Download This resource was written specifically for the South Sudanese

Introduction
This resource was written specifically for the South Sudanese community. The illustrations
reflect clothing styles and characteristics of people from South Sudan. It can be used for
other African communities but the level of engagement may not be the same.
The resource is based on the storytelling tradition used by many African cultures to relay
information.
Background
Where is South Sudan?
Sudan is located in North Africa and is the largest country in Africa. It shares borders with
nine other countries.
Why make the distinction between North and South Sudan?
This distinction is made by the community and relates to the turmoil in Sudan.
The distinction is predominantly religious with the north Sudanese being mainly Muslim
and the South Sudanese, being mainly Christian.
Why are there South Sudanese refugees?
Civil war has raged in South Sudan almost continuously since independence from Britain
in 1956. At the end of 1999, more than 4 million Sudanese were internally displaced and
some 420, 000 Sudanese refugees were living in neighbouring countries. Many have lived
for long periods of time in refugee camps in these countries.
The Cultural Diversity of South Sudan
The South Sudan is made up of numerous culturally diverse tribes each with its own
language. Using “South Sudan” tends to homogenise these differences but they should
be kept in mind.
Language
There has been a program of Arabicisation of language introduced by the government
in the north. Many South Sudanese will speak and understand African Arabic and, an
educated minority, speak and understand English. Literacy levels are low due to the
disruption in schooling caused by constant warfare. The Nuer language is written but can
only be read by those with schooling. Most of the other languages including African
Arabic and Dinka are mainly oral languages. For this reason these resources are in very
basic English and are accompanied by illustrations.
How do you use this resource?
This resource is designed to be used either in a one-to-one setting or for a group.
If using an interpreter make sure you read out the text rather than asking the interpreter
to read and translate.
It is important to remember that for some refugees the ordeals they have been through
effects their ability to remember. Keep the messages simple and if possible review and
reinforce them at every available opportunity.
What is this resource about?
This resource is about iron deficiency anaemia, it covers why iron deficiency is a problem,
the causes, and treatment.
Anaemia
Background
The most common symptoms of iron deficiency anaemia are:
• Feeling tired, lethargic and possibly irritable
• Loss of appetite
• Poor immune function resulting in recurrent infections and/or poor wound healing
It is important to stress that these symptoms can also be related to depression. It is not
uncommon for refugees, especially those who have been through significant trauma and
possible torture, to suffer from depression and/or post-traumatic stress.
If you suspect an underlying mental illness refer to the appropriate agency (the Association
for Services of Torture and Trauma survivors in your state will be able to assist, see the website
asetts.org.au for contact details).
Infants (0-6 months)
Iron stores in infants are heavily influenced by what has occurred in pregnancy.
Premature and low birthweight infants are at most risk of iron deficiency.
Infants (6-12 months)
Between 6-9 months is a particularly vulnerable stage for iron deficiency. This is due to
poor feeding practices, usually the late introduction of solids. Iron deficiency at this age
is of particular concern as there is rapid psychomotor development. Iron deficiency can
lead to cognitive and psychomotor delay.
Toddlers and Pre-schoolers
Iron deficiency occurs quite frequently in toddlers up to pre-school age. For these
children, the main nutritional issue is the need to broaden the range of foods and to
establish healthy eating habits. At the same time energy and iron demands for growth
continue to be high, although not as high as in the first year.
Adolescents
Adolescents are a particularly high-risk group for iron deficiency. A combination of extra
iron requirements due to the growth spurt, poor eating habits and the onset of
menstruation in girls, all contribute to the high prevalence of iron deficiency, particularly
among girls.
Adults
Pregnant and breastfeeding women are at high risk of anaemia especially if there
have been multiple pregnancies, concurrent breastfeeding with pregnancy and
extended breastfeeding.
This is Sara, her husband Michael and their
children Johnny and baby Monica.
However, a large number of children display no symptoms at all. Iron deficiency in
children is regarded as a serious illness, potentially resulting in physical and intellectual
impairment that may NOT be reversible.
The word unhappy has been used here instead of the word grumpy. Grumpy is a word
that early English learners are not familiar with, and although unhappy is not perfect it is
the closest word that would have a similar meaning for this group.
