Sprinkles Report For Web

Community Consultation
on Home Micronutrient
Supplementation ‘Sprinkles’
for Indigenous Children in the
Northern Territory
2007
The Fred Hollows Foundation

Indigenous Program
in collaboration with:
Anmatjere Health Service

Katherine West Health Board
Sunrise Health Service
Wurli Wurlinjang Health Service
Northern Territory Department of Health and Community Services
United Nations International Children’s Emergency Fund
Contents
Acknowledgements 4
Acronyms 5
Executive Summary 6
Introduction 12
Objective 13
Phase One 13
Phase Two 13
Method 13
Design of the questionnaire and pre test 13
Sampling, data collection and analysis approach 14
Data analysis 15
Findings from the consultations 16

1. Participant information 16
2. Feeding practices for babies aged 6 months to 2 years 17
3. Knowledge about food for babies, food nutrition and anaemia 23
4. Community member’s attitudes to ‘Sprinkles’ 27
5. Community member’s opinions of the best way to communicate
information about ‘Sprinkles’ and anaemia 29
Overall recommendation 32
Appendices 33
APPENDIX 1: List of partner organisations and communities involved
in the research
APPENDIX 2: ‘Sprinkles’ Steering Committee members (July 2007)
33
34
3
APPENDIX 3: Communities surveyed as part of the ‘Sprinkles’ research project 35
APPENDIX 4: Timeline for research project 36
APPENDIX 5: Focus group introduction answer sheet 37
APPENDIX 6: Semi-structured question guide for care takers of children
aged 6-24 months 39
APPENDIX 7: Healthy food story 43
APPENDIX 8: Picture game - which foods contain iron? 44
APPENDIX 9: Challenges of focus group discussions and advantages
of smaller group or individual interviews during the consultations 45
APPENDIX 10: ‘Sprinkles’ community consultants assisting with the project 46
APPENDIX 11: Additional information from health staff, carers and shop managers 47
NT Department of Health and Community Services:
APPENDIX 12: Anaemia educational materials 48
APPENDIX 13: Notes from the feedback trip to the communities
involved in the research 50
References 51
Acknowledgements
The partner organisations of this project would like to thank:
• Ms Robin Knox, employed by the Fred Hollows Foundation as the ‘Sprinkles’

Research Coordinator to conduct the formative research project.
• The excellent assistance of the community consultants who conducted the research
in their own communities.
• The ‘Sprinkles’ Steering Committee and sub committees for their support and
guidance throughout the formative research project.
• Mr Jerry Schwab, from the Centre for Aboriginal Economic Policy Research at
Australian National University for his pro bono assistance and guidance in the write
up of the project.
• The Fred Hollows Foundation Indigenous Program for providing full financial and
operational support for the project.
Special thanks is expressed to all carers and children who generously gave their time and
contributed to the findings of this report and the many community workers (health, council
coordinators, childcare workers) who assisted and supported with the research.
4
Acronyms
AMS Aboriginal Medical Services
ARDS Aboriginal Resource and Development Services Inc.
BRACS Broadcasting for Remote Aboriginal Communities’ Scheme
CAAMA Central Australian Aboriginal Media Association (Aboriginal

Corporation)
CARPA Central Australian Remote Practitioners Association
CDEP Community Development Employment Program
DHCS Department of Health and Community Services
FHF The Fred Hollows Foundation
GAA Growth Assessment Action
KWHB Katherine West Health Board
MI Micronutrient Initiative
NT Northern Territory
SHS Sunrise Health Services
UNICEF United Nations International Children’s Emergency Fund 5

UNU United Nations University
WHO World Health Organisation

Executive Summary
The social and economic situation of Indigenous children in remote Australia is critical. One
of the major health problems of Indigenous children in the NT is iron deficiency anaemia,
which can have significant health consequences, including impairment of mental and
motor development in children. Data from the NT DHCS Growth Assessment Action (GAA,
2006) program in 2005-06 suggests a 26% iron deficiency anaemia prevalence rate among
Indigenous children aged 6 months to 5 years. The WHO (2001) recommends blanket iron
and micronutrient supplementation, without screening, to all infants and young children 6 to
24 months of age in regions where the prevalence of anaemia exceeds 20-30%.
Current strategies in the NT to reduce iron deficiency anaemia in children emphasize

screening, treatment with intramuscular iron and health promotion campaigns. Despite
these treatment protocols and strategies being in place for the last ten years, rates of
anaemia in children have remained unacceptably high. Reductions in prevalence are
attributed to treatment, rather than prevention. This may in part be due to the fact that
there is no supplementation policy to prevent anaemia among children in the NT. Work is
currently in progress to develop GAA into a more comprehensive child health program for
under-5 year olds and supplementation could become a component of this program.
A best practice anaemia prevention and control program is multifaceted and incorporates
a range of initiatives, including supplementation, fortification, infection control, dietary
diversification and public health and maternal and reproductive health interventions. As
part of a multifaceted anaemia prevention program, a home micronutrient supplement,
‘Sprinkles’, has been shown to be effective.
The purpose of this six month formative research project is to inform the feasibility of
implementing a home micronutrient supplement, ‘Sprinkles’, for the prevention of anaemia
in Indigenous children aged 6 – 24 months in the NT. The report (Phase One) will provide
6 formative findings on community members’ knowledge, beliefs, sources of information and
practices relating to the feeding of indigenous infants, and; will seek community direction
for the distribution and implementation of ‘Sprinkles’ in the NT. The report will be followed
by Phase Two, a pilot project which would then inform future DHCS policy and program
guidelines in relation to iron and micronutrient supplementation for infants and young
children throughout remote communities of the NT.
Ngukurr community,
Katherine East.
Photo courtesy of
The Fred Hollows
Foundation.
The research has taken place in 8 communities within the NT and in collaboration with
the following partner organizations: Anmatjere Health Service; Sunrise Health Service;
Katherine West Health Board; Wurli Wurlinjang Health Service; Northern Territory
Department of Health and Community Services; United Nations International Children’s
Emergency Fund; and The Fred Hollows Foundation.
The research field team comprised of one Research Coordinator, employed by The
Fred Hollows Foundation, and assistants, scribes and translators from each community.
The field team was supported by key informants, individuals who reside in the sample
communities and members of staff from the AMS. Carers of infants aged 6-24 months
were purposively sampled for the final data collection phase. They were either invited to be
interviewed individually or in small groups. Other community workers, such as clinic staff
and childcare workers, were also informed about the research and given the opportunity
to express any ideas and their answers are incorporated in to the relevant sections of
the report. A Focus Group Discussion guide was developed from a structured interview
tool used by Helen Keller International, for formative research on the implementation of
‘Sprinkles’ in Cambodia and Indonesia. It was adapted for use in the Northern Territory
with advice from The Menzies School of Health Research and ‘Sprinkles’ NT Steering
Committee members.
The focal areas of the questionnaire are: feeding practices among young children aged
6 months to 2 years; knowledge about food for babies, food nutrition and anaemia;
community member’s attitudes to ‘Sprinkles’ and; community member’s perceptions/
attitudes toward methods and channels through which to distribute ‘Sprinkles’. The report
is presented in the following structure: a summary of findings for each focal area (listed
above); and conclusions, which suggest strategies to direct the next steps for Phase Two
of the project.
The following is a summary of participant information, and summary and conclusions for
each focal area.
1. Participant information1 7
Of the 8 communities that were engaged, 56 carers were interviewed. Mothers comprised
80% of people interviewed and nearly half (48%) of the mothers interviewed were under
the age of 25 years old.
2. Feeding practices for babies aged 6 months to 2 years

Feeding habits for under-2 year olds show some similarities across all communities. The
consultations showed that the majority2 of babies were breastfed; however there are no
consistent practices among carers regarding the age to introduce complementary foods
and drinks to babies. Most carers report introducing complementary foods to babies
between the ages of 3 to 7 months, however some carers reported starting earlier at 1
to 2 months or later at 9 months. Drinks are most commonly introduced between 5 and 7
months.
Babies are generally eating a diet high in carbohydrate, low in protein and low in most
micronutrients, suggesting that babies’ nutritional intake is inadequate. In addition, some
feeding and drinking practices may be leading to iron deficiency anaemia. Convenience
foods, such as: processed baby food; food from the take-away shop; and two-minute
noodles are often fed to babies. Some carers occasionally feed babies bush tucker3 when
it is hunted on the weekends, as well as beef from nearby cattle stations. Water and fruit
juice are the most common drinks given to babies and young children. Canned fizzy drinks
are also given to under-2 year olds. Many carers were very firm in reporting that they never
gave tea to their babies. Other carers reported giving tea with milk and sugar regularly to
babies, either as sips from their own cup or making the child their own cup of tea.
1
In this report the term ‘babies’ is used to refer to infants up to 2 years old. This is the term agreed upon by consulting the Aboriginal research assist-
ants. Throughout the questioning, when appropriate, interviewees were reminded about the age group being discussed.
2
It was reported by carers that 51 babies from a total of 58 babies were breastfed.
3
Bush tucker refers to Australian native food used as sustenance by the Indigenous Australians. During this research, bush tucker reported by carers
included fish, turtle, kangaroo, turkey and wild pig.
Predominantly mothers and grandmothers, or other female relatives, and occasionally
fathers, prepare food for babies. Boiling and stewing are the most common methods for
preparing food, although some people fry, grill or barbeque foods. Some carers are not
cooking food or preparing meals. It is reported that this is due to the fact that some people
have never learnt to cook. Convenience food is popular because it is accessed quickly
and easily and limits cooking and preparation time. Some older carers expressed concern
about the young age of many mothers and commented that some young mothers have
limited knowledge about cooking and feeding practices. Note that this was not expressed
by young mothers themselves.
Many babies from 6 months to 2 years old are fed by their mothers, or close family
members such as grandmothers or aunties. It is reported that fathers are only occasionally
involved in feeding their babies. The majority of carers feed their babies at home, with a
small number reporting that their babies are fed at childcare, at the shop or takeaway, at
family or friend’s houses or ‘out bush’. For most families eating is a communal activity and
babies eat with the family, however some carers reported feeding babies before or after the
family eats. Many babies are initially fed from a shared plate, with carers reporting a range
of ages that babies start to feed off their own plate. Some babies have their own plate at 6
months; however other babies may not have their own plate until 1 or 2 years old. Carers
reported that babies often try food from everyone’s plate.
Some carers report that they do not receive advice from anyone about feeding babies.
Where carers do report that they receive advice, it is mainly from health workers and/or
female family members.
Carers reported a variety of ways to look after sick babies and there appear to be some
mixed messages about what to do when a child is sick. Many carers seek assistance from
the clinic if their children are sick. Often an older female family member will take over care
of a baby from a young mother if the baby is sick. Bush tucker and bush medicine are often
quoted as being used to help sick babies.
8 Carers did not report that community stores had insufficient quantities of food, although
some reported having to wait for certain foods or stores having limited stock of certain food.
Some communities did not have a store close by and had to travel to a major town, such
as Katherine, to buy food. Transport is often difficult in this situation. In addition, families
sometimes do not have money to buy food, however it is reported that ‘families always help
each other out’ and in most shops ‘book up4’ is available.
Market gardens were operating in two communities, supplying eggs and fresh fruit and
vegetables free to all households. Some families had private vegetable gardens to
supplement the food supply from the shop.
There is evidence that child care centres provide an opportunity for babies to receive a
nutritious meal.
4
Credit offered by stores and other traders for the purchase of goods or services, thus allowing consumers to buy goods now and pay later.
Conclusions
• There is a need to improve the nutritional intake of babies’ 6 months to 2 years

old.
• There is a need to promote and support exclusive breastfeeding from 0 – 6
months old and the introduction of complementary foods from 6 months old,
together with continued breastfeeding.
• There is a need to increase the capacity of mothers and other carers to prepare
and cook nutritious foods for babies 6 months to 2 years old and encourage
active feeding practices.
• Due to the communal lifestyle and the fact that babies’ food preparation and
feeding is shared among family members, the whole community needs to be
involved in future nutrition- focused program initiatives.
• There are social and environmental barriers to improving babies’ nutrition in
remote communities. Some of these include accessibility to healthy food and
the low socio economic status of many families
3. Knowledge about food for babies, food nutrition and anaemia

