Results

Participants

Nine children with cerebral palsy were included in the study (Table 1). Their primary caregivers participated as respondents, with five children recruited through disability centres and four through social media.

 | Age (years) | Gender | GMFCS level | EDACS rating
Child 1 | 6 | Male | 3 | 2
Child 2 | 4 | Female | 4 | 2
Child 3 | 3 | Female | 4 | 2
Child 4 | 7 | Male | 4 | 3
Child 5 | 5 | Male | a | 5
Child 6 | 2 | Female | 5 | 3
Child 7 | 5 | Female | 5 | 5
Child 8 | 3 | Female | 5 | 3
Child 9 | 8 | Male | 5 | 4

The children represented in this study ranged in age from 2 to 8 years with the majority of children being (n = 5, 55.6%). Children's functional classifications reflected moderate to severe motor and feeding impairments. GMFCS levels ranged from level 3 to level 5, with level 5 being the most common. EDACS levels ranged from level 2 to level 5, with level 2 most frequently reported. Level 2 indicates that children can eat and drink orally with some assistance, whereas level 5 reflects the need for alternative, non‐oral feeding methods, such as a percutaneous endoscopic gastrostomy (PEG).

Caregiver characteristics are presented in Table 2. Caregivers in the study were all female (n = 9, 100%) with an average age of 38.1 years ± 9.69 (range 28–57 years). Most of the caregivers were mothers (n = 8, 88.9%) with one being a grandmother, and five (55.6%) participants reported being employed full time.

Caregivers | Age (years) | Relationship to child | Employment status | Monthly household income (USD)a | Number members in household including child and caregiver | Government grantb
Participant 1 | 39 | Mother | Employed full‐time | 125–312.50 | 3 | Government grant—not specified
Participant 2 | 29 | Mother | Employed full‐time | 625–1250 | 5 | No
Participant 3 | 49 | Mother | Employed full‐time | More than 1250 | 4 | Government grant—not specified
Participant 4 | 39 | Mother | Employed part‐time | 125–312.50 | 4 | Government grant—Child grant and care dependency grant
Participant 5 | 57 | Grandmother | Unemployed | 125–312.50 | 6 | No
Participant 6 | 28 | Mother | Employed full‐time | 312.50–625 | 5 | Government grant—Child grant and care dependency grant
Participant 7 | 37 | Mother | Unemployed and seeking employment | Less than 125 | 4 | No
Participant 8 | 29 | Mother | Unemployed | Less than 125 | 3 | No
Participant 9 | 36 | Mother | Employed full‐time | More than 1250 | 3 | No

Five children (55.6%) resided in households reporting an estimated monthly income of $312.50 or less (≤ R5000), and four households reported receiving some form of government grant support. Households with reported incomes between $125 and $625 per month (R2000–R10,000) were receiving government grants, whereas the two households reporting the lowest income bracket (less than $125 per month [< R2000]) were not receiving any grant support. Household size ranged from 3 to 6 members, with a mean of 4 additional members residing in each household. During the study period, South Africa's national minimum wage was approximately $1.72 per hour (R27.58/h), equivalent to roughly $275 per month (R4400/month) for full‐time employment (40 h per week) (National Minimum Wage Commission 2024). Several households therefore reported incomes at or below minimum wage levels. Food security status was assessed using the HFIAS, and results are presented in Table 3.

Participant number | HFIAS score | Category of food insecurity
1 | 1 | Food secure
2 | 0 | Food secure
3 | 3 | Mildly insecure
4 | 7 | Severely insecure
5 | 0 | Food secure
6 | 0 | Food secure
7 | 4 | Moderately insecure
8 | 14 | Severely insecure
9 | 0 | Food secure

Five households (55.6%) indicated that they were food‐secure households. One household was deemed mildly food insecure, and another one was deemed moderately food insecure. The two remaining households had scores that placed them in the category of severely food insecure.

Food Availability

All 9 households (100%) relied on purchased food as their primary food source with no caregivers reporting consistent access to home‐grown produce. Physical access to food outlets was generally reported as adequate, with most caregivers living near formal retailers. At the retail level, caregivers reported that a wide variety of foods was generally available through formal supermarkets, butchers and fresh produce markets. Most participants described accessing food from supermarkets such as Pick n Pay, Shoprite and Woolworths, and did not report household‐level shortages related to storage or food preservation. However, retail availability was seen as a primary concern along with financial and structural constraints. These limited caregivers' ability to utilize available food resources, ‘It's not just the money. Sometimes I cannot find the food that I need for my child to eat’ (P3). Although a variety of food was available to purchase, seven caregivers (77.8%) reported that available foods were often not appropriate for their child's feeding needs due to texture or preparation requirements. One caregiver explained, ‘He doesn't really eat a lot of things … he doesn't eat meat because sometimes when you blend the meat, he won't eat it’ (P8). This highlights how functional feeding limitations restricted the practical usability of otherwise available foods. These accounts suggest that while food may be physically present within the broader food environment, economic access and retail supply variability shaped household‐level availability.

