Not everyone can afford an apple a day: stigma and food insecurity in rural South African young adults

Abstract

The HIV epidemic in South Africa has created a generation of orphaned and vulnerable children (OVCs). Little is known about the experiences of these “former” OVCs once they pass their 18th birthday. We conducted a qualitative study to understand the experiences of food insecurity for rural South African young adults. We conducted 20 in-depth interviews with 11 men and 9 women aged 18–25, and 2 focus group discussions. Many ate a single meal a day provided by the school feeding scheme or by friends. Despite this, nearly all participants emphasised the emotional and social, rather than the physical, tolls of food insecurity. These experiences of social shame predominantly stem from instrumental stigma — the perception within the broader community that because these former OVCs lived in relative poverty they would not be able to contribute to the web of community ties which function as a social safety net. Interventions designed to support former OVCs must focus on building social capital and supporting emotional resiliency in addition to providing material support.

Background

Since the HIV epidemic began in South Africa, a generation of orphaned and vulnerable children (OVCs) has grown into a generation of orphaned young adults (Bray, 2003). In recent years the overall prevalence of HIV in South Africa has begun to plateau (Republic of South Africa, 2012), and has even decreased significantly in young adults aged 15–24 (Shisana et al., 2014). However, nearly 1 in 5 South African adults aged 15–49 are currently living with HIV (Shisana et al., 2014), and the South African government has highlighted young adults who are rural, impoverished and unable to access education as a key population in need of HIV services and support (Republic of South Africa, 2012). Much research and intervention work has focused on the many OVCs created in the wake of the HIV/AIDS epidemic (Bray, 2003; Cluver & Orkin, 2009; Cluver, Orkin, Boyes, Gardner, & Meinck, 2011; Nduna & Jewkes, 2012; Pappin et al., 2015; Thurman, Brown, Richter, Maharaj, & Magnani, 2006; Wild, Flisher, & Robertson, 2013). However, there is less information on the experiences and risks of these OVCs once they have passed their 18th birthday.

The term ‘OVC’ covers a range of childhood experiences. Orphans are typically any child who has lost at least one parent (UNICEF, 2015), however, the exact nature of ‘vulnerability’ can be more difficult to define. In the context of high HIV prevalence, international donors and stakeholders define ‘vulnerable’ children as those whose parents are living with HIV, who have had to take on primary caregiver roles, or are living in communities which have been particularly affected by poverty and HIV (United States Congress, 2008). Southern African caregivers and community based organisations view the concepts of both orphanhood and vulnerability as a matter of degree, and prefer to define OVC using a more holistic perspective which takes into account a child’s individual circumstances, family and household characteristics (Skinner et al., 2006). Children who grow up experiencing high levels of poverty, hunger and social marginalisation are at heightened risk of abuse, exploitation and HIV infection (Meinck, Cluver, Boyes, & Ndhlovu, 2015; Skinner et al., 2006), and there is some evidence that they remain at heightened risk at least into young adulthood (Jewkes, Dunkle, Nduna, Jama, & Puren, 2010).

A total of 29% of rural South Africans are food insecure, and an additional 20% are at risk of food insecurity (Shisana et al., 2013). Food insecurity encompasses not merely a lack of food, but an inability to access sufficient amounts of nutritious, acceptable food in a socially acceptable way (Radimer, Olson, Greene, Campbell, & Habicht, 1992). Food insecurity drives HIV vulnerability through multiple pathways. Malnutrition may increase susceptibility to infection, accelerate disease progression or lessen antiretroviral therapy (ART) effectiveness (Anema, Vogenthaler, Frongillo, Kadiyala, & Weiser, 2009; Weiser et al., 2011). Families that have lost adults to HIV are more likely to be food insecure, increasing the vulnerability of younger family members to HIV infection (de Waal & Whiteside, 2003; Naysmith, de Waal, & Whiteside, 2009). Women who are food insecure are more likely to report inconsistent condom use, transactional sex and decreased control over sexual encounters (Miller et al., 2011; Pascoe et al., 2015; Tsai, Hung, & Weiser, 2012; Weiser et al., 2007). Food insecurity harms psychosocial wellbeing as well as physical health (Cluver & Orkin, 2009). Poverty and food insecurity have been linked to increased bullying, feelings of stigma, poor mental health and a greater likelihood of experiencing physical or mental abuse in the home (Meinck et al., 2015; Pappin et al., 2015).