Most carers know what constitutes healthy and unhealthy foods, including understanding
that high fat and high sugar foods are not healthy for babies. A few people were able to
accurately report some symptoms of anaemia and many carers thought that eating healthy
food was a way of preventing anaemia. There was also recognition of the nutritious value
of bush foods.
However, there is limited knowledge from the majority of carers regarding vitamins and
minerals in food, the specific benefits of iron to health and the link between iron and
9
anaemia5. There is also very limited knowledge about the causes and symptoms of
anaemia, the consequences (long-term side-effects) of anaemia or whether anaemia is a
problem in the community. Most carers are aware that testing and treatment for anaemia
can be done at clinics.
Conclusions
• Building on existing knowledge about bush tucker and healthy and unhealthy
foods, there is a need to increase understanding and knowledge in the
community about vitamins and minerals in food and the impact of micronutrient
deficiency on children’s health (and the community at large).
• Future program initiatives need to address behaviour change around nutrition
(evidence suggests that knowledge alone does not necessarily lead to a change
in behaviour).
• There is a need to facilitate better community understanding and ownership of
growth and anaemia assessment data.
4. Community member’s attitudes to ‘Sprinkles’

The findings indicate that nearly all carers would be willing to trial ‘Sprinkles’ as it
would ‘make their babies strong’ and ‘stop them from getting sick’. Some carers thought
‘Sprinkles’ would be preferable as it was less painful than iron injections. There was very
little resistance shown to using ‘Sprinkles’ and no queries about its possible side-effects.
5
Many interviewees had not heard of anaemia but had heard of ‘weak blood’, though knowledge about ‘weak blood’ was limited.
Many carers reported that they would be prepared to pay for ‘Sprinkles’6. However, many
also stated that they would not pay for it or they were not sure. This was primarily because
they thought it should be available free from the health clinic.
Most carers chose breakfast as the preferred meal to add ‘Sprinkles’ to food because ‘the
babies are really hungry’ and ‘they always want to eat breakfast’. Some carers chose lunch
or dinner as the preferred meal. Carers said they would use ‘Sprinkles’ on all types of
food, however the most common food was mashed potato/pumpkin, Weetbix, porridge and
breakfast cereal. Carers were prepared to ensure that ‘Sprinkles’ was consumed only by
the baby.
The community store was the most commonly suggested supplier for ‘Sprinkles’. However
the health clinic was also a popular suggestion, mainly because it meant ‘Sprinkles’ would
be supplied free, but also so its use could be monitored. Other suppliers suggested were
the child care centre, women’s centre, government council and town food supplier7 (where
accessible).
The most popular storage suggestion for ‘Sprinkles’ was at home, in a high cupboard or
store room, where other children could not reach it. Other suggestions were in the carer’s
bag or in the fridge. The desired number of sachets in a packet/box varied from a single
sachet to 60 in a box, with most suggesting a box containing 15 to 30 sachets. Suggestions
for collection times ranged from daily to once every 2 months, however most carers wanted
to collect ‘Sprinkles’ weekly, then fortnightly or monthly.
Conclusions
Community members are willing to try ‘Sprinkles’. In a ‘Sprinkles’ pilot study the
following would need to be considered:
10 a. Feasibility and appropriateness of payment and non-payment options

b. Proper application of ‘Sprinkles’, including starting supplementation at six
months old, individual packets for use by one child, types of food to use
‘Sprinkles’ on, etc.
c. Development of a clear distribution channel for ‘Sprinkles’, including
assessment of the feasibility and appropriateness of supplying ‘Sprinkles’
through the community stores, take away or the town food supplier and the
financial viability of distribution through commercial outlets, as well as an
through other structures, such as the health clinic, women’s centre or child care
centre.
d. Appropriate packaging of ‘Sprinkles’ that will be acceptable to carers.
e. Monitoring issues
5. Community member’s perceptions/attitudes toward methods and channels through which

to distribute ‘Sprinkles’
Carers access information from a range of sources. This often depends on the functioning
services and systems in each community. The majority of carers referred to the health
clinic and health workers and trusted female family members as their main information
sources. Child care centres and women’s centres were also popular places to access
information. The council, church, TV, the internet and studying childcare at Batchelor were
also mentioned.
6
The price that people said they were willing to pay for Sprinkles ranged from $0.05/day to approximately $1.40/day, however most prices suggested
were $0.30 - $0.70/day.
7
Town food supplier refers to shops, such as Woolworths, Five Star or a chemist, in a large town that is regularly accessible for community members.
Common suggestions about the medium to promote ‘Sprinkles’ included: posters;
advertisements on TV and radio in the community’s dialect; magazines; and a video in
the local language explaining the issues. One community produced their own newspaper
and this was suggested. The most popular means to deliver the message was through
community meetings and community and family members, especially mothers, talking to
each other. Other suggestions were meetings held by the women’s centre, child care centre
and council or through existing health programs. Many wanted the message delivered in
the communities’ own language.
Most carers wanted information given to mothers during ante natal checks, when babies
are born and at regular intervals from 6 months old to 2 years old. Some carers suggested
teaching the whole community about ‘Sprinkles’, including fathers, so that everyone
understood the information.
Conclusions
In future program initiatives, communication about anaemia and ‘Sprinkles’ should:
a. Utilise specific functioning services and systems that are operating in each
community
b. Use the local language/s in delivering messages
c. Ensure that messages are delivered to the community by community members
d. Ensure that the whole community is targeted.
The overall recommendation from the report is that the use of a multi –micronutrient/iron
supplement for children aged 6 – 24 months form part of a more comprehensive approach
to address anaemia prevention in indigenous communities. Community education and
behaviour change initiatives around nutrition should be strengthened and expanded to
ensure anaemia is prevented in the long-term. In addition the social and environmental
11
barriers to improving nutrition in indigenous communities will determine the combination of
strategies required to prevent and control anaemia. In the immediate future, the findings
from this study, together with the poor growth and anaemia status of children, supports the
implementation of a pilot program of a home micronutrient supplement, ‘Sprinkles’, for the
prevention of anaemia in children aged 6-24 months in indigenous communities in the NT.
One year old baby from Lajamanu community tries

‘Sprinkles’ for the first time. Photo courtesy of The Fred Hollows
Foundation.
Introduction
The social and economic situation of Indigenous children in remote Australia is critical.
Indigenous children in the NT are among the most disadvantaged in Australia. Indigenous
infant mortality rates in the NT are up to 4 times the national average and comparable to
those of developing countries, while mortality rates in remote communities may be even
higher (Condon et al, 2001).
One of the major health problems of Indigenous children in the NT is iron deficiency
anaemia. Iron deficiency anaemia is the most common type of anaemia, and the most
common cause of microcytic anaemia. Iron deficiency anaemia occurs when the dietary
intake or absorption of iron is insufficient, and haemoglobin, which contains iron, cannot be
formed. It can have significant health consequences, including increased risk of premature
delivery, low birth weight and impairment of mental and motor development in children.
Iron deficiency anaemia remains at high prevalence among Indigenous children in the
NT. Data from the NT DHCS Growth Assessment Action (GAA, 2006) program in 2005-06
suggests a 26% prevalence rate among Indigenous children aged 6 months to 5 years.
The seasonal range for the 6 – 12 month age group and 1 to 3 year age group is even
higher; at 58% in the 6 months leading up to October and 46% in the 6 months leading up
to April for the 6 – 12 month age group and approximately 30% in the 6 months leading up
to October and April for the 1 to 3 year age group. The WHO (2001) recommends blanket
iron and micronutrient supplementation, without screening, to all infants and young children
6 to 24 months of age in regions where the prevalence of anaemia exceeds 20-30%. A
consensus of world health agencies in 1998 (UNICEF/UNU/WHO/MI Technical Workshop,
1998) suggested that the highest risk age for anaemia is 6 to 24 months for full term,
normal weight infants.
Current strategies in the NT to reduce iron deficiency anaemia in children emphasize

12 screening, treatment with intramuscular iron and health promotion campaigns. The health
promotion campaigns focus on infant feeding practices and the promotion of high iron
foods to parents. Despite these treatment protocols and strategies being in place for the
last ten years, rates of anaemia in children have remained unacceptably high. Reductions
in prevalence are attributed to treatment, rather than prevention. This may in part be due to
the fact that there is no supplementation policy to prevent anaemia among children in the
NT. Work is currently in progress to develop GAA into a more comprehensive child health
program for under-5 year olds and supplementation could become a component of this
program.
The appropriate use of iron and other micronutrient supplements is an important part of
anaemia control programs in almost all contexts, but supplements should be viewed as
one of several tools in the battle against iron deficiency anaemia (Stoltzfus and Dreyfuss,
1998). A best practice anaemia prevention and control program is multifaceted and
incorporates a range of initiatives, including supplementation, fortification, infection control,
dietary diversification and public health and maternal and reproductive health interventions.
Successful, sustainable programs link with broader health and nutrition initiatives,
incorporate communication strategies and have a well defined monitoring and evaluation
framework.
As part of a multifaceted anaemia prevention program, a home micronutrient supplement,

‘Sprinkles’, has been shown to be effective. A randomized placebo controlled trial that
included 1134 infants, was carried out in Indonesia, Peru, South Africa, and Vietnam.
This study used a common protocol to investigate whether improving status for multiple
micronutrients prevented growth faltering and anaemia during infancy. The infants were
randomized to 4 treatment groups8 of placebo, weekly multiple micronutrient supplement,
daily multiple micronutrient and daily iron supplement. The daily multiple micronutrient
8
The prevalence of multiple micronutrient deficiencies at baseline was high, with anaemia affecting the majority.
supplement group had a significantly greater weight gain and was shown to be the
most effective control of anaemia and iron deficiency (IRIS, 2005). In addition, evidence
from use of ‘Sprinkles’ overseas indicates that they are well-tolerated, are accepted by
caregivers and easy to administer (Zlotkin et al, 2005).
The purpose of this six month formative research project is to inform the feasibility of
implementing a home micronutrient supplement, ‘Sprinkles’, for the prevention of anaemia
in Indigenous children aged 6 – 24 months in the NT. The research has taken place in 8
communities within the NT and in collaboration with the following partner organizations:
Anmatjere Health Service; Sunrise Health Service; Katherine West Health Board; Wurli
Wurlinjang Health Service; Northern Territory Department of Health and Community
Services; United Nations International Children’s Emergency Fund; and The Fred Hollows
Foundation.
See Appendix 1 for a list of communities involved in the research and the health
organisations servicing each community and Appendix 3 for a map of the communities
involved in the research.
Objective
Phase One
The purpose of this report, or Phase One, is to: provide formative findings on community
members’ knowledge, beliefs, sources of information and practices relating to the
feeding of indigenous infants, and; to seek community direction for the distribution and
implementation of ‘Sprinkles’ in the NT.
Phase Two 13
The findings from Phase One will inform the implementation of anaemia prevention
strategies in the NT, including the feasibility of implementing a home micronutrient
supplement, ‘Sprinkles’, for the prevention of anaemia in Indigenous children aged 6 – 24
months. The results of a pilot project would then inform future Department of Health and
Community Services policy and program guidelines in relation to iron and micronutrient
supplementation for infants and young children throughout remote communities of the
Northern Territory.
Method
The method and approach was approved by the Top End Human Research Ethics
Committee and Central Australia Human Research Ethics Committee, of the NT
Department of Health and Community Services, and the Menzies School of Health
Research.
Design of questionnaire and pre test

