# Increased difficulty accessing food and income change during the COVID-19 pandemic among youth living in the eThekwini district, South Africa

Julie Jesson, Bongiwe Zulu, Kalysha Closson, C. Andrew Basham, Mags Beksinska, Erica Dong, Campion Zharima, Rishav Singh, Tatiana Pakhomova, Janan Dietrich, et al.

<figure><img src="image_1.png" /></figure>

## ► To cite this version:

Julie Jesson, Bongiwe Zulu, Kalysha Closson, C. Andrew Basham, Mags Beksinska, et al. Increased difficulty accessing food and income change during the COVID-19 pandemic among youth living in the eThekwini district, South Africa. Public Health Nutrition, 2024, pp.1-30. 10.1017/S1368980024001174. hal-04607407

HAL Id: hal-04607407

https://hal.science/hal-04607407

Submitted on 10 Jun 2024

HAL is a multi-disciplinary open access
archive for the deposit and dissemination of sci-
entific research documents, whether they are pub-
lished or not. The documents may come from
teaching and research institutions in France or
abroad, or from public or private research centers.

L'archive ouverte pluridisciplinaire HAL, est
destinée au dépôt et à la diffusion de documents
scientifiques de niveau recherche, publiés ou non,
émanant des établissements d'enseignement et de
recherche français ou étrangers, des laboratoires
publics ou privés.

<figure><img src="image_2.png" /></figure>
# Increased difficulty accessing food and income change during the COVID-19 pandemic among youth living in the eThekwini district, South Africa

Julie Jesson, Bongiwe Zulu, Kalysha Closson, C. Andrew Basham, Mags Beksinska, Erica Dong, Campion Zharima, Rishav Singh, Tatiana Pakhomova, Janan Dietrich, et al.

► To cite this version:

Julie Jesson, Bongiwe Zulu, Kalysha Closson, C. Andrew Basham, Mags Beksinska, et al. Increased difficulty accessing food and income change during the COVID-19 pandemic among youth living in the eThekwini district, South Africa. Public Health Nutrition, 2024, pp.1-30. 10.1017/S1368980024001174. hal-04607407

HAL Id: hal-04607407

https://hal.science/hal-04607407v1

Submitted on 10 Jun 2024

HAL is a multi-disciplinary open access
archive for the deposit and dissemination of sci-
entific research documents, whether they are pub-
lished or not. The documents may come from
teaching and research institutions in France or
abroad, or from public or private research centers.

L'archive ouverte pluridisciplinaire HAL, est
destinée au dépôt et à la diffusion de documents
scientifiques de niveau recherche, publiés ou non,
émanant des établissements d'enseignement et de
recherche français ou étrangers, des laboratoires
publics ou privés.

<figure><img src="image_1.png" /></figure>
# Increased difficulty accessing food and income change during the COVID-19 pandemic among youth living in the eThekwini district, South Africa

Julie Jesson¹, Bongiwe Zulu², Kalysha Closson³,⁴, C. Andrew Basham⁵, Mags Beksinska², Erica Dong⁴, Campion Zharima⁶,⁷, Rishav Singh⁴, Tatiana Pakhomova⁴, Janan Dietrich⁶,⁸,⁹, Angela Kaida⁴,¹⁰

¹Center for Epidemiology and Research in POPulation Health (CERPOP), Inserm, Université de Toulouse, Université Paul Sabatier, Toulouse, France

²MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa

³University of California San Diego, Center of Gender Equity and Health, La Jolla, CA, USA

⁴Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada

⁵Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA. Department of Medicine, Harvard Medical School, Boston, MA, USA

⁶Perinatal HIV Research Unit (PHRU), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.

<figure><img src="image_3.png" /></figure>

The
Nutrition
Society

This is an Accepted Manuscript for Public Health Nutrition. This peer-reviewed article has been accepted for publication but not yet copyedited or typeset, and so may be subject to change during the production process. The article is considered published and may be cited using its DOI 10.1017/S1368980024001174

Public Health Nutrition is published by Cambridge University Press on behalf of The Nutrition Society. This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution and reproduction, provided the original article is properly cited.
# Increased difficulty accessing food and income change during the COVID-19 pandemic among youth living in the eThekwini district, South Africa

Julie Jesson¹, Bongiwe Zulu², Kalysha Closson³,⁴, C. Andrew Basham⁵, Mags Beksinska², Erica Dong⁴, Campion Zharima⁶,⁷, Rishav Singh⁴, Tatiana Pakhomova⁴, Janan Dietrich⁶,⁸,⁹, Angela Kaida⁴,¹⁰

¹Center for Epidemiology and Research in POPulation Health (CERPOP), Inserm, Université de Toulouse, Université Paul Sabatier, Toulouse, France

²MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa

³University of California San Diego, Center of Gender Equity and Health, La Jolla, CA, USA

⁴Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada

⁵Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA. Department of Medicine, Harvard Medical School, Boston, MA, USA

⁶Perinatal HIV Research Unit (PHRU), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.