In
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children anaemia can present as:
being very tired
being very grumpy
not able to concentrate in class
falling asleep in class
recurrent illness
a general failure to thrive
Sara feels tired all the time.
Sara’s son Johnny is also very tired and
unhappy.
Sara and Johnny do not want to eat.
According to the Iron Advisory Panel (www.ironpanel.org.au) haemoglobin remains a
key screening measure for the detection of iron deficiency anaemia in the presence of
clinical symptoms. By combining haemoglobin and serum ferritin, its sensitivity ands
specificity are greatly improved.
Given this population is at high risk of iron deficiency anaemia these two tests should be
used to establish iron status:
• Full blood count: to determine whether the iron deficiency is severe enough to have
haematological effects (anaemia, microcytosis, hypochromia).
• Serum ferritin is a more sensitive test of iron deficiency.
In some cases more comprehensive iron studies need to be undertaken and concurrent
treatment measures conducted. Haemoglobin, red cell indices (provided as part of the
“full blood picture”) and iron studies provide the best screening for iron deficiency
anaemia. Ferritin can be “artificially” raised as a result of infection or inflammation and
may appear normal. Therefore, undertaking comprehensive iron studies in this high risk
group is best.
Haemoglobinpathies (for example, sickle cell and thalassaemia) are common in refugees
and may be confused with or compound iron deficiency anaemia. Haemoglobin
electrophoresis should be undertaken on those with a suggestive blood film or abnormal red
cell characteristics on the full blood picture.
Iron deficiency is the most common nutritional deficiency in Australia, and the world as a
whole. Iron deficiency causes anaemia, but this is not the total picture. One in twelve
women and teenage girls of reproductive age in Australia have biochemical iron
deficiency, but less than a quarter of these women are anaemic. Anaemia only occurs
towards the end of the process of falling iron stores, which in some cases may have been
in progress for many years.
Johnny’s teacher says he cannot do his work
at school, because he is too tired.
Refugees from South Sudan are at high risk of developing anaemia for a number of
reasons including:
Malaria and Worms:
Parasitic worms and malaria are endemic in parts of Africa. Amoebae, bilharzia, giardia
and hookworm are all common.
Inherited blood disorders:
Sickle cell and thalassemias in particular are relatively common in some African populations
including the South Sudanese.
Thalassemia minor is characterised by chronic mild anaemia. Thalassemia major is a life
threatening progressive hemolytic anaemia.
Thalassemias can be present with or without underlying iron deficiency anaemia. If there is
no underlying iron deficiency anaemia then supplementation with iron is not appropriate.
You need to be aware of these conditions and, if appropriate, ask advice from or leave
management to a haemotologist.
Sara and Johnny went to see the doctor.
The doctor checked their blood.
The doctor said they had ANAEMIA.
Anaemia is not having enough iron in your blood.
Pregnancy/Breastfeeding
Many women from Sudan are pregnant at a relatively young age, which already places
them at risk of iron deficiency. Women are also at high risk when they have multiple
pregnancies close together, concurrently breastfeed and/or breastfeed for an extended
period, which are all common in this community.
Anaemia can be caused by:
malaria and
worms
Poor access to food
Many refugees from the Sudan have been in refugee camps for considerable periods of
time. While in these camps the supply of food was limited to a cereal, usually wheat or
maize, a small amount of beans per person per day and a small amout of oil. Families
would make asida (a thick porridge like mixture) from the flour and a stew from the beans
(or a soup if there were not enough beans). Children were sometimes given a high
protein biscuit. Onions were occasionally available but generally fruit, vegetables and
meat were not available.
Some refugees have had long term poor access to iron rich foods. In addition, high levels
of food insecurity (not having enough money to buy food) in Australia means that this
limited access can continue.
A high incidence of anaemia has been noted in refugees arriving from Africa. This is most
probably a marker of overall poor nutritional status. Encouraging intake of high iron foods
and foods high in Vitamin C will improve overall nutritional status, whereas relying only on
supplements will not have the same effect.
Being pregnant or breastfeeding can also
cause anaemia.