A Focus Group Discussion guide was developed from a structured interview tool used by
Helen Keller International, for formative research on the implementation of ‘Sprinkles’ in
Cambodia and Indonesia. It was adapted for use in the Northern Territory with advice from
The Menzies School of Health Research and ‘Sprinkles’ NT Steering Committee members.
A total of five individuals were interviewed for the pre-test. The pilot participants were
purposively selected to participate since they had similar demographic profiles to the target
group for the study.
The information from the pilot provided a great deal of insight for designing the final
questionnaire and guided decisions to make content changes to the final questionnaire such
as language ambiguities and grammar. It also enabled the facilitators and scribes to further
familiarise themselves with the tool.
See Appendix 5 and 6 for copies of the structured interview tools used in the consultations.
Appendix 5 is the Focus Group Introduction Answer Sheet and Appendix 6 is the Semi-
structured Question Guide for Carers of Children aged 6-24 months.
First training session for facilitators and scribes for conducting research
in Kalano community. From left to right, Wilma Driver, Adrianna Weetra
and Sherryl Tomlins (Wurli Wurlinjang Aboriginal Health Worker
- Maternal and Child Heath). Photo courtesy of The Fred Hollows
Foundation.
Sampling, data collection and analysis

approach
14
The field team comprised of one Research Coordinator, employed by TFHF, and
assistants, scribes and translators from each community. The field team was supported by
key informants, individuals who reside in the sample communities and members of staff
from the AMS.
Some community members took on the roles of the assistants, scribes and facilitators. The
goal was to employ three people in each community, however this proved to be difficult and
in some communities only one research assistant was available9.
After identifying community research assistants, a training session was given before
conducting any interviews. The training session covered the following topics: objectives
of the research; identification of potential carers and most appropriate time and place to
conduct an interview; and role playing and clarification of the questionnaire.
Carers of infants aged 6-24 months were purposively sampled for the final data collection
phase. They were either invited to be interviewed individually or in small groups. They were
given the opportunity to try ‘Sprinkles’ and they were given a bag of fruit as acknowledgement
of their participation in the interviews and in keeping with the promotion of good nutrition.
The research project was designed to work with focus groups in each community. This
method was used in two communities but was found to be challenging in this context. In
the remaining communities smaller groups of people were interviewed and more interview
sessions were conducted so that the overall material collected would be richer, while not
involving any fewer participants. Challenges of focus group discussions and advantages of
smaller group or individual interviews in this context is outlined in Appendix 9.
9
Some reasons for this may include the short-term nature of the work and some community members’ lack of confidence to undertake the research due
to low levels of literacy. In addition, some community research assistants were not available on the day needed due to poor personal health.
The interview started with an Introduction Answer Sheet (See Appendix 5) and followed with
the Semi-structured Question Guide for Carers of Children aged 6-24 months (See Appendix
6). During the Question Guide, there was a general discussion about food nutrition and
carers were shown pictures of foods and asked if they knew which foods contained iron.
Further information about this activity is described in Appendix 8. Also during the Question
Guide, the interviewer explained some brief facts about vitamins, minerals and anaemia
called the Healthy Story. Further information about this activity is described in Appendix 7.
After the formal questions, the researchers asked carers if they had anything else they would
like to say about the topic. They also asked ‘How do you think we can stop babies becoming
anaemic?’ Their answers are incorporated in to the relevant sections of the report.
Many related community workers, including clinic staff, childcare and play group workers
were informed about the research and given the opportunity to express any ideas they had
on the topics. The researchers also talked with shop keepers, takeaway shop operators
and council staff. Their answers are incorporated in to the relevant sections of the report
and presented as Additional Information in Appendix 11. Information gained from these
discussions was through informal conversations; and therefore need to be interpreted with
caution.
The following list outlines the focal areas of the questionnaire:
1. Feeding practices among young children aged 6 months to 2 years;

2. Knowledge about food for babies, food nutrition and anaemia;
3. Community member’s attitudes to ‘Sprinkles’;
4. Community member’s perceptions/attitudes toward methods and channels through
which to distribute ‘Sprinkles’.
Data analysis
Data collection and analysis occurred concurrently. As soon as some consultation data was
collected and transcribed, open and thematic coding began. Open codes were given names 15
that described the particular subject being discussed, while thematic coding was guided by
pre-selected themes in the questionnaire and by themes that were generated inductively
during the pre-test phase.
‘Sprinkles’ Committee member

and Nutrition Promotion Officer
(NT Health) Jeannie Campbell
(left), conducts ‘Sprinkles’
interviews at Ti-Tree
community with Rosie Purula
and Eileen Purula Campbell,
who is holding Laneesha.
Photo courtesy of The Fred
Hollows Foundation.
In July 2007 the research findings were presented to the ‘Sprinkles’ Steering Committee
and participating communities were given a feedback report about the project findings. See
Appendix 13 for notes on the feedback trip.
The following structure has been used to present the findings for each theme:
• Descriptive summaries on the participants perceptions on the four focal areas outlined
• Conclusions which suggest strategies to direct the next steps for Phase Two of the
project.
Findings from the
consultations
1. Participant information10
COMMUNITIES BABIES HOUSEHOLDS INTERVIEWEES AGE
no. of
breast no. of
babies cared grand- Under 25- 45 over
fed individual mother other
for by mother 25 years 45
baby households
interviewees
Kalano 5 4 5 1 4 3 1 1
Binjari 5 5 5 4 1 aunt 3 2
Jilkminggan 9 8 9 9 7 2
Pmara Jutanta 6 6 5 2 4 3 1 2
Engawala 5 5 5 5 1 4
Yarralin, Lingara 9 6 7 4 5 4 3 3
Ngukurr 11 9 6 2 7 5 2 2
1
Lajamanu 8 8 6 2 5 2 7
father
58 51 48 11 43 2 28 22 8
56 interviewees caring for 58 babies
The table is based on information gathered from the introduction question sheet completed
16 with all interviewees. See Appendix 5.
Mothers comprised 80% of people interviewed and nearly half (48%) of the mothers
interviewed were under the age of 25 years old. Three of the interviewees cared for more
than one baby in the target age group, and one mother and father interviewed cared for
the same baby. The majority of babies had been breast fed or were still breast feeding.
Eight of the 56 people interviewed lived in the same house as someone else who was also
interviewed.
Summary and conclusions
Of the 8 communities that were engaged, 56 carers were interviewed. Mothers comprised
80% of people interviewed and nearly half (48%) of these were under the age of 25 years
old.
Conclusion
• Ensure that future program initiatives engage young mothers and are appropriate
and relevant to them
10
Terms: In this report the term ‘babies’ is used to refer to infants up to 2 years old. This is the term agreed upon by consulting the Aboriginal research
assistants. Throughout the questioning, when appropriate, interviewees were reminded about the age group discussed.
2. Feeding practices for babies aged 6
months to 2 years
This part of the survey attempted to ascertain as much detail as possible about what foods
and drinks were being consumed, how they were prepared and by whom. Carers were
asked: when they started feeding their babies something other than breast milk; who was
feeding the baby; who was making decisions about what the baby was fed; and, if anyone
was advising them about feeding practices. The research also asked at what age babies
ate the same food as other family members and whether they ate from their own bowls or
shared food bowls. This question was important when considering adding an additive such
as ‘Sprinkles’ to a babies’ food. Other questions enquired about what foods and drinks are
given to sick babies and the availability of food supply.
Tinned baby food and 2-minute noodles

in the Lajamanu community store.
Photo courtesy of The Fred Hollows
Foundation.
17
Introducing food and drinks

Most carers report introducing drinks and foods between the ages of 3 to 7 months,
however some carers start earlier at 1 or 2 months and others start later at 9 months.
Water is frequently given, as is fruit juice, and in some communities, juices are diluted with
water. Milk and infant formula are sometimes given. Milo, cordial, lemonade, tea and coke
is occasionally mentioned as an early introduction drink. Commonly quoted first foods to be
introduced are Weetbix, porridge and commercial baby foods. Mashed potato and pumpkin
are very frequently quoted, with foods such as baby cereal, spaghetti, noodles, yoghurt,
baby rice, damper, and chewed toast also being fed to young babies. Fruit, such as banana
or orange, are mentioned by only a few carers as an introductory food.
Carers state that the babies themselves give them the signals indicating that they want
to start having foods by ‘getting greedy’, ‘crying for it’ or reaching to ‘grab other people’s
food’. Some carers said they introduce solids because ‘the baby was hungry’ or when ‘the
baby started sitting by themselves’. One mother said that the baby grabs for food, but she
would not give food because ‘the baby is too young’. She felt that she should continue
breast feeding and not give her baby food until she was 9 months old.
Eating and drinking

