustainable implementation. The project commenced in 2019 and will be completed in 2023. It is a multi-centre collaboration that comprises eight consortium members, managed and coordinated by the Ludwig Maximilian University, with six partnering universities (three from South Africa and three from Europe), and two health professional organisations in South Africa, namely:

• Ludwig Maximilian University
• North-West University
• Stellenbosch University
• University of Cape Town
• University of Southampton, UK
• Medical University of Warsaw, Poland
• Association for Dietetics in South Africa
• Nutrition Society of South Africa

 According to Dr Shweta Feher from LMU, the EU seeks to build partnerships with low-and-middle income countries such as South Africa, and defines policies and actions for a high degree of cooperation in all fields of international relations. “The EU Erasmus+ Programme provides the opportunity for organisations and higher education institutions from partner countries to promote cooperation through actions that strengthen the capacity of management, governance and innovation to modernise their own higher education systems and foster regional integration and cooperation across different regions of the world."

Additional sources

1. National Department of Health (NDoH), Statistics South Africa (Stats SA), South African Medical Research Council (SAMRC), and ICF. 2018. South Africa Demographic and Health Survey 2016 Key Findings. Pretoria, South Africa, and Rockville, Maryland, USA: NDoH, Stats SA, SAMRC, and ICF. Available from: https://www.samrc.ac.za/sites/default/files/attachments/2019-01-29/SADHS2016KeyFindings.pdf
2. Harika R, Faber M, Samuel F, Kimiywe J, Mulugeta A, Eilander A. Micronutrient Status and Dietary Intake of Iron, Vitamin A, Iodine, Folate and Zinc in Women of Reproductive Age and Pregnant Women in Ethiopia, Kenya, Nigeria and South Africa: A Systematic Review of Data from 2005 to 2015.