Food Access

Six caregivers (66.7%) reported limited availability of fresh and nutritionally diverse foods within their local environments. The food inventory questionnaire was used to determine which foods were eaten by the child to illustrate the range of foods and types of foods consumed. Table 4 shows the different foods and food groups eaten and those that are eaten the most and least. Although children ate a variety of foods, affordability ultimately determined household food choices. Caregivers consistently emphasized that food purchasing decisions were shaped not by nutritional preference or suitability, but by cost. As one caregiver stated, ‘You buy what is there and what you can afford’ (P3), while another reflected, ‘Most of the food around here is bread and pap’ (P5). These accounts highlight that although food variety exists within the retail environment, economic constraints narrow practical options, particularly limiting access to nutritionally important foods.

Food group | Food item (%)
Meats, fish and proteins | Beef (100.0), Chicken (100.0), Eggs (100.0), Beef burgers (77.8), Chicken nuggets (77.8), Bacon (77.8), Sausages (77.8), Boerewors (77.8), Fish fried in batter/breadcrumbs (77.8), Tinned tuna (77.8), Lamb (66.7), Ham (66.7), Pork (55.6), Plain white fish (55.6), Biltong (55.6), Droëwors (55.6), Bobotie (22.2)
Carbohydrates | Porridge (oats/maizemeal) (100.0), Cereals (not frosted/high sugar e.g., Weetabix) (100.0), Pap (88.9), Rice (88.9), Samp and beans (77.8), Pasta (plain) (77.8), White bread (77.8), Brown bread (77.8), Chips (hot chips) (66.7), Pizza (66.7), Vetkoek (66.7), Crisps (55.6)
Liquids and dairy | Yoghurt (100.0), Fruit juice (e.g., Liquifruit/Oros) (88.9), Milk (88.9), Hard cheese (e.g., cheddar) (77.8), Amasi (66.7), Processed cheese (e.g., Baby Bells/cheese strings) (66.7), Cream cheese (e.g., Kiri) (66.7), Rooibos tea (66.7)
Vegetables | Cabbage (100.0), Green beans (100.0), Peas (100.0), Sweet potatoes (88.9), Broccoli (88.9), Cooked carrots (88.9), Onions (88.9), Salad greens (66.7), Cucumber (66.7), Mushrooms (66.7), Cooked peppers (66.7), Fresh tomatoes (66.7), Tinned tomatoes (66.7), Cauliflower (66.7), Sweetcorn (55.6), Raw carrots (55.6), Chakalaka (55.6), Raw peppers (44.4), Parsnips (33.3)
Fruit | Bananas (100.0), Oranges (88.9), Peaches/nectarines (88.9), Pears (88.9), Mango (88.9), Other fresh fruit (88.9), Strawberries (88.9), Grapes (77.8), Pineapple (77.8), Apples (raw) (77.8), Apples (baked/pureed) (66.7), Melon (66.7), Kiwi (44.4)
Snacks | Sweets (e.g., lollipops, gummy sweets) (88.9), Cake (77.8), Biscuits (77.8), Ice cream (77.8), Chocolate (77.8)

Analysis of the Food Preference Questionnaire indicated that most children had tried and consumed a wide range of commonly available foods across all food groups. Overall, staple carbohydrates, common protein sources, dairy products and several fruits were consumed by most children, while consumption of some vegetables and traditional dishes was more variable. Across the carbohydrate group, the food consumed by more than 80% of children were porridge (oats/maizemeal) (100%), cereals (not frosted/high sugar e.g., Weetabix) (100%), pap (88.9%) and rice (88.9%). This suggests that children's diets were largely centred around refined carbohydrates and convenience foods, which are often more affordable and accessible in many South African households. Within meats and protein sources, beef (100%), chicken (100%) and eggs (100%) were eaten by all children. However, several other protein sources such as pork and fish were only consumed by 55.6% of children, suggesting variability in protein intake across households. Furthermore, preparation of meat was also noted by caregivers as being hard to swallow and many caregivers reported on modifying texture through cutting or blending.