Many babies from 6 months old to 2 years old are fed by their mothers, or close family
members such as grandmothers or aunties, and sometimes by the fathers. Many babies
are initially fed from shared plates, and may have their own plate when 1 or 2 years old.
Some babies do start with their own plate from 6 months. Most babies eat with the whole
family and start eating the same food as everyone else at varying ages from 1, 2 or even
5 years. Carers talked about the way toddlers try food from everyone’s plates and food is
shared communally.
Carers in all communities report feeding 6 month to 2 year olds Weetbix and porridge
with milk and a little sugar. Some carers feed baby cereal, egg, banana, baked beans
or toast with jam, vegemite or peanut butter. During the day they are fed mashed potato
and pumpkin, spaghetti (homemade and tinned), two minute noodles, rice, tinned baby
food, mince and cheese sticks. Processed baby foods are a popular baby food in the
communities of Engawala11, Pmara Jutanta and Lajamanu. In the evening many families
are eating home made stews of red meat or chicken and vegetables served with damper
or rice, or sausages or mince. A few interviewees explained that the meat is first chewed
by the mother, then given to the baby12. Fish was occasionally eaten. The most common
vegetables are pumpkin and potato, with onion, carrots, cabbage, broccoli and peas also
being mentioned.
Asking carers to recall the feeding practices of the past twenty four hours revealed
additional details about feeding habits. The main difference being that takeaway food, soup
and sandwiches where added to the variety of foods quoted.
Most under-2 year olds are still breast fed frequently and before going to sleep. Water and
fruit juice are the most commonly quoted drinks fed to under-2 year olds. Milk and baby
formula is also given. Canned fizzy drinks such as lemonade or coke are occasionally
given, and some community nurses stated that young children are filling up on sweet
drinks, rather than eating food. One mother in Ngukurr said that it’s ‘hard to control what
drinks, because she (the baby) goes out with family and baby wants things, eating and
drinking’.
Many carers stated strongly that their babies did not ever drink tea13, and this was
particularly expressed in Pmarra Jutanta, Engawala and Lajamanu. Tea, when allowed,
is usually given as sips from an adult’s cup of tea but a few carers give it as a drink in the
child’s own cup. It is commonly served with milk and two sugars, although one carer said
that she gave ‘tea with milk and 5 or 6 sugars, everyday, anytime.’
18
“(Mothers) are not feeding meat, maybe they are lazy, mothers drink, they are silly,
don’t do the right thing and don’t listen to their Grandmother.”
“People used to give (babies) meat to suck on and lick, when the meat shrunk, they
would take it off the baby. When baby crawling and sitting up.”
Ti Tree, near Pmara Jutunta, May 2007
‘Mum’s are lazy’ (too lazy to cook proper meals)
Jilkminggan, March 2007
Snacks
Breast feeding is probably the most common snack, and is convenient. Food snacks
include sweet biscuits, fruit, salty plums, pop corn, takeaway food such as stir fry and
sometimes chips. Vanilla crème fruche is very popular in Lajamanu and is referred to as
yoghurt. Binjari carers talked about babies ‘crying for lollies, but they don’t eat them all the
time… only when shopping on pay day, once a week.’
11
Tinned baby foods, such as ‘beef and vegetables’ or ‘chicken and sweet corn’ are new lines carried by the Engawala store, which previously only carried
commercial baby food that did not include meat, such as custard and fruit.
12
When discussing this with a nutrition health worker, she said that they did not encourage mothers to give babies pieces of meat as they could choke
on them.
13
Tea is reported to inhibit the absorption of iron.
Feeding Centres
Babies attending childcare centres are eating cereal, fruit, cheese sticks, muesli bars, meat
and vegetable stews (including cabbage, beans and peas), salads and are drinking fruit
juice, cordial and Milo. Ngukurr childcare allows the children to choose their own breakfast
cereal from a selection, and Coco Pops is popular.
In Binjari it was reported that mothers used to come to the community building, where the
aged care meals were made, and boil up potato, pumpkin, and cabbage to make mashed
vegetables for their babies. The aged care program is no longer running so mothers are no
longer meeting to cook in the communal kitchen for their babies.
Food Availability
One person in Ngukurr mentioned that they sometimes ‘run out of money’, however
generally people reported that families always help each other out. One of the Binjari
researchers expressed the view that the interviewees did not respond clearly to the
question asking them to recall morning, daytime and evening feeding because some
mothers can’t afford to feed their infants three meals a day and as a result meals are not
eaten so regularly.
No-one reported shops running out of food, although one person in Ngukurr said
‘sometimes can’t get everything’14. One person in Yarralin said things were expensive
and sometimes you had to wait for bread or that there was not a big enough variety of
vegetables. Many people reported going bush on weekends with their families to get bush
tucker and feeding young children bush tucker such as fish, turtle, kangaroo, turkey or wild
pig.
Community members from Kalano and Rockhole mostly shop in Katherine, although they
also sometimes go to the Kalano Store and Takeaway. Binjari community members are
upset that their shop closed down as everyone now has to travel seventeen kilometres to
Katherine to shop and there is no bus service. One carer in Binjari said that ‘we sometimes
run out of food and we need to ask families’… ‘because there is no transport to get food.’15 19
Jilkminggan community members shop mostly at Mataranka, and occasionally in Katherine.
Although the Jilkminggan community store sells meats and tinned foods, the major sale
item is reported to be cold drinks16. The Jilkminggan CDEP operates a large market garden
growing vegetables and fruit and has many hens, producing large quantities of eggs daily.
These eggs and food from the market garden is distributed free to all households when it is
harvested. Interviewees also reported that some families ask the manager of Elsey Station,
which is largely owned by Traditional Owners, for a ‘killer’ (cattle) for their families. This
is usually ‘shared among the family, whoever turns up to get it.’ They report that they can
get this meat whenever they ask (though this probably depends on your family position).
Yarralin is another community that is growing some produce and reported getting or buying
‘killers’ from the nearby station. Lajamanu residents also inferred that there were cattle
around that could be eaten.
Colleen Cirriwe from Jilkminngan, with some produce from the Jilkminngan
Community Development Employment Program. Photo courtesy of The Fred
Hollows Foundation.
14
A new larger store and takeaway is designed for Ngukurr and is planned to be built next year. The community owners of the store do not want any more
non Indigenous people employed in the shop.
15
Binjari community members cannot do book up when shopping in Katherine at supermarkets as they used to do at their community store. The Binjari
clinic assists people with transport to Katherine when they can, or rings and orders a taxi for people.
16
This information was from a discussion with the non Indigenous man operating the shop for the leasee.
Pmara Jutunta community members purchase food from local suppliers, such as the Red
Centre Farm Store or the Roadhouse a few kilometres away, or travel to Alice Springs,
190 kilometres south. One interviewee at Ti Tree said that ‘The store (Ti tree Roadhouse)
should sell more green leafy vegetables . . ’. One family had their own productive
vegetable garden. Community members get seasonal work at the Red Centre Farm and the
Government Research Farm, where they sometimes receive free produce. This community
operates a breakfast feeding program 3 days a week at the crèche. The local health worker
says it is poorly attended because babies ‘fill up on canned drinks from a food van that
visits the community in the morning so babies don’t feel hungry for good food’.
In communities where childcare programs operate, children are fed free at some centres,
and carers can also have a meal for a fee of around $7. One interviewee at Pmara Jutunta
said, ‘if they run out of food, I go and have breakfast at childcare’. For many lifestyle
reasons people frequently eat directly from the shop.
As a Ngukurr interviewee said ‘Tuck shop, easiest food to get their hands on, can’t cook,
only can cook Weetbix and noodles, too lazy, they depend on other people to do it.’
Engawala community does not have an operating takeaway shop but the community
store has adapted by providing the use of four free microwaves outside the shop where
people can heat up frozen packaged products purchased from the store freezers. In this
community babies are predominantly fed tinned baby foods or ‘mince and noodles in a
foam cup’, as well as Weetbix and porridge.
Roper Bar Store, about 34 kilometres from Ngukurr, is operated by a family who has been
in the district for generations. They operate a bus weekly to bring people from Ngukurr to
their shop at Roper Bar Store. Although people know the food is more expensive than the
Ngukurr Store, people like to shop at Roper Bar because they allow people to ‘book up’
and don’t have the $50 ‘book up’ limit that is imposed by the Ngukurr Store. The Roper
Bar store bus service is the only bus service out of the community so also provides an
20 opportunity for an outing.
Community members near Katherine often frequent the Bucking Bull in Katherine, a café
and take away, serving mostly Indigenous clientele. People say they can leave their key
card here for ‘book up’.
Lajamanu Store has stopped selling hot chips, which were particularly popular for
children on their way to school, so now offers freshly made pop corn instead.
Yarralin Takeaway tried to restrict the sale of deep fried food to one day a week but
staff were instructed by the Community Government Council to serve it on 2 days a
week.
At Ngukurr Store an employee expressed the fact that the Takeaway always sell out
of the sandwiches and healthy food first. When asked why they don’t make more of
it, she said that they can’t get enough staff to work in the Takeaway so they have to
make more deep fried food because it is quick to prepare.
In contrast, the Takeaway shop at the Ngukurr Swimming Pool Complex employs
eight local staff and they took all their deep fryers to the tip and now cook in an
oven, donated by the Fred Hollows Foundation. Many community members come to
eat dinner at this Takeaway which is open every night except Sunday.
A health worker at Ngukurr observed that ‘They keep breast feeding their babies for
too long. They don’t introduce solids early enough, as everyone will tell you, I sup-
pose. They feed them noodles or foods that are easy.’ Such comments support the
reports of feeding practices by some carers and the habit of eating directly from the
shop or takeaway.
Outside Ngukurr community store. Photo courtesy
of The Fred Hollows Foundation.
Outside Engawala community store, where four

microwaves have been fitted so locals can heat
up frozen packaged products from the store.
Photo courtesy of The Fred Hollows Foundation.
Cooking and advice for feeding babies

People report boiling and stewing as the most common methods for preparing foods,
although some people do fry, grill or barbeque foods. Predominantly mothers and
grandmothers or other female relatives prepare foods or give advice on cooking and
feeding babies, but fathers are sometimes involved. Many people say that no-one gives
them advice about foods for babies. If advice is given it was to ‘spend money right way…
meat, cereal, vegetables’ (Kalano), ‘not give rubbish food from shop …’ and ‘don’t give junk
or greasy food’ (Ngukurr). As one grandmother also in Ngukurr said, ‘I tell them, give ‘em
the right food, meat, vegetables…’.
21
Others reported that at Binjari the ‘clinic ladies sometimes give advice’, as do health staff
at Jilkminggan, health workers at Pmara Jutunta and at Engawala, and someone from
Anmatjere Council Aged Care Program gives advice to mothers. At Lingara, a nutritionist
from Katherine West Health Board gives advice on feeding babies.
Concern was expressed about the young age of many mothers and the fact that they were
not all looking after their babies well. This is evidenced by the number of babies that are
being raised by grandmothers and other relatives. Frequently the older carer had taken
over the care of the baby after he or she was found to be ill. One Lajamanu carer said
‘need to teach young ones how to feed babies, the young ones don’t know.’ While another
in Ngukurr said ‘Some of the mothers play cards and smoke gunja and don’t look after their
babies properly’.
Feeding sick babies

Many carers reported that their babies did not want to eat when they were sick so they just
gave them ‘plenty of water and breast milk’ (Jilkminggan) and juice. For diarrhoea people
fry up flour and water (Yarralin), or give a drink of boiled leaf (Ngukurr)17, lemonade or
cordial. Some carers reported giving hot soup or small amounts of the food that is usually
given, such as rice, mashed potato and pumpkin, boiled egg, chicken. One interviewee
gave fried chops when babies were sick. Interviewees from Yarralin said ‘go and get fish’ or
give ‘bush medicine called malan’. One interviewee from Pmara Jutnuta said they gave the
‘same food but only a little bit when sick, sometimes give kangaroo meat to suck blood, to
help them get better, and bush medicine, bush herbs with a bit of oil, rub it all over her.’
17
Referring to the leaf of a native plant, Ngukurr
Feeding habits for under-2 year olds show some similarities across all communities. The
consultations showed that the majority18 of babies were breastfed; however there are no
consistent practices among carers regarding the age to introduce complementary foods
and drinks to babies. Most carers report introducing complementary foods to babies
between the ages of 3 to 7 months, however some carers reported starting earlier at 1
to 2 months or later at 9 months. Drinks are most commonly introduced between 5 and 7
months.
Babies are generally eating a diet high in carbohydrate, low in protein and low in most
micronutrients, suggesting that babies’ nutritional intake is inadequate. In addition, some
feeding and drinking practices may be leading to iron deficiency anaemia. Convenience
foods, such as: processed baby food; food from the take-away shop; and two-minute
noodles are often fed to babies. Some carers occasionally feed babies bush tucker19 when
it is hunted on the weekends, as well as beef from nearby cattle stations. Water and fruit
juice are the most common drinks given to babies and young children. Canned fizzy drinks
are also given to under-2 year olds. Many carers were very firm in reporting that they never
gave tea to their babies. Other carers reported giving tea with milk and sugar regularly to
babies, either as sips from their own cup or making the child their own cup of tea.
Predominantly mothers and grandmothers, or other female relatives, and occasionally
fathers, prepare food for babies. Boiling and stewing are the most common methods for
preparing food, although some people fry, grill or barbeque foods. Some carers are not
cooking food or preparing meals. It is reported that this is due to the fact that some people
have never learnt to cook. Convenience food is popular because it is accessed quickly
and easily and limits cooking and preparation time. Some older carers expressed concern
about the young age of many mothers and commented that some young mothers have
limited knowledge about cooking and feeding practices20.
Many babies from 6 months to 2 years old are fed by their mothers, or close family
22 members such as grandmothers or aunties. It is reported that fathers are only occasionally
involved in feeding their babies. The majority of carers feed their babies at home, with a
small number reporting that their babies are fed at childcare, at the shop or takeaway, at
family or friend’s houses or ‘out bush’. For most families eating is a communal activity and
babies eat with the family, however some carers reported feeding babies before or after the
family eats. Many babies are initially fed from a shared plate, with carers reporting a range
of ages that babies start to feed off their own plate. Some babies have their own plate at 6
months; however other babies may not have their own plate until 1 or 2 years old. Carers
reported that babies often try food from everyone’s plate.
Some carers report that they do not receive advice from anyone about feeding babies.
Where carers do report that they receive advice, it is mainly from health workers and/or
female family members.
Carers reported a variety of ways to look after sick babies and there appear to be some
mixed messages about what to do when a child is sick. Many carers seek assistance from
the clinic if their children are sick. Often an older female family member will take over care
of a baby from a young mother if the baby is sick. Bush tucker and bush medicine are often
quoted as being used to help sick babies.
Carers did not report that community stores had insufficient quantities of food, although
some reported having to wait for certain foods or stores having limited stock of certain
food. Some communities did not have a store close by and had to travel to a major town,
such as Katherine, to buy food. Transport is often difficult in this situation.
18
It was reported by carers that 51 babies from a total of 58 babies were breastfed.
19
Bush tucker refers to Australian native food used as sustenance by the Indigenous Australians. During this research, bush tucker reported by carers
included fish, turtle, kangaroo, turkey and wild pig.
20
Note that this was not expressed by young mothers themselves.
In addition, families sometimes do not have money to buy food, however it is reported that
‘families always help each other out’ and in most shops ‘book up’ is available.
Market gardens were operating in two communities, supplying eggs and fresh fruit and
vegetables free to all households. Some families had private vegetable gardens to
supplement the food supply from the shop.
There is evidence that child care centres provide an opportunity for babies to receive a
nutritious meal.
Conclusions
• There is a need to improve the nutritional intake of babies’ 6 months to 2 years

