Using non-experimental descriptive exploratory survey, this study sought to find out factors associated with delayed entry into HIV medical care among HIV positive people who are aware of their status. A quantitative design was used and a structured questionnaire was used as the data collection instrument. Respondents were patients in a hospital’s Opportunistic Infection Department whose hospital records indicated that they were HIV positive during the time of the study. The study found out that as much as 71.6% (n =43) first entered HIV medical care more than 12 months after testing HIV positive while 40% (n = 24) did so as a result of illness. Low education levels, unemployment and being single are associated with delayed entry into HIV medical care. A percentage of the population uses and trusts non-biomedical approaches to dealing with HIV/AIDS. Being diagnosed HIV positive is therefore not necessarily a strong reason enough for one to immediately enter into medical care. Intensive health education needs to be done at work places, health facilities, schools, through print and electronic media, churches and other community settings to equip the population with knowledge of the advantages of early entry into HIV care. / Health Studies / M.A. (Public Health)

Philosophiae Doctor - PhD / The school environment presents a valuable opportunity for the identification, monitoring and support of children made vulnerable by HIV/AIDS and poverty. Many children are caring for parents suffering from AIDS-related illnesses and/or they are the main breadwinner of the household. As a result of HIV/AIDS and poverty therefore, children might be dropping out of school, or their ability to perform adequately at school might be significantly reduced. The aim of this study was to use a case study approach to explore and describe support provision in a South African formal school, examining, in particular, the relative significance of leadership, organisational development and gender-related matters in addressing the needs of children made vulnerable by HIV/AIDS and poverty. The availability and quality of this support is analysed within the context of the Western Cape Education Department (WCED) transforming itself from a system focused on controlling schools to a system focused on supporting schools. The reflexive qualitative research approach was decided upon m order to describe and understand how, and to what extent, the teachers and the principal of a poverty-stricken primary school might benefit from the WCED's systemic change processes when addressing issues related to HIV/AIDS and poverty. The methodological rationale for this qualitative research approach forms part of a search for meaning within the cultural context(s) of the school in an effort to understand issues related to HIV/AIDS in schools. The research's second aim was to establish principles for an approach to educational support, which would be applicable in similar situations elsewhere. In the case study, the focus is on the WCED supporting the principal and teachers at a poverty-stricken primary school in carrying out their roles as leaders, teachers and caregivers. In order for the principal and teachers to provide quality support to the learners, they themselves need to receive appropriate forms of support from the education system. For this research to be contextually grounded, questions around HIV/AIDS and the growing number of orphans and vulnerable children in many communities were considered. One of the central questions was: How are the challenges of daily life in the running of a school met where issues related to poverty and health are dominant? Gender-based sexual violence and sexual abuse of children, as well as other social problems affecting learners in the school investigated for this thesis were included in the addressing of the main questions The complexity of the issues involved when exploring the research questions became increasingly more apparent during the research journey of this thesis. I experienced fully the potential of the case study to provide a 'thick' description and contribute significantly to an in-depth understanding of a complex phenomenon from a local and holistic perspective. I was able to focus on how the macro-narratives of support policy connected to the micro-narratives of teachers in primary schools. Based on the findings of the research, I concluded that the problems of HIV/AIDS-affected children, families and communities do not only overlap considerably with the problems related to poverty - a widely held view among researchers - but that poverty-related problems may, indeed, conceal the very existence of HIV/AIDS. The investigation shows that the wide-spread poverty affecting the case school learners, seems to have 'blinded' teachers in terms of 'seeing' the learner in a context of HIV/AIDS. This phenomenon in the case school was observed in spite of the HIV/AIDS Programme Coordinator claiming that the district's teachers had learned to 'see' the learner in ways which they had not prior to the introduction of the WCED's HIV/AIDS Life Skills Programme I trust that the different stakeholders within the field of education and HIV/AIDS will benefit from the findings and recommendations flowing from this investigation. First and foremost, I believe that the lessons learnt from the fieldwork, could be of use to South African stakeholders generally, and, in particular, to the Western Cape Education Department and those working as school support staff at district level (the EMDCs). The findings of the study may provide valuable feedback to the current practices of the school support structures, including the voluntary HIV/AIDS support structure, and form a basis for informed further action by the relevant government departments and other stakeholders in education. In this way, the thesis could contribute to improved formal school support provision in the context of HIV/AIDS, and therefore, serve to enhance the quality of education for all children.