The link between HIV, food insecurity and stigma is complex. The classic conceptualisation of stigma as a spoiled identity which resides at the locus of the individual (Goffman, 2009) has expanded to consider the reciprocal processes between individuals and their social world which create and reinforce a moral identity that in turn influence an individual’s experiences across his or her lifetime (Yang et al., 2007). Social ties may be severed if an individual is associated with an unacceptable, stigmatised identity like sex work, non-compliant gender expression, drug use or others that are stereotypically associated with HIV (Campbell, Nair, Maimane, & Nicholson, 2007; Fielding-Miller, Mnisi, Adams, Baral, & Kennedy, 2014; Goudge, Ngoma, Manderson, & Schneider, 2009; Kaschula, 2011; Schippers, 2007). In addition to the association between these spoiled moral identities and HIV diagnosis, the pervasiveness of HIV stigma in low resource settings especially may be partially explained by the effect of illness on an individual’s ability to work and contribute to the wealth of their family and community (Tsai, Bangsberg, & Weiser, 2013). Informal social safety nets, in which an individual can rely on loans of food or cash from neighbours, family and acquaintances in times of temporary financial crisis, are typical in Southern Africa. However, if an individual is ill or appears unlikely to ever emerge from poverty long enough to contribute reciprocally, they may be stigmatised and cut off from these aid networks (Kaschula, 2011; Tsai et al., 2013).

A rich literature exists on the food insecurity experiences and needs of people living with HIV (Anema et al., 2009; Grobler, Siegfried, Visser, Mahlungulu, & Volmink, 2013; Ivers et al., 2009; Kaye & Moreno-Leguizamon, 2010; Weiser et al., 2007; Weiser et al., 2011). Less is known about how the stigma of poverty and food insecurity itself is experienced by individuals who are at high risk but not necessarily living with the virus. Nor have any studies to date examined the experiences of former OVCs: young adults who experience the poverty, food insecurity and fractured social networks that result from HIV and create HIV vulnerability.

To address these gaps, we conducted a qualitative study designed to answer three connected research questions:

1. How do rural South African young adults who grew up as OVCs perceive and articulate their daily experiences with food insecurity and hunger?

2. What coping strategies do former OVCs use to mitigate this experience?

3. How do food insecurity and the attendant coping strategies impact rural South African young adults’ risk of HIV?

Methods

Setting

The research site is located in the former kaNgwane area, the designated Swazi ‘homeland’ during the Apartheid era. It was established in approximately 1954, when residents were forcibly removed from nearby areas so that sugar cane industries and game parks could be established. The site lacks consistent water access and was named after a small antelope that can survive for days without drinking water. During the period of data collection residents reported that municipal water services (a series of taps running down main roads) had been unavailable for the previous six to nine months, and that many had to buy water from wealthier neighbours or walk several miles to a local dam primarily intended for cattle. The main home based care centre in the village, which usually provided food for youth on weekends or for out of school youth during the week, had recently run out of government funds and was not able to offer food or other material support to community members. The first author served as a Peace Corps Volunteer in the research site from 2006 to 2008.

Participants

In-depth interviews (IDIs) and focus group discussions (FGDs) were conducted in June and July of 2012. Participants were young adults who lived in a single village in the Ehlanzeni district of rural Mpumalanga. Community leaders including teachers, non-governmental organisation (NGO) workers, and lay church leaders were asked to suggest potential participants whom they knew were experiencing food insecurity and considered vulnerable. The study was described to potential participants and if they agreed a meeting time was arranged for an interview. Participants were eligible if they were between the ages of 18 and 25 years old and comfortable conducting an interview primarily in English. The first author conducted IDIs and FGDs in a mixture of English and siSwati. IDI participants were eligible if they reported experiencing hunger in the last year. FGD participants were recruited based on age and willingness to engage in a group discussion on the topic.