old.
• There is a need to promote and support exclusive breastfeeding from 0 – 6
months old and the introduction of complementary foods from 6 months old,
together with continued breastfeeding.
• There is a need to increase the capacity of mothers and other carers to prepare
and cook nutritious foods for babies 6 months to 2 years old and encourage
active feeding practices.
• Due to the communal lifestyle and the fact that babies’ food preparation and
feeding is shared among family members, the whole community needs to be
involved in future nutrition- focused program initiatives.
• There are social and environmental barriers to improving babies’ nutrition in
remote communities. Some of these include accessibility to healthy food and
the low socio economic status of many families.
3. Knowledge about food for babies, 23

food nutrition and anaemia
In this part of the survey carers were questioned to find out what people already knew
about healthy foods, nutritional information about foods, and their knowledge of terms
used when discussing nutritional values of foods. A series of questions was also asked
about anaemia, which is commonly referred to as ‘weak blood’ in Aboriginal communities,
to ascertain what people knew about the condition, its causes, effects, treatments and
prevalence in the community.
Healthy and not so healthy foods

Carers were asked about what foods that they thought were good to feed young children
and why. Most interviewees are easily able to list a range of foods that they thought would
‘make them (babies) healthy and strong, so they won’t get sick’. These included foods such
as fruit, vegetables, fish, chicken, meat, half raw meat, rice, eggs, bush foods (kangaroo
tail, witchetty grubs, sugar bag, wild onion), baked beans, noodles, cereals (Weetbix and
porridge), baby tucker, tinned foods, cheese, damper, juice and Milo.
A few people could give examples of why these foods are good by saying:
• ‘Green vegetables good for blood’, ‘milk for health and grow bones’, ‘baked beans will
help them walk, give them energy’ (Yarralin),
• ‘Vegies and bush foods are best for health’ (Ngukurr),
• ‘Bush foods… it tastes good, not sour or anything’ (Jilkminggan), and
• ‘Fish on Sundays when we go fishing, soup, bush food, good for their blood’ (Ngukurr).
Carers had no hesitation in listing foods that they thought were not good for babies and
young children and generally understood that sugary foods were bad for teeth and greasy,
fatty foods were not good for your health. Tea is associated with low iron but no-one related
tea to inhibiting the absorption of iron. Foods listed as not so good for young children
included take away food (pies, hot chips), bubblegum, sweets, icy poles and chocolate.
‘Big people’s foods’, such as food with chilli, is considered as inappropriate and eating food
that is past its use by date21 is also mentioned as a concern for babies.
The drinking of too many sweet drinks is considered bad and junk food is said to make
babies sick and sleepy. One carer in Pmara Jutunta mentioned white bread as ‘no good’,
although this is the type of bread most people used if they were giving a sandwich or toast
to their babies.
Reasons given for why some foods were ‘not so good foods for babies’ included:
• ‘Lollies… because they (babies) have no teeth’ (Kalano),

• ‘Tea is low in iron’ (Kalano),
• ‘Drink tea, soft drink, coke, cordial, make their blood bit low, make you lazy, don’t work
in school, problem with teeth, tooth rusty, that cordial sweet’ (Yarralin),
• ‘Fried food is too greasy, too much fat, they cover your heart with fat, make you have
gall stones’ (Binjari),
• ‘They get rusty teeth from chocolate and lollies’ (Binjari), and
• ‘If they have too many sweets, they lose weight and get diarrhoea. There are no
vitamins in these things. They get sore teeth.’(Binjari).
Knowledge of vitamins and minerals

Most people say that they haven’t heard about vitamins and minerals in food and cannot
say much about the terms. A few people could talk a little about vitamins but people had
no knowledge of minerals in food. The majority of people didn’t know what foods contain
vitamins or minerals. Some people had heard of mineral water and a few interviewees from
24 Kalano thought that vitamins were ‘in oranges, vegies, meat and maybe in cereal’. Other
foods suggested as maybe containing vitamins were fruit juice, vegemite, baby food and
bush tucker. Vitamin C was the only vitamin named and was said to be in orange juice.
One person said that minerals were in bush foods (fruits, meat and fish).
Sharon Maroney feeding Maverick during a ‘Sprinkles’ focus group discussion

in Binjari community. Photo courtesy of The Fred Hollows Foundation.
21
Concern was expressed by some interviewees about out of date stock in the Yarralin store, though the store manager explained that some foods
had two expiry dates, one for the food if not frozen and another expiry date for the food if continuously frozen. It was reported that the health department
inspectors had been doing frequent visits to check on conditions in the store. In Ngukurr, people complained about feeling sick after eating some food
from the store takeaway.

Iron and Anaemia (weak blood)
The majority of carers interviewed had not heard of iron in food, except for a few people
who thought it was in Weetbix and other cereals, broccoli or leafy green vegetables,
liver and bush tucker (particularly meat and fish). Many people were very hesitant when
talking about iron in foods but thought it was important. As one person in Kalano said ‘...
not in food but I know it’s a healthy thing and it’s important ‘cause it’s healthy’. One person
remembered iron tablets as being a source of iron and another had heard about Iron Man
food as a type of breakfast cereal. A few people thought iron was important for babies’
blood. No interviewees linked the origins of iron in food as coming from iron as a mineral
found in the ground.
Interviewees did not know the word ‘anaemia’ though many had heard of ‘weak blood’.
People’s knowledge about ‘weak blood’ varied greatly. In response to ‘how can you tell if
your child has weak blood?’ some people suggested going to the clinic while one person
in Kalano said that you ‘can’t really tell’. Those who do know something about weak blood
described a range of symptoms including ‘kids are weak and sick with a temperature’,
‘don’t laugh, don’t want to eat’, ‘a cough’ and ‘(weak blood) stops you growing’. Others
described symptoms such as ‘his palms are not white, his tears are dry’ (Kalano) and ‘they
cry a lot and feel sick’(Jilkminggan). Some people said babies ‘eyes look weak, dark under
the eyes, hot fever’ (Yarralin) while others said they have ‘white under the eye or on the
lips, no energy’(Ngukurr).
Some people stated the causes of anaemia as not eating the right foods (‘not enough
vegetables and meat’), not enough liquids or drinking tea. In Pmara Jutunta, some people
said it came from ‘eating sweets and cool drinks and chocolate’. One mother said the
cause is when the mother is not eating the right food when she is breast feeding. Others
said it is when the babies have worms, diarrhoea or not enough water and one carer said
that mothers maybe had low blood during the antenatal period.
One mother reported that her baby had had a needle for weak blood on Tuesday. 25
She took her baby to the clinic because she had a boil. She was given an injection
in her thigh that was painful. When questioned she said that the nurse hadn’t given
her any advice or instructions. On further questioning, she said that Sophie at the
clinic had talked to her about weak blood and said to give vegetables, pumpkin,
potato and greens. She said she didn’t eat much red meat, mostly take away
chicken.
Lajamanu, June 2007
‘Have nutrition people come and talk to the mothers, talk for 2 weeks every month,
come regularly, mother will see that you care, so they will come.’ (to listen)
Ngukurr, May 2007
Many people thought that eating the right foods would help to prevent anaemia, particularly
solid food, meat and vegetables, bush tucker and plenty of liquids. People talked about
giving ‘kangaroo blood or kangaroo meat’ (Pmara Jutunta) or getting a killer or turkey to
treat and prevent anaemia. One carer in Yarralin said ‘Right foods, a lot of love and care.’
One mother from Binjari said ‘My son got better by himself, eating iron food’.
Most people listed treatments for anaemia as visiting the clinic and some related it to
having a finger prick (screening test for anaemia), but were unsure what the treatment was.
A few people spoke about injections (iron needle) or syrup for anaemia.
“My first daughter, Mum helped, cooked good food for her blood, she had
weak blood making her feel sick. When Mum cooked good food, it helped you
know. I checked her at the clinic, come good and didn’t get sick with Mum
helping. Mum was a health worker so she knew what to do”.
Jilkminggan, March 2007
The majority of interviewees did not know if anaemia was a problem in their community.
One carer in Ngukurr said that ‘Family talk about it, if notice baby sick, parents get growled
from family to make them understand’.
At Lajamanu one person said ‘yes, a big issue, because parents not giving them right
foods, giving them tea, Sprite, Coke.’ Some knew of babies who had had needles, syrup or
had to go to hospital. Some felt that they would be treated straight away with iron medicine
at the clinic if it was a problem. One interviewee in Yarralin said ‘I think the Mum’s and
Dad’s need to be educated in this area, by Aboriginal Health Worker.’
No-one talked about the long term side affects of anaemia.

Most carers know what constitutes healthy and unhealthy foods, including understanding
that high fat and high sugar foods are not healthy for babies. A few people were able to
accurately report some symptoms of anaemia and many carers thought that eating healthy
food was a way of preventing anaemia. There was also recognition of the nutritious value
of bush foods.
26
However, there is limited knowledge from the majority of carers regarding vitamins and
minerals in food, the specific benefits of iron to health and the link between iron and
anaemia22. There is also very limited knowledge about the causes and symptoms of
anaemia, the consequences (long-term side-effects) of anaemia or whether anaemia is a
problem in their community. Most carers are aware that testing and treatment for anaemia
can be done at clinics.
Conclusions
• Building on existing knowledge about bush tucker and healthy and unhealthy
foods, there is a need to increase understanding and knowledge in the
community about vitamins and minerals in food and the impact of micronutrient
deficiency on children’s health (and the community at large).
• Future program initiatives need to address behaviour change around nutrition
(evidence suggests that knowledge alone does not necessarily lead to a change
in behaviour).
• There is a need to facilitate better community understanding and ownership of
growth and anaemia assessment data.
22
Many interviewees had not heard of anaemia but had heard of ‘weak blood’, though knowledge about ‘weak blood’ was limited.
4. Community member’s attitudes to
‘Sprinkles’
Carers were given the opportunity to sample ‘Sprinkles’ and were told how to use the
product. They were told;
‘Sprinkles’ have no taste and the content of one packet should be mixed with food and
should be given to children from 6 months to 2 years. ‘Sprinkles’ have vitamins and
minerals, including iron, in them. We want to know what you think about them.’
In some communities people tried ‘Sprinkles’ on all sorts of food including chopped fruit and
sandwiches, but it was always offered with baby food as well. Most carers gave it to their
babies to taste. No babies in the research group reacted adversely to food with ‘Sprinkles’
added.
The research questions focused on whether carers would use ‘Sprinkles’, the types of
food they would add Sprinkles to and with which meal they would serve ‘Sprinkles’. Other
questions asked if carers would pay for ‘Sprinkles’, what would be the best packaging
quantities and people’s preferred storage method.
A boy at the Yarralin Childcare Centre tries ‘Sprinkles’.