The purpose of the study was to describe the effects of an EMR on patient management in selected HIV clinics in Johannesburg. A quantitative, descriptive, cross-sectional study was undertaken in four HIV clinics in Johannesburg. The subjects (N=44) were the healthcare workers selected by stratified random sampling. Consent was requested from each subject and from the clinics in Johannesburg. Data was collected using structured questionnaires. Median age of subjects was 36, 82% were female. 86% had tertiary qualifications. 55% were clinicians. 52% had 2-3 years work experience. 80% had computer experience, 86% had over one year EMR experience. 90% used the EMR daily, 93% preferred EMR to paper. 93% had EMR training, 17% used EMR to capture clinical data. 87% perceived EMR to have more benefits; most felt doctor-patient relationship was not interfered with. 89% were satisfied with the EMR’s overall performance. The effects of EMR benefit HIV patient management. / Health Studies / MA (Public Health)

The purpose of the study was to determine the effect of antenatal health education on postnatal care (PNC) among Human Immunodeficiency Virus (HIV) positive women in Francistown city, Botswana. This study followed a quantitative research paradigm. Data was collected with the aid of a questionnaire from eligible women who consented in writing to participate in the study. Forty-five percent (45%) (n=45) HIV positive women came with babies for 6 weeks PNC and 55% (n=55) brought 8 weeks old babies either for weighing or for the two months immunisation from 28 April to 10 June 2014. The responses regarding the source of health education received were as follows: 40% lay counselors, 31% midwives, 15% doctors, 5% nurses without midwifery, 5% cadre unknown, 2% both lay counselors and midwives, 1% by a health education assistant and 1% was not health educated at all. Conclusion: The study revealed that HIV positive pregnant women received health education from different cadres of health and mostly by lay counselors. Literature indicates that lay counselors may give health information but at a very superficial level. / Health Studies / M.A. (Health Studies)

Le syndrome d'Evans est défini par l'existence concomitante ou séquentielle de cytopénies auto-immunes, le plus souvent, anémie hémolytique et thrombopénie immunologique. Chez l'enfant, il peut être secondaire à une infection, une maladie auto-immune systémique ou un déficit immunitaire primitif. Alternativement, chez une grande partie des patients, l'étiologie n'est pas clairement identifiée. Les patients atteints de syndrome d'Evans présentent parfois d'autres atteintes, telles une auto-immunité d'organe, une lymphoprolifération bénigne ou un déficit immunitaire. L'objectif de ce travail était d'identifier des causes génétiques chez des enfants présentant un syndrome d'Evans sans étiologie sous-jacente identifiée. Nous avons centré notre étude sur des formes sévères à début pédiatrique en faisant l'hypothèse qu'une maladie monogénique serait plus fréquente dans ce groupe de patients. Nous avons mis à profit les technologies de séquençage haut débit « nouvelle génération » (NGS) pour réaliser et analyser le séquençage de l'exome de patients et de certains de leurs apparentés afin de mettre en évidence des gènes candidats potentiels. Ce travail a permis l'identification de 4 gènes candidats : LRBA, CTLA-4, STAT3 (mutations gain de fonction) et NFKBIA. L'implication des 3 premiers gènes dans de nouvelles maladies monogéniques où l'auto-immunité est au premier plan a été confirmée par d'autres équipes au cours de ce travail. Pour chacun de ces gènes, nous avons poursuivi 2 objectifs complémentaires : d'une part, tenter de valider l'implication des gènes identifiés dans la maladie des patients. Nous avons pour cela utilisé des approches et techniques variées : biochimie et protéomique afin d'identifier des partenaires protéiques, microscopie confocale pour localiser les protéines et leurs interactions, tests cellulaires in vitro pour mettre en évidence un défaut fonctionnel, marquages en cytométrie en flux pour identifier des modifications dans les sous-populations lymphocytaires. D'autre part, nous avons recherché d'autres mutations de ces gènes chez des patients de phénotype clinique similaire. Nous avons ainsi constitué et exploré 3 cohortes de patients présentant des mutations de LRBA, CTLA-4 ou STAT3. Nous avons rassemblé une cohorte de 18 patients porteurs d'une mutation de LRBA, répartis dans 11 familles. Cela nous a permis de préciser et d'étendre le spectre clinique de cette maladie de découverte récente, avec en particulier des atteintes articulaires sévères s'associant à un diabète précoce, ou des entéropathies. Nous avons identifié 15 nouvelles mutations de transmission autosomique récessive dans le gène LRBA, codant une protéine de fonction