We treated informed consent as an ongoing process throughout the interview. Participants gave oral informed consent before beginning the interview, and were told that they could stop at any time. When participants became upset during particularly emotional discussions, the interviewer would stop, ask them how they felt, and offer to stop the interview.

Participants were invited to choose their own pseudonyms before beginning the interview. These are used throughout the manuscript and are shown in Table 1. All interviews were digitally recorded, transcribed verbatim and translated where needed. IDIs and FGDs were conducted in classrooms or offices at local churches, schools and a neighbourhood care point.

Table 1:

Informant pseudonyms and descriptor variables

Name	Gender	Orphan	Lives with parent(s)	Social grant
Precious	F	No	Both	Yes
Forgiveness	F	No	Mother	Yes
Sihle	F	No	Both
Lwandle	F	No	Mother
Carol	F	Yes		Yes
Sunshine	F	Yes		Yes
Linky	F	Yes		Yes
Lucky	F	Yes		Yes
Ayanda	F	Yes
Thabo	M	No	No	Yes
Rubin	M	No	No
John	M	Yes		Yes
Malema	M	Yes		Yes
Nelson	M	No	Mother	Yes
Singsong	M	Yes		Yes
Sipho	M	Yes		Yes
Donny	M	Yes
Sizwe	M	Yes
Thulani	M	Yes
Wiseman	M	Yes

Analysis

Inductive themes based on participants’ experiences and priorities were allowed to emerge from the transcripts. These were categorised into codes based on a combination of theoretical considerations, participants’ voices and discussion between the authors. Two authors coded the transcripts using MaxQDA analytic software. Discrepancies in coding were resolved through discussion.

Ethical considerations

The University of KwaZulu-Natal’s Humanities and Social Science Research Ethics Committee and the Emory University Institutional Review Board approved this study. Research approval was sought and granted from the local ward counsellor. Results were shared with the community through discussion with community leaders and sharing a preliminary conference poster with a large local church.

Results

We conducted 20 IDIs and 2 FGDs with a total of 28 young men and women. Eleven IDIs were conducted with men and nine were conducted with women. One FGD was conducted with five young women and one FGD with three young men. We used memoing, discussion between co-authors and consultation with local colleagues to ensure that we had reached data saturation by the conclusion of data collection. While most participants were comfortable in English, three female participants preferred to use siSwati when discussing sensitive or nuanced topics. While some informants did become emotional or upset, none chose to end the interview when the interviewer offered them this option.

IDI participant demographics are shown in Table 1. Thirteen participants identified themselves as orphans at some point in the interviews. Of the seven who did not, two did not live with either parent, three lived with only their mother, and two lived with both parents. A total of 12 participants reported that they or their household were reliant on some form of social grant, typically a grandmother’s old age pension or a younger sibling’s child support grant. The one participant who lived with both parents and was not reliant on a social grant (Sihle), said she did not regularly experience hunger. However, her father had recently fallen ill, seriously imperilling the family’s finances and her ability to continue her education.

Six main themes emerged when participants shared their experiences of food insecurity as young adults: Participants’ perceptions of social and income inequality within their community, the stigmatising experience of poverty, the paradoxical importance of school feeding schemes in spite of their potential to increase stigma, the importance of distancing oneself from ‘bad things,’ and orienting oneself towards the future as a coping mechanism.

Inequality

In absolute terms, the village has a relatively flat socio-economic gradient. However, participants were keenly aware of differences in social status, prestige, and relative wealth within the village. Social status was demonstrated through food and clothing choices as well as the social position of a young adult’s parent. Impoverished young adults do receive food or money from neighbours when it is needed, although they sometimes must resort to begging. However, those from ‘good’ families are far more likely to receive instrumental support from the community, including employment, educational assistance from their teachers and services at the local clinic. Participants from the women’s FGD had this to say:

Participant 1: Those from a bad background are not recognised. They only recognise those whom they know their parents are well off.