Photo courtesy of The Fred Hollows Foundation.
27
Receptiveness to ‘Sprinkles’
Nearly everyone interviewed thought that they would use ‘Sprinkles’ if it was available.
There was a general attitude that everyone wanted to do the very best they could for their
babies. The reasons given for using ‘Sprinkles’ are that it would make sure babies get
enough iron, stop them getting sick and would make them strong. A couple of interviewees
thought it was a ‘good idea, to make them want to eat more’ (Lajamanu) and said that it
tasted better than iron medicine. Another in Ngukurr said that ‘yes, try something new,
different, don’t want to take notice of me or my good advice, so try something new.’
What foods and meals

Carers thought ‘Sprinkles’ should be added to Weetbix, porridge, baby food, mashed foods
such as potato and pumpkin, a sandwich and fruit, such as banana. Some interviewees
said that they would not serve ‘Sprinkles’ with beef and vegetables because these foods
have already got iron in them. Others said that they would not serve ‘Sprinkles’ with tuck
shop food because it is too greasy. Breakfast is the preferred meal when most people said
they would add ‘Sprinkles’ to the food. In Ngukurr carers thought this was ‘because they
(the babies) are really hungry. They always want to eat breakfast’ and people thought all
the ‘Sprinkles’ would be eaten at this mealtime. A few people suggested lunch or dinner as
meals to add ‘Sprinkles’ to food.
The visiting nurse at the Engawala clinic felt that people might say that they would use
‘Sprinkles’ every day but she did not think that they would be good at giving it to babies
every day because they were not good at giving medicine to themselves regularly.
Purchasing ‘Sprinkles’
Many interviewees said that they would be willing to pay for ‘Sprinkles’. The amount people
were willing to spend on ‘Sprinkles’ ranged considerably. Answers ranged from five cents/
day to $5/week or $20/month and even $40/month. Some people were unsure as to how
much they would pay for ‘Sprinkles’. One interviewee in Binjari said that ‘for a lolly, I pay
50cents’ so was willing to pay this for a ‘Sprinkles’ daily dose. Some said that they would
not pay for it and thought that it should be available free from the clinic. It was suggested
that the clinic could also do monitoring of the distribution of ‘Sprinkles’.
The community store was the most common suggested supplier, followed by the clinic
or childcare centre, women’s centre and the council. Where people shopped away from
the community, such as in Katherine or Mataranka, people said they would like to get it
from these town food suppliers. In Katherine, the Bucking Bull Cafe said that they would
be happy to supply ‘Sprinkles’ because they liked to work with Wurli Wurlinjang Health
Services.
The desired number of sachets in a packet varied from a single sachet to 60, with people
considering collecting it bi-weekly, weekly, monthly or bi-monthly. Some suggested the
bigger packet because there may be more than one baby in the household.
Storage
The most popular storage suggestion is a high cupboard or store room at home where
other children could not reach it, and a few people suggested keeping it in their bag or a
fridge. As one mother in Yarralin said ‘…if going to town, make sure you had them with
you.’ A point of concern is that other children may want to take ‘Sprinkles’ because the
packet looks desirable.
28 Health workers expressed concern that ‘Sprinkles’ may get lost in the house, especially for
those people living in overcrowded housing.
The general opinion of ‘Sprinkles’ is best summed up by the comment:
“Yes, if I saw it on the shelf I would try it out for him, we want to make sure he is
always healthy, try to look after him as much as we can.’
Yarralin, June 2007

The findings indicate that nearly all carers would be willing to trial ‘Sprinkles’ as it
would ‘make their babies strong’ and ‘stop them from getting sick’. Some carers thought
‘Sprinkles’ would be preferable as it was less painful than iron injections. There was very
little resistance shown to using ‘Sprinkles’ and no queries about its possible side-effects.
Many carers reported that they would be prepared to pay for ‘Sprinkles’23. However, many
also stated that they would not pay for it or they were not sure. This was primarily because
they thought it should be available free from the health clinic.
Most carers chose breakfast as the preferred meal to add ‘Sprinkles’ to food because ‘the
babies are really hungry’ and ‘they always want to eat breakfast’. Some carers chose lunch
or dinner as the preferred meal. Carers said they would use ‘Sprinkles’ on all types of
23
The price that people said they were willing to pay for Sprinkles ranged from $0.05/day to approximately $1.40/day, however most prices suggested
were $0.30 - $0.70/day.
food, however the most common food was mashed potato/pumpkin, Weetbix, porridge and
breakfast cereal. Carers were prepared to ensure that ‘Sprinkles’ was consumed only by
the baby.
The community store was the most commonly suggested supplier for ‘Sprinkles’. However
the health clinic was also a popular suggestion, mainly because it meant ‘Sprinkles’ would
be supplied free, but also so its use could be monitored. Other suppliers suggested were
the child care centre, women’s centre, government council and town food supplier24 (where
accessible).
The most popular storage suggestion for ‘Sprinkles’ was at home, in a high cupboard or
store room, where other children could not reach it. Other suggestions were in the carer’s
bag or in the fridge. The desired number of sachets in a packet/box varied from a single
sachet to 60 in a box, with most suggesting a box containing 15 to 30 sachets. Suggestions
for collection times ranged from daily to once every 2 months, however most carers wanted
to collect ‘Sprinkles’ weekly, then fortnightly or monthly.
Conclusions
a. Feasibility and appropriateness of payment and non-payment options

b. Proper application of ‘Sprinkles’, including starting supplementation at six
months old, individual packets for use by one child, types of food to use
‘Sprinkles’ on, etc.
c. Development of a clear distribution channel for ‘Sprinkles’, including
through the community stores, take away or the town food supplier and the
financial viability of distribution through commercial outlets, as well as an as
sessment of the feasibility and appropriateness of supplying ‘Sprinkles’ through
29
other structures, such as the health clinic, women’s centre or child care centre.
d. Appropriate packaging of ‘Sprinkles’ that will be acceptable to carers.
e. Monitoring issues
5. Community member’s opinions of the

best way to communicate information
about ‘Sprinkles’ and anaemia
In this part of the research we wanted to find out the best way to tell people about anaemia
and ‘Sprinkles’. Carers were asked where they go to get advice about health and nutrition
and what would be the best way to communicate information about ‘Sprinkles’ to their
community. They were also asked when carers should be informed about ‘Sprinkles’.
Information sources
Answers in relation to where people go to get advice about health and nutrition varied with
each community, depending on the particular functioning activities, services or systems that
operated in that community. Answers predominately referred to the clinic, and in particular,
the nutrition workers and health workers, but childcare centres and women’s centres were
also mentioned if operating in the community. Other sources suggested for disseminating
information were other mothers, grandmothers and other relatives, and the council or
24
Town food supplier refers to shops, such as Woolworths, Five Star or a chemist, in a large town that is regularly accessible for community members.
community coordinator in locations where other services are not functioning. The internet,
Austar TV (in particular, the cooking channel) and studying childcare at Batchelor Institute
were other sources of information. Particular trusted people in the community, such as
those at the rectory, were also places where people gleaned knowledge.
Promoting ‘Sprinkles’
There was some hesitation when answering this question and this may have been because
people were tiring from the questioning. With some prompting people suggested a range
of methods for informing their community about ‘Sprinkles’. These included putting
posters around the community (at the shop, council, clinic, childcare, school, church),
advertisements on Imparja TV (and all TV stations) and radio (CAAMA, Hot 100, 103
Katherine, BRACS). These advertisements should be in people’s own language. Many
people thought there should be community meetings held by health staff and community
people, or should involve the Strong Women, Strong Babies Program.
At Yarralin it was suggested that people ‘sit down and show them a picture book’. Others
suggested mothers, grandmothers and family members should explain ‘Sprinkles’. Another
suggestion was that people should go from house to house to talk to people in their homes.
One suggestion was that the ‘Sprinkles’ research assistants employed in each community
(see Appendix 10) could be employed to do this work. Another suggestion was to show a
video25 in the local language explaining the issues.
At Binjari women suggested ‘Sprinkles’ be explained at their women’s health camp, and
at Yarralin it was thought the women’s program run by the council should explain it. At
Engawala they suggested the play group worker talk to mothers. Ngukurr operates its own
community newspaper, called the Ngukurr News, and this was suggested.
People thought that the message about ‘Sprinkles’ should be delivered around the time of
ante natal checks, when the mothers were in hospital with their new born and when the
baby was 6 months old. Some people thought that all the community needed to be taught
30 about ‘Sprinkles’, so that all family members, including fathers, understood the information.
As a Yarralin carer said ‘…it should be all the time’ and ‘as soon as possible, tell everyone,
the whole community.’
Eileen Purula Campbell, who was interviewed for the ‘Sprinkles’

research, with Laneesha. Photo courtesy of The Fred Hollows
Foundation.
25
A video called “Gulangbuy Dalkunhawuy Weyika (Blood Strengthening Element - Iron)” explaining anaemia has been produced by ARDS in the
Yolngu language of NE Arnhem Land. This could be translated into local languages and some interviews replaced with interviews conducted with local
people from each community.
Carers access information from a range of sources. This often depends on the functioning
services and systems in each community. The majority of carers referred to the health
clinic and health workers and trusted female family members as their main information
sources. Child care centres and women’s centres were also popular places to access
information. The council, church, TV, the internet and studying childcare at Batchelor were
also mentioned.
Common suggestions about the medium to promote ‘Sprinkles’ included: posters;

advertisements on TV and radio in the community’s dialect; magazines; and a video in
the local language explaining the issues. One community produced their own newspaper
and this was suggested. The most popular means to deliver the message was through
community meetings and community and family members, especially mothers, talking
to each other. Other suggestions were meetings held by the women’s centre, child care
centre and council or through existing health programs. Many wanted the message
delivered in the communities’ own language. Most carers wanted information given to
mothers during ante natal checks, when babies are born and at regular intervals from 6
months old to 2 years old. Some carers suggested teaching the whole community about
‘Sprinkles’, including fathers, so that everyone understood the information.
Conclusions
a. Utilise specific functioning services and systems that are operating in each
community
b. Use the local language/s in delivering messages
c. Ensure that messages are delivered to the community by community members 31
d. Ensure that the whole community is targeted
Overall recommendation
It is recommended that the use of a multi –micronutrient/iron supplement for children
aged 6 – 24 months form part of a more comprehensive approach to address anaemia
prevention in indigenous communities. Community education and behaviour change
initiatives around nutrition should be strengthened and expanded to ensure anaemia is
prevented in the long-term. In addition the social and environmental barriers to improving
nutrition in indigenous communities will determine the combination of strategies required to
prevent and control anaemia. In the immediate future, the findings from this study, together
with the poor growth and anaemia status of children, supports the implementation of a pilot
program of a home micronutrient supplement, ‘Sprinkles’, for the prevention of anaemia in
children aged 6-24 months in indigenous communities in the NT.
32
Appendices
APPENDIX 1 - List of partner
organisations and communities involved
in the reserach
The partner organisations are:
• Anmatjere Health Service

• Sunrise Health Service
• Katherine West Health Board
• Wurli Wurlinjang Health Service
• Northern Territory Department of Health and Community Services
• United Nations International Children’s Emergency Fund
• The Fred Hollows Foundation
The research has taken place in the eight communities listed below. The health
organisation servicing each community is also listed.
HEALTH ORGANISATION COMMUNITY
Anmatjere Health Services Pmara Jutanta, including Ti Tree
Engawala 33
Katherine West Health Board Yarralin, including Lingara
Lajamanu
Sunrise Health Service Jilkminggan
Ngukurr
Wurli Wurlinjang Health Service Kalano and Rockhole
NT Department of Health and Community Binjari (funded via Wurli Wurlinjang

Services Health Service)
APPENDIX 2 – ‘Sprinkles’ Steering
Committee members (July 2007)
The ‘Sprinkles’ Steering Committee Members from each organization are;
Anmatjere Health Services Jeannie Campbell
NT Department of Health and Community Services Alison McLay