In children the most common cause of iron deficiency anaemia is not introducing solids
at around 6 months. Other causes include:
• breastfeeding without iron supplementation (of the mother)
• exclusively breastfeeding after 6 months
• introduction of cow’s milk in the first year of life and over reliance on it thereafter
• lack of meat
• inadequate food intake: food refusal (see the resource on loss of appetite), grazing,
dieting, eating disorders
• lack of vitamin C, excess tannin (tea), phytate (fibre primarily from cereal sources)
If you suspect that a child has anaemia there are five essential questions to ask:
1. Was the child breastfed or formula fed? What age did breastfeeding cease and what
was the child weaned onto? (infant formula or cow’s milk).
2. At what age did the child start solids? Were the foods iron fortified? When did the child
start to eat red meat, chicken and fish? How much?
3. What does the child eat now?
4. At what age did the child start on cow’s milk and how much is consumed?
5. What about the volume of other fluids - other animal milk, juices, cordials, soft drinks,
tea, coffee?
From Australian Iron Status Advisory Panel at http://www.ironpanel.org.au
Anaemia is also caused by not eating enough
high iron foods.
This can happen when there is not enough
to eat.
Oral supplements can often take from weeks to months to work.
A variety of iron supplements are available as a liquid, tablet or powder that can be
sprinkled on food. Always follow the dose carefully.
The side effects of iron supplementation can include nausea, constipation and “black poos”.
The most cited reason for discontinuing supplementation is constipation.
Encourage your client to:
• choose wholemeal bread and cereals
• eat plenty of fruit and vegetables
• drink plenty of water
• do some form of physical activity everyday, such as walking, gardening, playing soccer
• alternatively, medication can be taken every second day
The literature suggests (exemplified by Viteri, Ali & Tujague, 1999) that iron supplementation
every second day or even weekly is as efficient in building up iron stores as daily
supplementation.
Iron in high doses can be toxic, especially in young children. Encourage the safe storage
of supplements, in cupboards not easily reached by children.
In babies anaemia can be caused by
not giving some high iron foods at around
6 months of age.
The iron found in food is divided into haem and non-haem sources.
Haem iron sources are readily absorbed while non-haem sources require the addition of
Vitamin C or small amounts of meat to improve absorption.
Haem sources of iron include:
• Red meat
• Chicken, pork
• Fish and shellfish
Non-haem sources of iron include:
• Beans/lentils
• Eggs
• Spinach
• Broccoli
• Dried fruit, in particular dried apricots and prunes
• Milo
• Fortified breakfast cereals
• Wholemeal bread
• Other wholegrain cereals
Foods that may contribute significantly to the iron content of the South Sudanese diet
include:
• Red meat, chicken, fish
• Beans/lentils
• Dried fruit
• Spinach and other green leafy vegetables (we do not currently have data on the iron
content of items such as sweet potato leaves, cow pea leaves etc)
• Peanut butter
• Tahini
It is important to encourage the consumption of familiar foods wherever possible.
The foods chosen for the photos as high iron foods are those commonly eaten by the
South Sudanese.
The doctor gave Sara some tablets and
Johnny some medicine to take every day.
It is important to keep taking this medicine.
Foods rich in vitamin C increase the absorption of non-haem iron, when eaten at the
same meal. Non-haem iron is the type of iron found in plant foods, such as wholemeal
bread, beans and lentils.
The foods chosen for the photos as high vitamin C foods are those commonly eaten by
the South Sudanese
Camel’s milk, which is relatively common in Sudan, is high in vitamin C and may have
assisted the absorption of iron. Vitamin C in cow’s milk is not as abundant and will not help
the absorption of iron.
The whole family began eating more
high iron foods.
liver
beef
eggs
beans
and lentils
wholemeal
bread
and cereals
spinach
The consumption of tea with meals and as the main drink is very common in South Sudan.
However, the tannin in tea reduces the absorption of iron particularly when drunk with
meals containing high iron foods.
They also ate foods which helped iron
get into the blood.
orange
tomatoes
capsicum
fruit juice
Children also consume tea from a young age. In countries where the water supply is not
safe, children may be encouraged to drink fluids made by boiling water such as tea.
The family stopped drinking tea with all meals.
Tea stops iron getting into the blood.