Participant 3: This thing happens in public schools.

Participant 1: It’s everywhere!

Participant 3: Because in public schools we come from different backgrounds yet in private schools everyone is from a good background. When you are from a good background people pay you respect.

Participant 1: Like when you visit a certain place and tell them that your father is a principal, you get the best seat. They remove someone else’s seat [laughs]. Yeah, that’s what happens around here. There is a lot of discrimination.

Participant 3: Even in the local clinics when you go there and find a queue they take [wealthier people] first in line…We use a public clinic so if I am from a bad background…they can take [someone else] first because she is from an advantageous background.

Participant 2: Even if you are seriously sick and it’s closing time, they’ll tell you to come back the next day.

Female FGD participants felt that wealthier men and boys were especially likely to target girls from poor families, as these girls were more vulnerable and less able to stand up for themselves.

Most of the boys from good families go for the girls from poor families, and promise that they will give them all that, and then [they] leave them when they fall pregnant. Those girls are fooled into believing that [they] can be a partner with that boy because he is from a good background

(Women’s FGD, participant 1).

Poverty identities

While all participants were over the age of 18, many had grown up as orphaned or vulnerable children. Participants who identified as orphans spoke of the differences between their own home lives as children and that of their wealthier friends and neighbours:

Sometimes I feel uncomfortable…like when I see some other families, and compare them to my home. Eish. It’s very difficult for me. Most of them are nuclear families

(Donny, male IDI).

Others grew angry when they discussed their families. One young man felt betrayed by parents whom he perceived as capable but unwilling to provide him with the support that all his friends had been given:

It’s not that I don’t have parents at home. I do have parents, but…they are not taking good care of me… There are so many things that come into my head. What has been done to my parents that they can do this to me? … It’s not that they aren’t working, they’re working. They do have the potential to bring food to me so that I can focus on my studies, but they are not doing so…You know, it’s very painful

(Rubin, male IDI).

Two participants reported that an older family member had resorted to selling livestock to provide money for food or school fees. In rural South Africa large livestock are stable and visible reservoirs of wealth, and the decision to sell or slaughter livestock is not made lightly. One participant became visibly affected when telling the story of her grandmother’s decision to sell a goat to pay for her university fees and other family expenses:

Ok, my granny sold that goat, neh? Not because she wanted to…she did that because… she saw that, ah we are suffering a lot. Because at the morning we had to have some breakfast, things like that, you know? I can say, you know, she is working hard for us. To have something every day. To have something maybe like pocket money, things like that…And my younger brother even has shoes, for school. So we bought those shoes for him. And then, as it is now winter time, some jerseys, you see? Some jackets, so he can be warm

(Sunshine, female IDI).

Participants compared themselves to those who were ‘living a good life’ in general. They discussed being marginalised and disrespected because they were from impoverished backgrounds.

We were poor spiritually and socially… I am talking about the way you live at home because you are poor and when you are playing with children… they didn’t want to play with us because we were wearing torn clothes and we were dirty because we didn’t have soap

(Sipho, male IDI).

Asking, or begging, for help creates the risk of revealing the participant’s ‘situation at home’: their hunger and poverty. Because of this, participants were careful to only ask for help from a few people whom they knew well or whom they felt they could trust to not gossip or make fun of them. Instrumental and psychological support were often combined in the same act of giving, as participants felt that a neighbour or friend who shared food with them was also showing them love, care and support:

Sundays, I go to church. Then after that, my friends they used to say “No, let us go home.” Then they will go at their home maybe later. So if I’m there, then they give me food. What they are eating then I must eat too…I feel happy because …I see that they have that love for me

(Wiseman, male IDI).

Nearly all participants, men and women, reported that they would sometimes resort to ‘begging’ from friends, neighbours or even strangers for food or money. While common, begging was considered a last resort strategy, and was associated with feelings of shame, embarrassment and anxiety.