Dr Barbara Paterson
Judith Myers
Jenny Busch-Hallen
Katherine West Health Board Dr Andrew Bell

Danielle Aquino
Alexandra Walker
Sunrise Health Service Dr Naru Pal
The Fred Hollows Foundation Alison Edwards
UNICEF Eva Sarr
Wurli Wurlinjang Health Service Dr Brad Gray

Karen Rosas
The sub-committees formed to work on particular issues were a methodology committee

which guided and approved the method on consultations and a communications committee
34 which informed health staff in the relevant regions about the research.
APPENDIX 3 – Communities surveyed as
part of the ‘Sprinkles’ research project
35
APPENDIX 4 - Timeline for research
project
NO. WEEK COMMENCING ACTIVITY
1. 29 Jan Orientation, collecting information
2. 5 Feb Meet Steering committee, assess info available

Prepare trying material, Methodology clarification and
3. 12 Feb
committee meeting
Meet Katherine region researchers/facilitators and program
4. 19 Feb
visits
5. 26 Feb 1st Training session and pilot focus group, Katherine region
Review process and notify all parties on planned focus group
6. 5 March
dates
Alice Springs Steering Com meeting and visit to Ti Tree,
7. 12 March
preparation for focus groups and documentation of data
8. 19 March Training and Binjari focus group and documentation of data
9. 26 March Write up of report
10. 2 April Training and Jilkminggan interviews
11. 9 April 4 days Rec leave and Easter
12. 16 April Bookings, analysis write up, administration and meetings

Anzac Day in middle of week so planning and write up of
13. 23 April
report
36 14. 30 April
Training and interviews with 4th and 5th communities Pmara
Jutanta and Engawala
15. 8 May Data recording, Write up and planning
Training and interviews with 6th community- Yarralin
16. 14 May
Data recording
17. 21 May Analysis, and Write up of report
18. 28 May Training and interviews with 7th community - Ngukurr
19. 4 June Analysis, and Write up of report
20. 12 June Training and interviews with 8th community - Lajamanu
21. 18 June Analyse data and Write report

Chase GAA data, arrange presentation meeting and
22. 25 June
accommodation
23. 2 July Rec Leave
Prepare feedback and report and present to steering
24. 9 July
committee Feedback to communities
Finish report, and prepare feedback and photos for
25. 16 July
communities
26. 23 July Present to steering committee, give feedback to communities
27. 30-31 July Clean up files and handover all ‘Sprinkles’ material
APPENDIX 5 - Focus group introduction
answer sheet
For babies aged 6 months to 2 years old
1. How many babies aged 6 months to 2 years old are you looking after?
2. What age are the babies you care for? Were or are they breast fed?
3. How are you related to the baby? (Grandmother/Grandfather/Mother/Father/Sister/
Brother/Aunt/UncleNiece/Nephew/Other)
BABIES AGES BREAST FED Y/N RELATIONSHIP
Person 1
Person 2
Person 3
Person 4
Person 5
Person 6
Person 7
Person 8 37
Person 9
Person 10
Person 11
Person 12
Person 13
Pesron 14
4. How many households are represented in this focus group?
5. What age groups are the mothers and carers? Are they male or female?
M/F UNDER 25 25 - 45 Over 45yrs
Person 1
Person 2
Person 3
Person 4
Person 5
Person 6
Person 7
Person 8
Person 9
Person 10
Person 11
Person 12
Person 13
38 Pesron 14
APPENDIX 6 - Semi-structured question
guide for care takers of children aged
6-24 months
A. We are going to talk about feeding young children aged 6 months to 2 years. We would
like to ask about how and what you feed your babies.
Let’s talk about when you start giving your baby foods, as well as breast milk or milk
1. At what age do you start giving babies something other than breast milk?
a) When are drinks introduced?
b) What drinks?
c) When are foods introduced?
d) What foods?
2. How do you decide when to start giving babies something other than breast milk?
3. How are babies fed?

a) Do they eat with the family or by themselves?
b) Do babies share food from the same plate as other family members?
c) At what age do they have their own plate?
d) What age do children eat the same foods as everyone else?
4. Who usually feeds babies? 39

a) Do community members outside of the family feed them? Who?
5. What do they usually drink most days?

a) In the morning
b) In the daytime
c) In the evening
d) For snacks
6. Do babies drink tea?

a) How is it made?
b) How often do they drink it?
7. What food do they usually eat most days?

a) In the morning
b) In the daytime
c) In the evening
d) For snacks
8. Where do they eat each meal? (Home, store, childcare, other house, out bush, other)
9. Where do you get food and drinks from?
10. Is it available when you need it?

Why? Or Why not?
11. Let’s talk about what happened yesterday. What did your baby eat? (24 hour recall)
a) In the morning
b) In the daytime
c) In the evening
d) For snacks
e) What drinks?
12. Who prepares or cooks food for the baby you care for?
a) Who makes decisions on what foods to feed babies?
b) How is the food prepared? Boiled, fried, grilled, bbq
c) What do you give the baby when he/she is sick?
13. Does anyone tell you what foods to give babies?

a) Who?
b) What advice?
c) Why some foods/why not some foods?
B. Before we talk about ‘Sprinkles’, we would like to ask you what you already know about
foods for babies.
40 1. What foods are good for babies?

a) Why?
2. What foods are not so good for baby?

a) Why?
3. Can you tell me about vitamins in food?

a) What foods are they in?
4. Can you tell me about minerals in food?

a) What foods are they in?
5. Can you tell me about iron in food?

a) Is it important?
b) Why? Why not?
c) Where can iron come from?
d) What foods is it in?
6. Can you tell me what anaemia (weak blood) is?
a) How can you tell if babies have anaemia (weak blood)?
b) How does weak blood affect babies?
c) What do you think causes weak blood?
d) What stops you getting weak blood?
e) What is the treatment for weak blood?
f) Is weak blood an issue in the community?
Tell healthy food story (use a new page)
C. How to use the ‘Sprinkles’. Now we will talk about the ‘‘Sprinkles’’ and how to use them.
Show the participants the ‘Sprinkles’ and allow them to taste, smell etc… them
‘Sprinkles’ have no taste and the content of one packet should be mixed with food and
should be given to children from 6 months to 2 years. ‘Sprinkles’ have vitamins and
minerals, including iron, in them. We want to know what you think about them.
1. What do you think about feeding ‘Sprinkles’ to your babies?

a) Would you feed them to your baby?
b) Why? Why not? ( eg. Because you are not at home…out visiting people
Because baby is away with other people)
2. What types of foods would you put the ‘Sprinkles’ on?

a) Why that food?
b) Which meal would you add the ‘Sprinkles’ to? (Breakfast/Lunch/Dinner)
41
3. Are there any things you would not add ‘Sprinkles’ to? Why not that food?
4. Would you pay for ‘Sprinkles’?

a) How much would you pay for one packet for day?
5. Where would you like to get ‘Sprinkles’ from?

Community shop, health clinic, women’s centre, childcare centre?
6. How often would you want to collect them?

Every day or once a week or …?
a) If it comes in packets, how many packets should be in a box?
(e.g. 10 packets in. a box)
7. Where would you keep the ‘Sprinkles’? In your bag?, in your home?
D. During this part of the talk, we want to find out the best way to tell the story about weak
blood (anaemia) and iron and ‘Sprinkles’ to other parents.
1. Where do you go for more story when you want to know about health and nutrition?
2. How do you think the story about ‘Sprinkles’ should be told to the community? (Eg. TV,
radio, poster, leaflet, sticker, banner, newspaper, magazine, individual person)
a) Name the place or station name (eg. Imparja)
3. Who should talk about the importance of the ‘Sprinkles’? (Eg. family members?,
health clinic staff?)
4. When should mothers and carers be told about ‘Sprinkles’?
Is there anything else you would like to say?
This is the end of our discussion.
Thank you for helping us.

42
Question for interviewers
Why do you think some babies have anaemia (weak blood)?
How do you think we can stop babies being anaemic?

APPENDIX 7 - Healthy food story
Healthy foods give us energy and help keep our bodies healthy and to grow strong.
Different foods have different types of vitamins and minerals. That is why it is important to
eat different foods such as fruits, vegetables, breads and cereals, meats and dairy foods.
Minerals are found in foods and are important to make us strong.

Iron is a mineral in food. Iron is needed to keep blood strong and help the blood carry
oxygen around the body.
LOOK AT FOOD PICTURES What foods have iron?
Iron is found mainly in red meat, but also white meats and fish.
Smaller amounts of iron are in baby cereals, wholegrain cereals, dried beans, eggs, dried
fruits and green vegetables.
If we don’t eat enough food with iron we become anaemic (WEAK BLOOD). Then the blood
does not carry enough oxygen around the body. Weak blood is usually caused by not
enough iron in the blood.
This can cause babies and children to be cranky and tired, and can lead to poor learning
and sickness. They may:
• Be sleepy or have no energy

• Find it hard to learn and concentrate
• Have slow growth of their brains because the brain is not getting enough 43
oxygen
• Get sick more easily than children with strong blood
Sometimes it is hard to tell if babies have weak blood.

That’s why babies blood is checked with a finger prick every 6 months at the clinic.
Babies with weak blood are treated by health worker with injections or iron syrup.
APPENDIX 8 - Picture game: which
foods contain iron?
Carers were shown photographs of commonly available foods and asked if they could sort
the pictures into two groups- foods with iron in them and foods with no iron in them. They
were shown the following foods:
Eggs Hamburger with salad Orange
Corned beef Hamper tinned corned beef Orange juice
Meat pie Tinned meat pie White rice
T bone steak Cauliflower Fish
Selection of green leafy

Mars bar Weetbix
vegetables
Coca Cola Dried spaghetti Multigrain salad sandwich
Iced Coffee Reduced fat tasty cheese Peanut butter
Flavoured crisps Tinned baked beans
Fried crumbed chicken and

