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Nutritional appraisal of Tsabana, a dietary intervention product for the four-month- to five-year-old age group, and assessment of its acceptance and use in rural districts of Botswana
Child undernutrition is the outcome of numerous complex and interrelated factors. It is considered a worldwide health concern, also in Botswana. Undernourished infants are especially vulnerable to develop nutritional deficiencies and diseases. Tsabana was developed as a weaning food to improve the diet quality of undernourished infants in Botswana but also as a dietary intervention product for the four-month- to five-year-old age group to improve the nutritional status of Batswana children. The study undertook a theoretical nutritional appraisal of Tsabana and assessed its acceptance and use in rural districts of Botswana. A quantitative approach that incorporated a survey was used as the research design for the study. A pre-tested questionnaire consisting of close-ended questions in the multiple choice format was used to collect the data on the field acceptance and use of Tsabana. The questionnaire was completed by 105 caregivers of infants aged six to 36 months old visiting the selected clinics with the research sites the Ngamiland, North East, Central and Kweneng rural districts. The energy, macro- and micronutrient content adequacy of Tsabana was compared to the Codex Alimentarius Standard for Processed Cereal-based Foods for Infants and Young Children (Codex Standard 074) and the Proposed Nutrient Composition for Fortified Complementary Foods (PNCFCF). Sorghum and soya are the two major ingredients of Tsabana which contribute to its protein and energy provision. The nutrient appraisal revealed that the level of energy provided by Tsabana is more than the specified Codex Alimentarius Standard composition but slightly less than the PNCFCF specified range, whereas the protein level is within the specified ranges as put forward by both the Codex composition and the PNCFCF, respectively. The results further revealed that in comparison to the PNCFCF the content of vitamins A, E, C and pyridoxine, zinc, iodine and iron were less than the specified ranges. The content of vitamins A and D met the compositional guidelines of the Codex Alimentarius Standard. The micronutrient provision of Tsabana in relation to the World Health Organization (WHO) recommended nutrient intakes was mostly adequate except for pyridoxine which was inadequately provided for both seven- to 18-month-old (33% provision) and one- to three-year-old (52% provision) infants at the daily rations of 75 gram (g) and 200 g powder respectively. Some minerals also were provided at inadequate amounts, e.g. iodine at a daily provision of 42% as well as iron at 26% for seven- to 12-month-old and 12- to 18-month-old infants both provided at a daily ration of 75 g Tsabana powder. Zinc was only provided at 19% of the WHO recommended intake for seven- to 12-month-old and 14.8% for 12- to 18-month-old infants. As with the absence of omega-3 and omega-6 fatty acids, the minerals selenium and copper are not provided by Tsabana. The micronutrient fortification compounds used in Tsabana for the mineral and vitamin additions as vitamin A palmitate, cholecalciferol, vitamin E acetate, calcium pantothenate, carbonate and tri-calcium phosphate (ratio 1:18:482), zinc sulphate and potassium iodate are readily bioavailable, but not the vitamin A and vitamin E compounds used. The iron fortificant used is not stipulated on the Tsabana package. The field survey results revealed that Tsabana was well accepted by the infants as perceived by their caregivers as the majority indicated that Tsabana was enjoyed (80%) and that it tasted nice (71.4%). The majority (78.1%) of the caregivers also indicated that the wellbeing of the infants improved on receiving Tsabana. Most (51.4%) of them also knew that Tsabana is more nutritious than other cooked porridges. Tsabana though was not used properly as most of the caregivers fed Tsabana to the infant only once a day (60.9%) instead of two to three times (for infants six- to 18-month-olds) and did not use enough water (3½ cups) (76.2%) to cook one feeding of Tsabana as stipulated on the Tsabana package. The product use factors, which include the number of daily Tsabana feedings provided, the addition of sugar to the cooked Tsabana, the amount of water used to cook one feeding of Tsabana and the cooking period of one feeding were the factors significantly (p < 0.05) linked to the perceived infant acceptance of Tsabana. The number of daily Tsabana feedings was linked to the perceived enjoyment of Tsabana (p < 0.05) and its perceived texture (p < 0.05) and colour (p < 0.05) acceptance. While the addition of sugar to the cooked Tsabana was linked to its perceived enjoyment (p < 0.05), the amount of water used to its perceived taste acceptance (p < 0.05) and the cooking period of one feeding to its perceived colour acceptance (p < 0.05). For instance, more caregivers in relation to the enjoyment of Tsabana and its colour and texture acceptance who perceived it not to be enjoyed and not having a nice colour or texture, indicated not to feed it daily in comparison to caregivers who perceived that Tsabana was enjoyed by the infants and that it had a nice colour and texture. The caregiver perceived infant wellbeing improvement through the provision of Tsabana and the perceived difference between Tsabana and other cooked porridges were the only two clinic-related factors which significantly (p < 0.05) influenced the infant acceptance of Tsabana as perceived by the caregivers. For instance, while the majority (86.2%, 84.8% and 80%, respectively) of the caregivers who perceived the infant taste acceptance of Tsabana as very nice, nice or acceptable indicated that providing Tsabana to the infant improved the infant’s wellbeing, the majority (80%) who perceived it as not tasting nice indicated that providing Tsabana to the infant had not improved the infant’s wellbeing. More than half of the caregivers who perceived the infant texture acceptance of Tsabana as acceptable (59.4%) or nice (56.8%) indicated that Tsabana provides more nutrition to the infant. However, less than half (46.2%) of the caregivers who perceived the texture of Tsabana as not nice indicated that it provides more nutrition to the infant. The caregiver education level was the only demographic factor that significantly (p < 0.05) influenced the acceptance of Tsabana. The majority (90.3%) of the caregivers who attained a secondary education level (form 1 to form 4) and higher, perceived the infant texture acceptance of Tsabana as nice, acceptable or not nice. In contrast, the majority who perceived the texture acceptance as very nice attained either no schooling/standard one to seven (73.9%) and not a secondary level or higher (26.1%). It could be speculated that caregivers who attained a higher education level may be more critical of such attributes such as the texture acceptance of Tsabana. Most (59%) of the caregivers indicated that they did not receive any information regarding Tsabana from the clinic personnel. Caregiver education on Tsabana and infant nutrition will impart sufficient knowledge and skills to prepare, store and adequately feed Tsabana to their infants as well as provide a variety of foods in adequate amounts to contribute to their optimal growth and development. This is a vital undertaking as it was evident from the study that most of the factors that influenced the acceptance of Tsabana were the product use factors. The study additionally found that foods such as meat, poultry and fish, as well as fruit and vegetables, which should be included in the daily dietary provision, were provided to most of the study infants on a weekly basis only.