Encourage the consumption of other fluids, in particular water. Stress that water is safe
to drink directly from the tap in Australia. Many new arrivals remark that the water in
Australia tastes different from the water they are used to. The addition of lemon juice
will change the taste of the water as well as helping iron absorption.
Remember to emphasise that for children under 12 months of age, breast milk, infant
formula, and cooled boiled water are the drinks of choice.
The baby does not get tea at all.
Johnny only gets tea once a day or not at all.
Tea is not good for children.
These points should be stressed:
• Children under the age of 3 should be discouraged from drinking tea
• Tea should not be consumed at meal times where it will reduce the absorption of iron
• When tea is consumed ensure that it is not too strong
• Limit consumption to three cups/day
Tea drinking is very common and contributes significantly to the social fabric of the
community. Ceasing tea drinking will be almost impossible for many. Tea also forms a
significant part of fluid intake. However, discouraging the consumption of tea until two
hours after eating will help iron absorption. Alternatively making sure the tea is very weak
and flavour is added by using cloves, cinnamon or other spices.
Water is a good drink.
Water from the tap is safe to drink in Australia.
Important points to remember here:
Mothers should be encouraged to breastfeed for as long as possible. The World Health
Organisation recommends that children be breastfed exclusively for the first 6 months of
life and continued to at least 2 years of age, if possible.
Women from the Sudan usually exclusively breastfeed their children until 2 years of age
because the giving of food before this time caused diarrhoea and illness. They may be
reluctant to introduce solids especially meat and, therefore, will need to be encouraged
and supported to do so. In addition, many women use breastfeeding as a form of
contraception - it may be appropriate to discuss this with your client.
If children are not breastfed ensure that the alternative is an infant formula NOT cow’s milk.
Cow’s milk is not recommended as the main milk drink before 12 months of age. Small
amounts of cow’s milk can be used in cereal and as custard, cheese and yoghurt. Cow’s
milk when used should always be full cream milk up to the age of two unless advised
otherwise by a doctor or dietitian.
Iron rich foods should be introduced from 6 months of age.
Foods that may be introduced are:
• Asida made with maize or millet flour.
• An iron fortified infant rice cereal
• Egg yolks
(introduction of eggs should be delayed until after 9 months of age in those families
without a history of egg allergy in families with a known egg allergy, eggs should be
delayed until after 12 months)
• Lentils/beans at the right consistency
• Spinach, green leafy vegetables
• Peanut butter is a common inclusion in the South Sudanese diet - encourage the delay
of peanut butter until after nine months of age if there is no history of nut allergy. If there
is a history of nut allergy, introduction of peanut butter should be delayed until after
12 months. Peanut butter should always be the smooth variety.
It was hard not to drink as much tea as before.
Now they have tea between meals and only
have 3 cups of tea a day.
It is important to stress that they return to the doctor and have a repeat blood test once the
supplementation cycle is finished. Many refugess may be concerned about repeated blood
tests, especially if they are feeling better, reassure them and emphasise the importance of
checking their iron status.
Iron supplementation may no longer be necessary. If this is the case it should be stressed
that high iron foods and foods high in vitamin C need to be a regular part of the diet.
Sara kept breastfeeding and began giving
her baby some food.
References
Australian Iron Status Advisory Panel http://www.ironpanel.org.au
Viteri, FE, Ali, F & Tujague, J 1999, ‘Long term weekly iron supplementation improves and
sustains women’s iron status as well as or better than currently recommended short-term
daily supplementation’, Journal of Nutrition, vol. 129, pp. 2013-2020.
Sara and Johnny went back to the doctor.
The doctor checked their blood again.
He told them they now had enough iron in
their blood, but they still need to eat foods
high in iron.
Where can you get more copies of this resource?
The Commonwealth Department of Health and Ageing provided funding for this project
through the National Child Nutrition Program.
This resource was produced by the Association for Services to Torture and Trauma
Survivors (ASeTTS) and the East Metropolitan Population Health Unit, in Perth, Western
Australia for the National Child Nutrition Program. 2003.
Please see www.asetts.org.au for information on where to access ‘Good Food for New
Arrivals’ resources.
Now Sara, Johnny and the whole family are
feeling strong and healthy.