Diet yoghurt
chips
44
Most people had no hesitation sorting the pictures into foods that they thought contained
iron and those which did not contain iron. A few people said that they were unsure about
some foods. Everyone seemed willing to sort the food pictures even though most people
had previously said that they did not know what foods contained iron.
The results reflected the fact that people chose foods that would be considered ‘healthy’
foods rather than foods that contained iron. The most striking anomaly is the fact that very
few people saw a T-bone steak as containing iron. When questioned, interviewees said that
it was not good food because it contained fat along the edge of the meat. Similarly, tinned
beef was not chosen as containing iron because it was said to contain too much salt and
sugar.
This picture exercise shows that people have very little knowledge of the iron content of
most foods, with the exception of Weetbix which was a common choice.
APPENDIX 9 – Challenges of focus
group discussions and advantages of
smaller group or individual interviews
during the consultations
The research project was designed to work with focus groups in each community. This
method was used in two communities but was found to be challenging, for the reasons
listed below. Therefore, an individual approach was adopted. The Research Coordinator
then recommended that smaller groups of people be interviewed at a time and that more
interview sessions be conducted so that the overall material collected would be richer while
not involving any fewer participants.
The challenges of gathering information from focus groups for this project were:
• Difficulty in hearing what was being said when there could be up to 8 babies and their
siblings and carers all together in a small area.
• Trying to gather 8 carers together on the same day at the same time was difficult, so
some of the target group was not participating.
• Not all members of the target group wished to participate together in one activity at the
same place for personal or cultural reasons.
• Questions were of a personal nature and some answers could be judged by other
participants, thus there was a reluctance to answer some questions openly and
honestly.
• More articulate participants dominated the focus group. Some participants are
particularly quiet and do not speak unless asked a question directly.
• More senior community members dominate the focus group, as occurred in the pilot
focus group.
• The trained facilitators, scribes and translators only had one opportunity to practice
what they had been trained to do. Once employed it was not appropriate to mentor or
45
advise them publicly in front of the focus group, which was comprised of their peers.
• In the wet season it was necessary to find an indoor area that was available as a
gathering place for a large group of carers and babies together.
• Difficulty finding community members who were willing to be scribes. Aboriginal Health
Workers agreed to assist but participant’s replies and comments may have been
influenced by the presence of the Health Worker.
• Because the focus group is perceived as a fairly formal structure, other carers such as
fathers and extended family members, did not attend the group.
Advantages of smaller group or individual interviews were:
• Hearing what is being said is easier and infants’ needs can be accommodated.
• Timing of the interview can fit in with the interviewee.
• Interviews are private and interviewees are not influenced by others answers.
• If translating, one on one communication is easier.
• Interviews can be conducted anywhere that is appropriate for the interviewee.
• Research assistants have more opportunity to practice their skills and could be tutored
between interviews to improve their skills.
• When recruiting researcher assistants, it was difficult to find anyone willing to be the
note taker, so in a one on one interview, one scribe was sufficient. The ‘Sprinkles’
Research Coordinator filled this role.
• The informal nature of individual interviews allowed other family members who were
interested to join in the process, thus contributing to the richness of the data.
APPENDIX 10 - ‘Sprinkles’ community
consultants assisting with the project
Kalano – Rockhole
Sherryl Tomlins (Health Worker)
Wilma Driver
Adrianna Weetra
Binjari
Sharon Marony (Health worker)
Tilly Raymond
Jessie Brown
Jilkminggan
Raylene Roberts
Leonie McDonald
Stephanie Daniels
Patrina Baker
Pmara Jutunta
Jeannie Campbell (Health worker)
Doreena Stirling
Engawala
Jeannie Campbell (Health worker)
Rachael Tilmouth
46
Yarralin and Lingara
Reanne Short
Natasha Campbell at Yarralin
Aileen Daly at Lingara
(For distributing feedback: Patrina Harrison; who works at Childcare Centre and Godooga
Billy; who works at Childcare Centre)
Ngukurr
Grace Daniels
Gwen Rami
Lajamanu
Alison Luther
Atheleta Lewis
APPENDIX 11 - Additional information
from health staff, carers and shop
managers
Many related community workers, including clinic staff, childcare and play group workers
were informed about the research and given the opportunity to express any ideas they had
on the topics. The researchers also talked with shop keepers, takeaway shop operators
and council staff. Their answers are incorporated in to the relevant sections of the report
and are included in this section. Information gained from these discussions was through
informal conversations and therefore must be interpreted with caution.
Communication and resource materials for health staff

In Jilkminggan, nurses reported that there is anaemia in ‘pretty much all the kids. We test
them and treat them, but we don’t tally up the results.’ They reported that they thought the
fact that they drink a lot of tea had a lot to do with anaemia. Some babies don’t come into
the clinic, but the Aboriginal Health workers are pretty good and they go and get those kids
and bring them in. The clinic has posters up showing healthy food and not to give tea. The
nurses tell mothers to give the babies healthy food and not to give them tea, even if they
want it. (Jilkminggan, March 2007)
A health worker at Ngukurr commented that ‘We need some information to give out to
people when they have anaemic children; something they can take home and read later
because they forget what we tell them.’ After each interview, interviewees were given four
colourful laminated pictorial pages of nutritional information showing foods that are good
for preventing anaemia, and foods and drinks to be avoided. These were developed in
2005 as part of the NT Infant Feeding Guidelines Project facilitated by the NT DHCS. When
visiting the clinics the researcher did not see these handouts available at any clinic.
47
Shifting the trend to healthy food
Changing people’s eating habits will not be easy as expressed in this statement by
a mother at Ngukurr ; ‘School breakfast is free - cereal, apple or orange juice, and a
sandwich for lunch which they have to buy. Some kids don’t like the lunch at school,
because they are used to greasy food, so they don’t go back to school.’
Katherine West Health Board is working in conjunction with the Lajamanu store to educate
shoppers about healthy foods. The shop employs 2 local nutrition workers who are
employed half-time with Katherine West Health Board and half-time with the store. They
put healthy food stickers on particular food items for sale in the shop and are trained and
supported by the Katherine West Health Board nutritionist and the Store Manager.
At Yarralin the operators of the takeaway make up small containers of colourful food that
looks appealing to the children. They contain salad and pineapple and cheese. They
believe that they can entice people to eat good healthy food if it is marketed correctly. They
suggested the Health Department could employ food marketing experts to manage the
promotion of nutritional foods in the mass media, such as on Imparja Television.
Desperation expressed
Some Aboriginal health workers expressed desperation in their attempts to help people
with comments such as ‘We really try. Mothers are too young. I don’t know what to do’
(Lajamanu) and ‘I try to tell some families to feed their babies correct foods but they don’t
want to hear it from me’ (Yarralin). Another person said ‘I used to be a health worker, I’m
a single Mum….the community won’t give me a house. I’m sick of doing things for the
community’ (Lajamanu).
APPENDIX 12 - NT Department of
Health and Community Services:
Anaemia educational materials
48
49
APPENDIX 13 - Notes from the
feedback trip to the communities
involved in the research
After the presentation of this research report to the ‘Sprinkles Steering Committee,
communities were visited and the preliminary suggestions for the direction of Phase Two
were discussed with the community research assistants and other interested community
members. These included people working at childcare centres, health clinics, women’s
projects and stores.
There was a positive response to the suggestions of:
• employing community based nutritionists, (supported by health board nutritionists)

• teaching cooking and
• renaming of the project to ‘strong bella blood’ or ‘healthy blood’ project.
The comment was made that young mothers are very shy so it was suggested that the
teaching of nutrition be done at a place where the young mothers feel very comfortable or
at school as some young mothers are going back to school.
There was also support for the phasing out of ‘Sprinkles’, if introduced as a short term
measure. Other suggestions offered from community health workers were:
• ‘Sprinkles’ should be available from the shop or the clinic but not both places
• ‘Sprinkles’ should be available from somewhere other than the clinic, so it is not
thought of as a medicine
• Put ante natal women on the aged care feeding programs
• Start trying to fix the problem in the worst communities rather than trying to cover
50 too many communities (referring to the nutritionist support that can be given to a
limited number of community nutrition workers)
• Would like to see more research into anaemia as a reported condition. Central
Australian Remote Practitioners Association (CARPA) Manual has recommended
lowering the measurement of the reportable rate for anaemia in babies. If this is
done it may affect the number of reported anaemia cases in the NT.
• Subsidise commercial baby food
• Need a specialist person to focus on anaemia or get the community nutritionist to
focus on anaemia
One clinic was surprised when they checked their handout material and discovered that no
anaemia handouts were listed in the CARPA guide manual and that they did not have any
handouts about anaemia.
Some clinics are using cherry flavoured ‘Incremin’ iron mixture and that is reported to be
more popular than other iron syrups.
Some communities reported that they were already considering establishing a childcare
program that could incorporate a feeding program. At Pmara Jutunta the baby breakfast
program operates three days per week and the mothers learn cooking while preparing their
meals. Families have to prepare their own meals on the other days, thus not becoming
dependent on community feeding programs.
Educational material
Health workers were also interested to learn that people appear to not understand the
messages that are being given out in relation to weak blood. One community thought that
anaemia handouts would not be looked at or used if given out personally, though they did
think it was worth putting them up on a wall or notice board. It was noted that the anaemia
handouts that had been left at Ngukurr clinic during the research, had been stuck up on the
wall of the clinic.
References
Condon, J., G. Warma, et al. (2001). The Health and Welfare of Australian and Torres Strait
Islander Peoples. Darwin, Northern Territory, Territory Health Services.
GAA Data Collection (April 2006), Northern Territory Government, Department of Health
and Community Services.
International Research on Infant Supplementation (IRIS) Study Group (2005), ‘Efficacy of a

Foodlet-Based Multiple Micronutrient Supplement for Preventing Growth Faltering, Anemia,
and Micronutrient Deficiency of Infants: The Four Country IRIS Trial Pooled Data Analysis’,
The American Society for Nutritional Sciences, J. Nutr. 135:631S-638S, March 2005
UNICEF/UNU/WHO/MI Technical Workshop (1998), Preventing Iron Deficiency in Women

and Children: Technical Consensus on Key Issues, New York.
Stoltzfus, R.J. and Dreyfuss, M.L. (1998), Guidelines for the Use of Iron Supplements to
Prevent and Treat Iron Deficiency Anemia, International Life Sciences Institute (ILSI) Press,
Washington.
WHO (2001) ‘Iron Deficiency Anaemia assessment, Prevention, and Control: A guide to
Program Managers’, World Health Organisation, Geneva.
Zlotkin, S.H, Schauer, C., Christofides, A., Sharieff, W., Tondeur, M.C., Ziauddin Hyder,
S.M., (2005) ‘Micronutrient Sprinkles to Control Childhood Anameia’, PloS Med 2 (1):el
51
For further information please contact:
The Fred Hollows Foundation

Indigenous Program Manager
on +61 08 89415145

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Community Consultation

The Fred Hollows Foundation

Anmatjere Health Service

Findings from the consultations 16

• Ms Robin Knox, employed by the Fred Hollows Foundation as the ‘Sprinkles’

ARDS Aboriginal Resource and Development Services Inc.

BRACS Broadcasting for Remote Aboriginal Communities’ Scheme

CAAMA Central Australian Aboriginal Media Association (Aboriginal

CARPA Central Australian Remote Practitioners Association

CDEP Community Development Employment Program

DHCS Department of Health and Community Services

FHF The Fred Hollows Foundation

GAA Growth Assessment Action

KWHB Katherine West Health Board

SHS Sunrise Health Services

UNICEF United Nations International Children’s Emergency Fund 5

WHO World Health Organisation

Current strategies in the NT to reduce iron deficiency anaemia in children emphasize

2. Feeding practices for babies aged 6 months to 2 years

• There is a need to improve the nutritional intake of babies’ 6 months to 2 years

3. Knowledge about food for babies, food nutrition and anaemia

4. Community member’s attitudes to ‘Sprinkles’

10 a. Feasibility and appropriateness of payment and non-payment options

5. Community member’s perceptions/attitudes toward methods and channels through which

In future program initiatives, communication about anaemia and ‘Sprinkles’ should:

One year old baby from Lajamanu community tries

Current strategies in the NT to reduce iron deficiency anaemia in children emphasize

As part of a multifaceted anaemia prevention program, a home micronutrient supplement,

Design of questionnaire and pre test

Sampling, data collection and analysis

The following list outlines the focal areas of the questionnaire:

1. Feeding practices among young children aged 6 months to 2 years;

‘Sprinkles’ Committee member

56 interviewees caring for 58 babies

Summary and conclusions

Tinned baby food and 2-minute noodles

Introducing food and drinks

Eating and drinking

Ti Tree, near Pmara Jutunta, May 2007

‘Mum’s are lazy’ (too lazy to cook proper meals)

Jilkminggan, March 2007

Outside Engawala community store, where four

Cooking and advice for feeding babies

Feeding sick babies

• There is a need to improve the nutritional intake of babies’ 6 months to 2 years

3. Knowledge about food for babies, 23

Healthy and not so healthy foods

• ‘Lollies… because they (babies) have no teeth’ (Kalano),

Knowledge of vitamins and minerals

Sharon Maroney feeding Maverick during a ‘Sprinkles’ focus group discussion

from the store takeaway.

Lajamanu, June 2007

Ngukurr, May 2007

Jilkminggan, March 2007

No-one talked about the long term side affects of anaemia.

Summary and conclusions

A boy at the Yarralin Childcare Centre tries ‘Sprinkles’.

What foods and meals

The general opinion of ‘Sprinkles’ is best summed up by the comment:

Yarralin, June 2007

Summary and conclusions

a. Feasibility and appropriateness of payment and non-payment options