inconnue dont l'absence entraine une maladie principalement caractérisée par une poly-auto-immunité. Nous avons identifié 29 partenaires protéiques potentiels de LRBA et précisé la localisation de LRBA dans les différents compartiments cellulaires. Nous avons également établi une cohorte de 12 patients dans 10 familles présentant un déficit en CTLA-4 par haplo-insuffisance. Au delà de la mise en évidence de 9 nouvelles mutations, nous avons décrit une famille où la variation est transmise de façon autosomique récessive. Dans les déficits en LRBA et CTLA-4, nous avons mis en évidence une diminution du pourcentage de lymphocytes T régulateurs parmi les PBMC et une diminution de l'expression de CTLA-4 dans les lymphocytes T activés. Ceci corrobore l'interaction entre ces 2 protéines décrite en parallèle par une autre équipe. Nous avons montré que les spectres cliniques des déficits en LRBA et CTLA-4, fortement chevauchant dans les premières descriptions publiées, pourraient se différencier, malgré l'implication des lymphocytes T régulateurs dans ces 2 maladies. (...) / Evans syndrome is defined by the occurence of autoimmune cytopenias, either at the same time or sequential, mainly autoimmune hemolytic anemia and immune thrombocytopenia. In children, it may be secondary to infections, systemic autoimmune disease, or primary immune deficiency, though in most patients, its etiology isn't obvious. Patients affected with Evans syndrome can also present other features, such as autoimmunity toward a particular organ, benign lymphoproliferation or immunodeficiency. The main goal of this work was to identify genetic causes in children presenting an Evans syndrome without a known underlying etiology. We focused our study on severe, early onset forms of the disease, with the hypothesis that a monogenic disease would be more frequent in this group of patients. Taking advantage of high throughput "Next Generation" sequencing (NGS) techniques, we sequenced and analyzed exome from patients and their relatives in search for adequate candidate genes. We identified 4 candidate genes: LRBA, CTLA-4, STAT3 (gain-of-function mutations), and NFKBA. Implication of the first 3 genes in new monogenic diseases with autoimmunity as a key feature was also confirmed by others during the course of this work. For each gene, we pursued 2 complementary goals: First, we sought to validate the implication of the gene in the patients' disease. To do so, we used various techniques and approaches: biochemistry and proteomics to identify protein partners, confocal microscopy to localize proteins and interactions, in vitro cellular assays to bring to light functional defect, flow cytometry to identify changes in lymphocytes subpopulations. We also looked for other mutations of each gene in patients with a similar clinical presentation. Hence we created and explored 3 cohorts of patients presenting with mutations of LRBA, CTLA-4 or STAT3. We constituted a cohort of 18 patients with LRBA mutations within 11 families. We then were able to precise and extend the clinical spectrum of this recently described disease. In particular, we observed patients with severe chronic arthritis associated with diabetes mellitus or enteropathies. We identified 15 new mutations of autosomal recessive transmission in the LRBA gene, coding a protein of unknown function, which absence is responsible for a disease mainly characterized by autoimmune features. We identified 29 candidate protein partners of LRBA and precized LRBA localisation in cell compartiments. We also established a cohort of 12 patients within 10 families presenting CTLA-4 haploinsufficiency. Beyond describing 9 new mutations, we report a family with autosomal recessive transmission.In LRBA and CTLA-4 deficiencies, we showed a decrease of regulatory T lymphocyte subset proportion among PBMC and a decrease of CTLA-4 expression in activated T cells. These results support the interaction between these 2 proteins, described concurrently by another team. We showed that the clinical spectra of these 2 diseases, although widely overlapping in first published reports, could be different despite a role of regulatory T cells in both. Hence, organ-specific autoimmunity and lymphoproliferation are more frequent in LRBA deficiency whereas granuloma and hypogammaglobulinemia are more present in CTLA-4 deficiency. Theses results suggests a role of genetic modifyers, which remain to identify. Among our cohort of patients with Evans syndrome, we also identified 5 patients within 5 families presenting gain-of-function mutations of STAT3. 3 of those mutations were reported by others during our work and appeared de novo in our patients. Functional validation of the 4th one is in progress. The last mutation follows a recessive transmission and could exemplify a new transmission modality of this disease. (...)

