Food insecurity can affect the mental health of mothers, with dire consequences for the development of their babies. But can mental-ill health, in turn, affect food security? We are asking this question in our next research project.

1. Economy, Equality & Access to Mental Health Services
Food insecurity and maternal mental health
Simone Honikman, Zulfa Abrahams, Thandi van Heyningen,
Michael Onah, Sally Field, Mark Tomlinson, Landon Myer
www.pmhp.za.org

2. In South Africa
In High Income Countries (HIC)
Perinatal depression
16-20% (Fisher, 2011)
22-47% (Hartley 2011, Tomlinson 2014,
Cooper 1999, Rochat 2006;
van Heyningen 2016)
In Low and Middle Income
Countries (LMICS)
11-12% (Witt 2010, Strat 2011; Woody et al 2017)
Higher prevalence than general population
and anxiety?

3. Photo credit: Bev Meldrum

4. • Approx 35 000 people living in socioeconomic
adversity
• 69% of adults are unemployed
• 89% of adults live on less than R1600pm
• Less than 20% of adults have completed high school
• Alcohol and substance use is high
• High levels of intimate partner violence,
physical and sexual violence/abuse
• High levels of community-based violence,
perpetuated by gangs and drug trade.
[Community Action for a Safer Environment (CASE) statistics; 2014]
Study setting: Hanover Park

5. Outputs to date
• Major Depressive Episode (MDE)
• Anxiety (Anx)
• Alcohol and Drug Use (AOD)
• Suicidal ideation and behaviour (SIB)
• Domestic violence
• Screening tool development

6. Study participants
n-376
• Demographic mean: 27 yrs old, 2nd pregnancy
• 55% are unemployed with a grade 10 education
• 90% in long term relationship but only 60% live with their partner
• 69% earn < R2000/mth
• 42% food insecurity (13% food insufficient)
• 30% had experienced at least one threatening life event in the
past 6 months

7. Food insecurity
Food security – assured access to nutritionally adequate and safe
foods without resorting to emergency food supplies, scavenging,
stealing or other coping strategies
Food insecurity – the availability of nutritionally adequate and
safe foods or the ability to acquire acceptable foods in socially
acceptable ways, is limited or uncertain
Food insufficiency/ Hunger – a severe form of food insecurity as
a result of extended nutritional deprivation

8. Food insecurity in South Africa: policy and plans
Food security prioritised by the SA government in 2010 (national Integrated Food
Security Strategy IFSS) – linked to MDG 1 “to eradicate hunger, malnutrition and food
insecurity by half by 2015.”
The strategy identifies five objectives:
• increased household production and trading
• improved income generation and job creation opportunities
• improved nutrition and food safety
• increased safety nets and food emergency management systems
• improved analysis and information system management
The IFSS has five broad pillars:
• production and trading
• income opportunities
• nutrition and food safety
• safety nets and food emergency
• information and communication
Lacks implementing power !

9. Food insecurity : status quo
Western Cape Finance MEC report October 2017
• Poverty 2011-2015: 33.7%-37.1%
• Food poverty 2011-2015: 6.9%-10%
• Social grants demand increasing: greatest increase between 2015-2017
• 2017: 65% grant beneficiaries: child support
• Gini co-efficient getting worse= worse inequality
• Drought – agricultural sector impacts, businesses, supply chains
• Unemployment: 20.7% - more women unempl
Cape Argus 2 Oct 2017

10. • Severe acute child malnutrition < 5 years : 4.5 / 1000
• Stunting (< 15 years) – v low height or weight for age
• 14-17%
• Anaemia
• 11% children < 5 years
• 23% women reproductive age
• Obesity
• Men 14%
• Women 42%
• Vitamin A deficiency < 5 years: 44%
Nutrition indicators
South African Health Review
2016 (Health Systems Trust)

11. Food Insecurity measure:
Household Food Security Survey Module HFSSM
In last 6 months
1. The food that (I/we) bought just didn’t last, and
(I/we) didn’t have money to get more
Often
true
Sometimes
true
Never
true
DK or
Refused
2 (I/we) couldn’t afford to eat balanced meals Often
true
Sometimes
true
Never
true
DK or
Refused
3. Did (you/you or other adults in your
household) ever cut the size of your meals or skip
meals because there wasn't enough money for
food?
Yes No
(Skip FS-4)
DK
(Skip
FS-4)
4. [IF YES ABOVE, ASK] How often did this
happen—almost every month, some months but
not every month, or in only 1 or 2 months?
Almost
every
month
Some months
but not every
month
Only 1
or 2
months
DK or
Refused
5. In the last 12 months, did you ever eat less than
you felt you should because there wasn't enough
money for food?
Yes No DK
6. In the last 12 months, were you every hungry
but didn't eat because there wasn't enough
money for food?
Yes No DK
Score
0-1 food secure
2-4 food insecure
5-6 food insufficient

12. Comorbid Common Mental Disorders
Hanover Park
n=376
Major
Depressive
Episode (22%)
Any Anxiety
Disorder
(23%)
Alcohol
and Other
Subs Use Dx
(17%)
MDE + ANX
= 12%
AOD +
ANX = 6%
MDE +
AOD = 6%
MDE +
ANX +
AOD = 5%

13. Prevalence
(diagnostic)
Odds of Food
Insecurity
Major Depressive
Episode
22% 2.5
Any Anxiety
Disorder
23% 2.6
Alcohol and Drug
Use
18% 3.7
Suicidal Ideation
and Behaviour
18% 2.4
Domestic Violence 15% 2.0
What are the odds* of food insecurity?
Van
Heyningen
et al 2016
Van
Heyningen
et al 2017
Onah et al
2016
Onah et al
2017
Field et al in
press
* For each outcome, multivariable regression analyses were conducted, aOR all clinically signif

14. • Major Depressive Episode X 6
• Suicidal behaviour X 5 (Abrahams et al, unpublished data)
What are the odds* of mental ill health
when food insecure?
*Multivariable regression analysis was conducted, controlling for confounding variables;
aOR clinically signif

15. Common
perinatal mental
disorders
Food
insecurity
Cycle of food insecurity and common perinatal mental
disorders: causal hypotheses
Social
withdrawal
↓ income generation
and control
Dysfunctional
intimate relationships
Impaired
planning and
prioritising
Drug and
alcohol use
Reduced social
engagement
Stress and distress
Nutritional
deficiencies
Hunger
Poor social
support
Strained
domestic
relationships
↓ Productivity ↑ Debt
Impulsivity,
aggression =
High risk
behaviour
Risky sexual behaviour – ↑ children
Integrated
maternal
mental
health care
Social grant/
food
security
intervention
Drug and
alcohol use Nettle 2017

17. Acknowledgements
• PMHP clients
• PMHP staff: clinical, research, training, admin,
advocacy
• DoH frontline staff and management
• DoH programmes, leadership
• Department of Social Development
• UCT
• PMHP donors for Hanover Park: Cordaid, MRC,
Harry Crossley, DG Murray Trust, Ackerman Family
Foundation, Anglo American Chairman’s Fund,
Truworths Community Foundation, HCI Foundation
• PMHP friends, supporters
• NGO partners
• Research partners

18. Simone.Honikman@uct.ac.za
Dr Simone Honikman
PMHP Director
www.pmhp.za.org
http://perinatalmentalhealth.wordpress.com/
make-a-difference/