For liquids and dairy, milk yoghurt (100%) was consumed by all children. High consumption was also reported for fruit juice (88.9%) and milk (88.9%). Consumption of vegetables varied across items. Cabbage (100%), green beans (100%) and peas (100%) were eaten by all children, while sweet potatoes (88.9%), broccoli (88.9%), cooked carrots (88.9%) and onions (88.9%) were also widely consumed. Fruit consumption was generally high. Bananas (100%) were eaten by all children, while oranges (88.9%), peaches or nectarines (88.9%), pears (88.9%), mangoes (88.9%), other fresh fruit (88.9%) and strawberries (88.9%) were also widely consumed. In South Africa, access to fruit is widely available and speaks to participants' access to different options eaten. Finally, snack foods were widely consumed, with sweets (88.9%) reported most frequently. These patterns may reflect the influence of food affordability, household preferences and the feeding adaptations required for children with CP, particularly where softer or energy‐dense foods are easier to prepare and consume.

Based on HFIAS responses, seven households (77.8%) experienced food access constraints, including anxiety about food sufficiency and inability to purchase appropriate foods. Monthly household food expenditure varied widely, with most caregivers reporting spending between $56 and $140 (R1000–R2,500) or $140 and $280 (R2,500–R5,000), and two caregivers reporting expenditures above $280 (R5,000) despite low or absent household income. Reported food expenditure did not consistently align with employment status or receipt of social grants, indicating reliance on informal financial support such as family assistance or community food donations. One caregiver described supplementing grant income with family assistance, explaining, ‘I'm using my UIF … and I have money from the disability grant … and my mother … my mother is helping’ (P5). Seven caregivers (77.8%) reported that disability grant income was insufficient to meet household food needs, particularly when accounting for the child's feeding requirements. One caregiver explained, ‘The grant helps, but it is not enough for food the whole month’ (P2). Five caregivers (55.6%) reported receiving intermittent community food support, primarily in the form of food parcels, which were described as inconsistent. One caregiver stated, ‘We only received the food parcel once, that month it helped’ (P4).

Food Utilization

Food utilization played a critical role, as this directly impacted which foods children were able to consume. Children with greater feeding and functional impairments experienced heightened vulnerability. Those classified at higher EDACS levels (III–V) (n = 5, 55.6%) reported greater difficulty eating available foods that were able to meet their nutritional needs. In addition to food type, mealtime duration emerged as an important consideration. Caregivers identified prolonged mealtimes between 30 and 90 min as reported by two caregivers ‘It can take even like 40 minutes feeding her’ while another shared, ‘I have to spend more than an hour and 30 minutes … until he can really eat’ (P8). All caregivers (100%) reported adapting foods through texture modifications and preparation changes. One caregiver explained, ‘He doesn't eat solid food. It's only soft, we have to blend everything for him … Everything we blend’ (P8). Another caregiver described steaming and blending meals to preserve nutritional value while ensuring safe administration, stating, ‘I've got a steamer … I steam the stuff, or I boil it … and then I've got a hand blender. I blend it … We have to mix it actually with formula milk to make it as liquid as possible’ (P7). These accounts illustrate not only the practical implementation of texture modification but also the reliance on specific equipment, ingredients and resources to enable safe feeding.

Food inventory data showed limited dietary diversity in six households (66.7%). Foods that all or most children ate included soft staples such as pap, porridge, mashed vegetables, white bread and yoghurt. Foods that many children did not eat included raw vegetables, whole fruits and certain meats due to chewing or swallowing difficulty. Caregivers described restricting food choices to items their child could safely manage. One caregiver stated, ‘I only give foods that I know he won't choke on’ (P6), while another explained, ‘Some foods I just avoid because it's too difficult for her to eat’ (P1). Therefore, additional dimensions to food security were brought in related not only to the foods that the child would eat but also to how they would eat them.

Food Stability

Five caregivers (55.6%) reported fluctuations in food access across the month, with improved access immediately after grant payments and increased constraints toward month‐end. During periods of instability, caregivers described reducing dietary variety and relying on staple foods, as one caregiver explained, ‘At the end of the month, we eat whatever is left’ (P8). Caregivers also reported that rising food costs, unexpected expenses, illness and employment uncertainty disrupted feeding routines over time, contributing to fluctuating household food security. One caregiver reflected on financial instability, stating, ‘Financially things are so bad …’(P7), while another expressed concern about future income security, explaining, ‘Will you still have your job in the future? … Will it be enough?’ (P2). Similarly, a caregiver described periods of economic strain, noting, ‘Sometimes there's a lack of money to buy food … I'm struggling’ (P3). These accounts illustrate how broader economic vulnerability directly shaped the stability of household food access over time.