L’association entre déficits immunitaires primitifs (DIPs) et manifestations auto-immunes peut sembler paradoxale lorsque l’on aborde les DIPs comme des défauts d’immunité opposés à l’autoimmunité vue comme excès d’immunité adaptative à l’encontre du soi. Néanmoins, loin de se résumer à un simple défaut d’une ou plusieurs composantes du système immunitaire qui prédispose aux infections par divers agents pathogènes, les DIPs sont fréquemment associés à une autoimmunité; parfois révélatrice. Ainsi, les données épidémiologiques issues de registres ou de larges séries de patients atteints de DIPs s’accordent sur une prévalence globale de 25 à 30% de complications auto-immunes (au premier rang desquelles figurent les cytopénies auto-immunes). Différentes hypothèses sont avancées pour rendre compte de l’auto-immunité dans les DIPs. On peut citer : 1°) une perturbation profonde de l’homéostasie lymphocytaire, en particulier dans les déficits immunitaires combinés sévères (CID) avec lymphopénies T et B ; 2°) des défauts intrinsèques des lymphocytes B permettant une rupture de tolérance précoce des LB auto réactifs ; 3°) un comportement aberrant des LT (défaut de maturation, excès d’activation) ; 4°) une absence de lymphocytes T ou de B régulateurs ; 5°) une production inappropriée de certaines cytokines proinflammatoires comme dans les interféronopathies. Ces hypothèses concernent surtout les DIPs pédiatriques sévères. Mon travail de thèse explore la rupture de tolérance immunitaire adaptative au cours des DIPs de l’adulte par différentes approches. Nous nous sommes en particulier attachés au plus fréquent, le DICV (Déficit Immunitaire Commun Variable), déficit immunitaire humoral pas toujours bien défini sur le plan génétique et physiopathologique qui constitue un défi thérapeutique lorsqu’il est compliqué d’une auto-immunité nécessitant un traitement immunosuppresseur. / The association between primary immune deficiency (PID) and autoimmunity may seem paradoxical when PID is considered only as an immune response defect against pathogens and autoimmunity only as an excess of immunity. Nevertheless, far from being simple immune defects increasing the risk of infections, DIPs are frequently associated with autoimmunity. Even more, autoimmunes manifestations can sometimes reveal a PID. Thus, epidemiological data from registers or large series of patients with PIDs agree on an overall prevalence of 25 to 30% of autoimmune complications (with auto-immune cytopenias as first causes). Several hypotheses have been proposed with different underlying mechanisms to explain the tolerance breakdown in PIDs. We can cite : 1°) a severe disturbance of lymphocyte homeostasis, for example in severe combined immunodeficiencies ; 2°) an impaired B-cell developpement with earlystage defects of tolerance ; 3°) a dysregulation of T cells (developpement or activation impairments) ; 4°) a dysfunction of T-reg (or B-reg) ; 5°) an excess of production of proinflammatory cytokines. These hypotheses are especially true for early-onset PIDs (in infancy). In this work (PhD), we explore the mechanisms of tolerance breakdown involved in adults PIDs. We use several approaches to describe the pathways leading to autoimmunity, focusing on the most common PID in adult : CVID (common variable immunodeficiency). This syndrome is not well defined on the genetic and physiopathological level. It is still a therapeutic challenge when complicated by autoimmunity (requiring immunosuppressive therapy).