Well I have never stolen before. My mother always tells me, work for something you need. But sometimes, I try and make you give me money. I just talk, I’m good at talking… like, make you feel as if you’ve got money then you can give it to me then… just make you feel that way. OK, I’d come to you and then I’d: “Ah! Ah! Oh! Hey, help me out here, I just want some of your money I know that you’ve got money — I don’t have money — ah, come on, I’m hungry, know? I want to buy food for now!” And then you go, eish, let me just look — in your pocket. When I see that, I go like, “Ah! You have one! Give me man, I can see 20 bucks there!” And then you’ll give it to me… when I take money I like paying it back. But when I do that I don’t pay you back because you gave it to me. So it makes me kind of bad. Know? I’m mostly feeling that I’m a bad person …It’s like I’m doing fraud, you know? Its fraud

(Nelson, male IDI).

Some participants reported that friends would help them avoid the embarrassment of asking for help by pre-emptively inviting them over for meals on the weekend (when the school feeding scheme was unavailable), especially Sunday dinners after church. Participants felt grateful and cared for by these ‘true friends’ who offered them instrumental support, while avoiding the embarrassment of discussing their situation at home.

He’s a good friend… because when I’m asking food, he doesn’t go and tell others that hey I’m asking food…Some people, when you ask food they will think that you don’t have food. So, they will go and tell other people that you don’t have food. That is why I don’t want, I don’t want my friend to tell another friend that I don’t have food at home

(John, male IDI).

Young men would often engage in ‘piece work’ to raise small amounts of money. Young women did not report engaging in piece work, likely because this work tends to take place out of doors, is labour intensive and typically coded as masculine. No young women reported engaging in income generating activities, although female OVCs in the region who are taken in by extended family are often expected to take on much of the household domestic work as a sort of informal repayment. One young man had been trained in carpentry by his father and took a great deal of pleasure in using his skills to provide for his family and friends whenever he was able to do so. He spoke about his dream of opening a small business in the village to train his friends and support his family:

My father, who is now in Jo’burg, he is a carpenter. Sometimes when he is here he teaches me, because I am a fast learner you know, he tells me ok, this is how you do it. When doing a coffee table this is how you do it. This is how you machine, I bought you new machines, you know…It’s just that I don’t have money now to open a company or a firm or a place now to teach people. Because now I think it’s me and my friends and some of the guys have asked to go and help. Because they know something although they are not as good as I am. But I try and teach them: This is how you do it

(Nelson, male IDI).

Some worked making bricks, clearing brush from plots of land or doing landscaping for neighbours or teachers. The reliability and value of this work often depended on the generosity of the young men’s employers. Piece work employers had near total control over the negotiation process. One young man reported that employers could refuse to pay after the work was completed, or would pay less than the amount initially agreed upon. He felt that he and his brother had little control over these encounters and no recourse when they were denied payment:

Maybe there is someone who has a stand, meaning that he wants to build his home. Then we go to this person [and ask], “Can you hire us?” Then he says, “No problem, I can hire you.” But …then he asks how much do you want, then we say that maybe 800 if the stand is big, then he will cry at you… Then he says ok, I’ll give you that money, then we don’t refuse it, we accept it because we need something to put bread on our table… When the food is finished, we have to start afresh. Maybe he says he can’t afford [that], maybe he says 600 or 650, we say no problem… Maybe he says, no I’ll do this next year… Then eish, we feel like there is nobody who feels for us… But some of them they use us to work, but they did not pay us … We don’t have words [for them]. We even shut our mouths. Then we say, “No, God knows”

(Thulani, male IDI).

Stigma made visible: school feeding schemes

Feeding scheme meals are provided to all students regardless of family background. While all participants were aged 18–25 years, many still attended secondary school. Some had dropped out of school for a time due to illness or poverty and had only recently re-enrolled. Others had repeated grades at various points during their academic careers.

Students who relied totally on the feeding scheme were bullied and stigmatised. Wealthier students would sometimes mock the feeding scheme food, calling it ‘dirty’ or making a point of visibly eating ‘better’ foods — usually processed meats or packaged snacks — and eschewing the line for the feeding scheme. Participants in the female FGD said:

Participant 1: They show off on those who cannot afford.

Participant 2: They buy KFC [Kentucky Fried Chicken].

Participant 1: And you find them eating apples and bananas.

Participant 3: They prefer those fruits to vegetables.

Participant 2: Not everyone can afford an apple every day. If I eat an apple it means I come from a good background…it’s like I am showing off to those who cannot afford [better food].

Participant 1: You can find that I eat the food provided by the school, and then my friend is eating KFC and she will be like, “I don’t like your food.”

Participant 3: She makes me feel bad. They might say things like, “Did you really eat that? Are you sure that the person who cooked this was clean?” Things like that.

Participant 1: It’s to discourage [people from] eating from the feeding scheme. That’s how they show off.

Produce was a particularly nuanced symbol of haves and have-nots. The research site is located in an agricultural area that specialises in bananas, citrus, avocados and sugar cane. Banana farms in particular would frequently donate surplus fruit to afterschool programmes. Because of this, citrus and bananas were somewhat accessible while non-local produce — especially apples — had to be store bought and remained status symbols.

For participants who were still enrolled in school and relied on the feeding scheme as their main or only meal of the day, eating the school meal required balancing hunger with the shame and humiliation of standing in line. Despite this, feeding schemes were vital to participants’ continuing education and often the sole thing that prevented them from dropping out of school to find work. Some participants reported eating alone to avoid being teased:

Many people were saying bad things…like that the food is not suitable… They even say, “That food is not cooked well, that food is too bad, I can’t eat it…I don’t even eat beans, and why did the government not buy meat?”…I feel very bad while the person is sitting near me. I can’t even ask why. Because I’m afraid, you see?… People say bad things…They go behind your back, they talk bad things, they even say look, he is suffering, he doesn’t eat in his home. Maybe he is sick with hunger… I feel so bad that I may leave that food [without] eating it… I feel shamed… I have to eat the food, because I know that when I am leaving school for home I’m not going to get food, you see, I must eat the food here

(Thulani, male IDI).

Despite complicated feelings about needing to rely on feeding schemes, many participants framed school food — or food from the home based care centre when it was available — as a manifestation of care from the school itself, a volunteer or teacher who provided extra food, or the South African government writ large. Participants in the male FGD said:

Participant 1: The government sends us to school.

Participant 2: Like in school we eat healthy food. For example, samp, beans, and on Friday we have milk and porridge. And they give some fruits such as banana or orange.

Participant 1: Government tries by all means to satisfy us with food that is healthy.

Participant 2: So that we can be healthy.

Interviewer: Why is the government doing that?

Participant 2: Because it cares a lot about us.

Bad things: gossip, crime, and sugar daddies

Participants were asked about “things people might not otherwise do if they weren’t hungry”. There was a consensus that these ‘other things’ were ‘bad things’, and that ‘bad things’ manifested by gender: men or boys who were hungry would be driven to crime, and women or girls would be driven to ‘sugar daddies’. When probed, female participants added that in addition to seeking support from boyfriends or sugar daddies, young women would also engage in defensive gossip intended to draw clear lines between haves and have nots.

Some of them [steal]. If I know I’m hungry and I don’t have anything, and I saw something there, I can try by all means… [to] get something to eat. Interviewer: Is it boys or girls who steal? It’s boys. Girls … girls like talking. Talking. Gossiping. Undermining each other. And discrimination also. Me and you, we are competing. And I have to make sure that we are not the same. I have to show you that I’m not the same. I can wear expensive clothes, rather than you. I can do this, you can’t do… that’s why they have to undermine the other one. Because … the other friend has a group. And I have my own group next to me. So…that is so…a lot of girls do. They are stealing…a lot of boys, I can’t say stealing every day. I can say months, or weeks, but girls talk talk talk talk talk

(Lwandle, female IDI).