The purpose of the study was to determine the effect of antenatal health education on postnatal care (PNC) among Human Immunodeficiency Virus (HIV) positive women in Francistown city, Botswana. This study followed a quantitative research paradigm. Data was collected with the aid of a questionnaire from eligible women who consented in writing to participate in the study. Forty-five percent (45%) (n=45) HIV positive women came with babies for 6 weeks PNC and 55% (n=55) brought 8 weeks old babies either for weighing or for the two months immunisation from 28 April to 10 June 2014. The responses regarding the source of health education received were as follows: 40% lay counselors, 31% midwives, 15% doctors, 5% nurses without midwifery, 5% cadre unknown, 2% both lay counselors and midwives, 1% by a health education assistant and 1% was not health educated at all. Conclusion: The study revealed that HIV positive pregnant women received health education from different cadres of health and mostly by lay counselors. Literature indicates that lay counselors may give health information but at a very superficial level. / Health Studies / M. A. (Health Studies)

The lack of a contextualised, relevant communication strategy focusing specifically on HAST diseases in the Limpopo Province was the impetus for this research. The purpose of this study was, therefore, to explore the knowledge, perceptions and utilisation of health facilities for HAST in order to develop an acceptable and effective communication strategy for the Province to address the high rate of HAST diseases. The study followed a qualitative approach guided by the major tenets of the Health Belief Model, namely, to determine modifying factors, individual beliefs and cues for action. An in-depth literature review was followed by focus group interviews with the community members and personal interviews with District and Provincial Deputy Directors. Based on these findings, a communication strategy was drafted and piloted for three months in one of the districts in Limpopo. Further refinement of the communication strategy followed after member-checking and further interviews with directors HAST. The final strategy specifically focused on risk groups with each of the diseases in terms of their beliefs and perceptions. It further resulted in guidelines for health providers in terms of the content and implementation of effective communication strategies within the context of educational, cultural, social and economic factors relevant to Limpopo / Health Studies / D. Litt. et Phil. (Health Studies)

The purpose of the study was to describe the effects of an EMR on patient management in selected HIV clinics in Johannesburg. A quantitative, descriptive, cross-sectional study was undertaken in four HIV clinics in Johannesburg. The subjects (N=44) were the healthcare workers selected by stratified random sampling. Consent was requested from each subject and from the clinics in Johannesburg. Data was collected using structured questionnaires. Median age of subjects was 36, 82% were female. 86% had tertiary qualifications. 55% were clinicians. 52% had 2-3 years work experience. 80% had computer experience, 86% had over one year EMR experience. 90% used the EMR daily, 93% preferred EMR to paper. 93% had EMR training, 17% used EMR to capture clinical data. 87% perceived EMR to have more benefits; most felt doctor-patient relationship was not interfered with. 89% were satisfied with the EMR’s overall performance. The effects of EMR benefit HIV patient management. / Health Studies / MA (Public Health)

Made available in DSpace on 2014-07-29T15:29:11Z (GMT). No. of bitstreams: 1 Marianne de Oliveira Falco.pdf: 1327193 bytes, checksum: f2c63ea5da2350c16f08f39b5e787803 (MD5) Previous issue date: 2011-12-16 / Objective: To assess the available scientific knowledge on the effect of nutritional treatment abnormality metabolic in adult patients living with Aids in the use of HAART and adherence of nutritional/diet therapy. Methods: A systematic review of literature was conducted through a search protocol developed by the authors: articles were searched in Pubmed, Lilacs and Cochrane, between 1996 and 2010, of the type: controlled clinical trial, randomized or crossover; were adults, living with HIV/Aids under anti-retroviral therapy showing no opportunistic diseases. The intervention of interest was oral nutritional supplementation and/or lifestyle changes through specific nutritional therapy: dyslipidaemia, insulin resistance, lipodystrophy and systemic arterial hypertension. For qualitative classification of the articles we used the Jadad scale. The clinical trials, was controlled, randomized, open label, with a target population of adults with Aids in antiretroviral therapy and without opportunistic diseases. In the study on adherence was held randomized controlled trial and open. Among the 165 patients randomly assigned to two treatment groups for nutritional / dietary. The group treatment 1 (T1) and Treatment 2 (T2) received nutrition care, and the stage of nutritional diagnosis performed similarly in both groups and with service until completing treatment. With respect to conduct diet therapy groups (T1) and (T2)received nutritional counseling, group T2 also received individualized dietary plan. The groups had returns quaterly (T1) and monthly (T2). We considered dietary before and after the intervention and attendance at meetings as parameters of adherence to treatment. Results: In a systematic review 385 papers were found and seven met the inclusion criteria. The interventions applied in such studies were: diet plus physical exercises, diet plus supplement and only supplements. Dyslipidaemia was the common outcome to all studies. The studies assessing supplementation with omega 3 found significant reduction on triglycerides. Specific diet plus omega 3 supplementation showed an increase on HDL cholesterol. Supplementation with chromo nycotinate showed no effect on dyslipidaemia. Lifestyle modification,including diet and physical activity, drastically reduced the waist circumference, lipodystrophy and systolic arterial pressure. In the clinical trial among 165 patients in the study were 83 T1 and 82 T2. At the end of 7,3 months, 20% patients dropped out of the nutrition therapy. The T1 and T2 groups showed no significant difference in relation to socio demographic parameters. 15,63% of group T2 reached the goal considered optimal for adhesion while 42.65% of group T1 were 100% adherence to queries. The T1 and T2 groups showed a reduction to the risk of food consumption, increased consumption of protective foods, increased fractioning meals in T2 group. Conclusion: In the systematic review by lowering triglycerides with omega 3 supplementation was the greatest nutritional intervention with scientific evidence. Prescription diet seems to be the most appropriate intervention to increase HDL. Still can not make inferences about the nutritional treatment of total cholesterol, LDL and insulin resistance. In the study of adherence, there were no differences between groups T1and T2, in relation to adherence and in relation to the goals of food consumption. / Objetivo: Avaliar o conhecimento científico disponível sobre o efeito do tratamento nutricional nas alterações metabólicas em pacientes com Aids e a adesão destes ao serviço de Nutrição e ao tratamento nutricional/dietoterápico. Métodos: Para revisão sistemática, conduziu-se revisão sistemática de literatura por meio de protocolo de busca nas bases de dados: Pubmed, LIlacs e Cochrane, entre 1996 e 2010, do tipo ensaio clínico, controlado, randomizado, crossover, sendo a população alvo: adultos, vivendo com HIV/Aids, em uso de terapia anti-retroviral e sem doenças oportunistas. A intervenção de interesse foi suplementação nutricional via oral e/ou mudança de estilo de vida através de tratamento dietoterápico específico: dislipidemia, resistência insulínica, lipodistrofia e hipertensão arterial sistêmica. Para o estudo de adesão realizou-se ensaio clínico controlado, randomizado e aberto. Cento e sessenta e cinco adultos com Aids em uso de TARV, alocados aleatoriamente em dois grupos para tratamento nutricional/dietoterápico. Os grupos Tratamento1(T1) e Tratamento 2 (T2) receberam consulta de nutrição, sendo a etapa de diagnóstico nutricional realizada de mesma forma em ambos os grupos e com atendimento até completar o tratamento. Os grupos (T1) e (T2) receberam orientações nutricionais, o grupo T2 recebeu ainda plano alimentar individualizado. O grupo T1 tinha agendamento de retornos trimestrais e o T2 mensal. Consideraram-se repercussões dietéticas após a intervenção e assiduidade às reuniões como parâmetros de adesão ao tratamento. Resultados: Na revisão sistemática, após localizar 385 artigos, sete foram incluídos. As intervenções utilizadas nesses estudos foram: dieta, dieta mais exercício físico, dieta mais suplemento e somente suplementos. Dislipidemia foi desfecho avaliado em todos os estudos. Os estudos que avaliaram suplementação com ômega 3 encontraram redução significativa dos triglicérides. Dieta específica mais suplementação de ômega 3 mostrou aumento de HDL-colesterol. Suplementação com nicotinato de cromo não teve efeito sobre a dislipidemia. Modificação de estilo de vida reduziu, significativamente a circunferência da cintura, lipodistrofia e pressão arterial sistólica. No ensaio clínico dentre os 165 pacientes incluídos no estudo 83 receberam o T1 e 82 o T2. Ao final de 7,3 meses, 20% pacientes desistiram do tratamento nutricional. 15,63% dos pacientes do grupo T2 e 42,65% do grupo T2 atingiram a meta considerada ótima para adesão. Os grupos T1 e T2 apresentaram redução para o consumo de alimento de risco, aumento do consumo de alimentos de proteção, aumento e no fracionamento das refeições no grupo. Conclusão: Na revisão sistemática a redução de triglicérides pela suplementação com ômega 3 foi a intervenção nutricional com maiores evidências científicas. A prescrição de dieta parece ser a intervenção mais adequada para aumentar HDL. Ainda não é possível fazer inferências sobre o tratamento nutricional do colesterol total, LDL e resistência insulínica. No estudo de adesão, não houve diferenças entre os grupos T1 e T2, em relação à adesão às consultas analisada pela assiduidade e em relação às metas de consumo alimentar avaliada pelas modificações de hábitos alimentares.