Nearly every participant distanced him or herself from these ‘bad things’, often contrasting these negative strategies with their own good behaviour. Good behaviour in these cases including attending church, being respectful and studying hard at school. While only one participant explicitly stated the link, many implied that ‘good behaviour’ increased the likelihood that a food insecure young adult would receive help from their community when they were in need.

They do help me, because, you know, the way I’m pushing at the school. They see that no, I do behave. And that I do have a potential to perform at school. Then they help me, they give me some money to buy food. That’s the way I survive, actually

(Rubin, male IDI).

Looking beyond the present: church and school

Despite the feelings of anger, sadness and confusion that often came with impoverished and OVC identities, nearly every participant expressed hope about the future. Participants positioned this hope, and their own resiliency in the face of difficult social and economic situations, in a variety of ways. Some saw education as the key to a better future.

I mean when you are in a situation whereby you don’t have your own money, you don’t have your own things, you have to just focus on your studies to beat that hunger. That’s why every day when I’m waking up I’m saying I’m gonna change this. I’m gonna change this. I’m carrying my books and I go to school and say, “I’m gonna change this. I’m gonna change the situation whereby I am forced to eat that thing, because I have no choice

(Carol, female IDI).

For many informants, faith was vital. A reliance on God and faith provided participants with a source of internal resiliency that helped them brush off gossip and other stigmatising experiences.

I’m depending on God and I’m also depending on the other people who help me. So you must know that I don’t have to listen to gossipers and live my life

(Forgiveness, female IDI).

As referenced in previous discussions of emotional and instrumental support, church communities simultaneously fulfilled a range of social needs. In addition to formal support — supplying school uniforms and feeding schemes as official church activities — many informants labelled friends or neighbours who were most willing to help them as ‘good Christians’ informed by the ethos of their church:

Here at church there are some families who have a good heart. I live with my mother and when I am feeling hungry and at home we don’t have food I go to my grandfather, and if he doesn’t have [anything] I go to the people I assemble with here [at church] and yes, they give me food

(Sipho, male IDI).

Discussion

Young adults who are living with food insecurity require social and emotional support in addition to material assistance. Many, though not all, of the participants we spoke with ate a single meal a day provided by the school feeding scheme or friends. Despite this, nearly all participants emphasised the emotional and social, rather than physical, tolls of food insecurity. Participants who grew up orphaned, impoverished or otherwise vulnerable were keenly aware of the difference between their own ‘situation at home’ and that of their relatively better off friends and neighbours. They used several internal and external strategies to manage this stigma, including orienting themselves towards the hope of a better future and revealing their poverty to only a select few whom they felt could be trusted not to spread gossip. While female informants were more likely to highlight gossip among women and girls, both men and women engaged in careful reputation management to protect themselves from gossip. This often included distancing themselves from other food insecure individuals who engaged in ‘bad things’.

South Africa currently provides a range of social grants and services for its most vulnerable citizens. A national school feeding scheme provides one meal a day to all children at lower income primary and secondary schools (DBT, 2012), and the government has emphasised community based responses including food distribution at home based care centres and collaboration with community based organisations (Republic of South Africa, 2012). The national system of social grants has been shown to increase adult participation in the labour market, buffer local and global economic shocks and increase children’s nutritional status and school attendance (Tiberti et al., 2013). To supplement formal government programmes, those who live in rural areas frequently rely on social networks as informal social safety nets in times of financial crisis or when food is running short (Kaschula, 2011; Miller & Tsoka, 2012). However, individuals who are marginalised, isolated or labelled with the stigma of HIV are more likely to lack social capital and to access social networks, increasing their risk of food insecurity (Kaschula, 2011; Tsai et al., 2011).

Previous work in Southern Africa has shown the importance of distancing oneself from ‘bad things’ to demonstrate worthiness of support from one’s community (Kaschula, 2011; Stoebenau et al., 2011). However, even those young adults who avoided perceptions of criminality or promiscuity still felt a great deal of social stigma and shame over their poverty. The distinction between symbolic and instrumental stigma suggests that this is because while our informants managed to distance themselves from the spoiled identity associated with unacceptable social practices, their relative poverty still rendered them unable to reciprocate material assistance within the social network of the village (Tsai et al., 2013).

Stigma is not a static element, but an ongoing social process that is predicated on pre-existing vulnerability and potentially a lifetime driver of poverty and hunger as the result of social exclusion (Yang et al., 2007). Many informants discussed the distinction between ‘good’ and ‘bad’ families — that is, relatively affluent vs. relatively impoverished families. The stigma faced by ‘bad’ families may result from instrumental stigma predicated on their perceived inability to contribute to the community. The moral career of instrumental stigma for former OVCs thus begins in childhood for those from ‘bad’ families, shaping their access to clinics, education and social opportunities, and continues into young adulthood as they begin to attempt to manage their own reputations and social presentation.

Young adults experiencing food insecurity require interventions that target ‘what is at stake’ across the life course as a result of this stigma (Yang et al., 2007). Our findings suggest that ‘what is at stake’ includes both instrumental and social needs. Research in Brazil, Uganda and Malawi suggests that efforts to reduce poverty across an entire community, not simply for people living with HIV, may reduce the intertwined stigmas of poverty and HIV, reduce HIV risk for individuals who are not infected and improve outcomes for those who are living with the virus (Miller et al., 2011; Miller & Tsoka, 2012; Takada et al., 2014; Tsai et al., 2013; Tsai et al., 2012). Interventions in India and South Africa that sought to mobilise an entire community have shown success in generating the social capital and ties that are crucial for resiliency in food insecure young adults (Cornish, Priego-Hernandez, Campbell, Mburu, & McLean, 2014; Kerrigan et al., 2015; Pronyk et al., 2008; Wild et al., 2013).

Schools and churches are sources of food, emotional support and optimism for food insecure young adults. These institutions play important community roles in the fight against HIV. While not all teachers or church communities may be fully equipped to appropriately support food insecure young adults who are at risk of HIV, interventions designed to partner with or support pre-existing efforts are likely to be more acceptable and sustainable within communities than standalone pilot projects (Hussen et al., 2014; Magano & Rambado, 2012; Mavedzenge, Luecke, & Ross, 2014; Root & van Wyngaard, 2011; Smith & Harrison, 2013; Wingood et al., 2013). Future research on the perspectives and experiences of caregivers for OVCs and young adult OVCs would also shed light on the role of instrumental stigma in rural communities, and provide important insights for potential interventions.

Based on the voices of our participants, we argue that food insecurity for South African young adults cannot be fully understood or addressed without accounting for the stigmatising nature of poverty. While it is possible to design a food security intervention without accounting for stigma, both our own participants descriptions of their experiences with school feeding schemes and previous attempts to design nutrition interventions in South Africa without considering possible stigmatising effects suggest that these efforts would not be completely effective (Doherty, Chopra, Nkonki, Jackson, & Greiner, 2006). This study was qualitative, and as such makes no claims to generalisability, however, framing our findings using the distinction between instrumental and symbolic stigma as a theoretical framework increases transferability. The first author had spent two years living in the community as a Peace Corps Volunteer several years before this study, and this prolonged engagement serves to enhance our study credibility, as does triangulating our findings through the use of both FGDs and IDIs.

Conclusion

We conducted 20 IDIs and 2 FGDs with former OVCs, young adults who grew up as orphaned or vulnerable children and were experiencing food insecurity in rural South Africa. We found that young adults who experience food insecurity require emotional and social support in addition to food aid. Many of them experience instrumental stigma, likely because community members within the village question their future ability to contribute to the informal social safety net. Interventions designed to assist these young adults must focus on building social capital and supporting emotional resiliency in addition to providing material support. Schools and churches already provide these to some degree, although teachers and staff at both may need assistance to deliver high quality services.