<figure><img src="image_2.png" /></figure>

The
Nutrition
Society

This is an Accepted Manuscript for Public Health Nutrition. This peer-reviewed article has been accepted for publication but not yet copyedited or typeset, and so may be subject to change during the production process. The article is considered published and may be cited using its DOI 10.1017/S1368980024001174

Public Health Nutrition is published by Cambridge University Press on behalf of The Nutrition Society. This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution and reproduction, provided the original article is properly cited.
⁷Centre for Health Policy, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa

⁸African Social Sciences Unit of Research and Evaluation (ASSURE), a division of the Wits Health Consortium, Johannesburg, South Africa

⁹Health Systems Research Unit, South African Medical Research Council, Bellville, South Africa

¹⁰Women's Health Research Institute, Vancouver, BC, Canada

**Corresponding author:** Julie Jesson, PhD - Centre d'Epidémiologie et de Recherche en santé des Populations de Toulouse – CERPOP, UMR 1295 Inserm - Université Toulouse III Paul Sabatier, 37 Allées Jules Guesde, 31073 TOULOUSE CEDEX 9, Email: julie.jesson@inserm.fr

**Short title:** Difficulty accessing food and income change

**Acknowledgments:** The AYAZAZI RIGHTS research team thanks our youth participants for all their contributions to this study. We also thank our international team of co-investigators, collaborators, youth representatives and our partnering organisations for supporting this study.
⁷Centre for Health Policy, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa

⁸African Social Sciences Unit of Research and Evaluation (ASSURE), a division of the Wits Health Consortium, Johannesburg, South Africa

⁹Health Systems Research Unit, South African Medical Research Council, Bellville, South Africa

¹⁰Women's Health Research Institute, Vancouver, BC, Canada

**Corresponding author:** Julie Jesson, PhD - Centre d'Epidémiologie et de Recherche en santé des Populations de Toulouse – CERPOP, UMR 1295 Inserm - Université Toulouse III Paul Sabatier, 37 Allées Jules Guesde, 31073 TOULOUSE CEDEX 9, Email: julie.jesson@inserm.fr

**Short title:** Difficulty accessing food and income change

**Acknowledgments:** The AYAZAZI RIGHTS research team thanks our youth participants for all their contributions to this study. We also thank our international team of co-investigators, collaborators, youth representatives and our partnering organisations for supporting this study.
**ABSTRACT**

**Objective:** To estimate the effect of income change on difficulty accessing food since the COVID-19 pandemic for South African youth, and evaluate whether this effect was modified by receiving social grants.

**Design:** A cross-sectional, online survey was conducted between December 2021 and May 2022. Primary outcome was increased difficulty accessing food since the COVID-19 pandemic. Income change was categorized as “Decreased a lot”, “Decreased slightly” and “Unchanged or increased”. Multivariable logistic regressions were used, with an interaction term between social grant receipt and income change.

**Setting:** eThekwini district, South Africa

**Participants:** Youth aged 16-24 years

**Results:** Among 1,620 participants, median age was 22 years (IQR 19-24); 861 (53%) were women; 476 (29%) reported increased difficulty accessing food; 297 (18%) reported that income decreased a lot, of whom 149 (50%) did not receive social grants. Experiencing a large income decrease was highly associated with increased difficulty accessing food during the COVID-19 pandemic (adjusted odds ratio [aOR] 3.63, 95% Confidence Interval [CI] 2.70-4.88). The aORs for the effect of a large income decrease on difficulty accessing food, compared to no income change, were 1.49 (95%CI 0.98-2.28) among participants receiving social grants, and 6.63 (95%CI 4.39-9.99) among participants not receiving social grants.

**Conclusions:** While social grant support made a great difference in lowering the effect of income decrease on difficulty accessing food, it was insufficient to fully protect youth from those difficulties. In post-pandemic recovery efforts, there is a critical need to support youth through economic empowerment programming and food schemes.
**ABSTRACT**

**Objective:** To estimate the effect of income change on difficulty accessing food since the COVID-19 pandemic for South African youth, and evaluate whether this effect was modified by receiving social grants.

**Design:** A cross-sectional, online survey was conducted between December 2021 and May 2022. Primary outcome was increased difficulty accessing food since the COVID-19 pandemic. Income change was categorized as “Decreased a lot”, “Decreased slightly” and “Unchanged or increased”. Multivariable logistic regressions were used, with an interaction term between social grant receipt and income change.

**Setting:** eThekwini district, South Africa

**Participants:** Youth aged 16-24 years

**Results:** Among 1,620 participants, median age was 22 years (IQR 19-24); 861 (53%) were women; 476 (29%) reported increased difficulty accessing food; 297 (18%) reported that income decreased a lot, of whom 149 (50%) did not receive social grants. Experiencing a large income decrease was highly associated with increased difficulty accessing food during the COVID-19 pandemic (adjusted odds ratio [aOR] 3.63, 95% Confidence Interval [CI] 2.70-4.88). The aORs for the effect of a large income decrease on difficulty accessing food, compared to no income change, were 1.49 (95%CI 0.98-2.28) among participants receiving social grants, and 6.63 (95%CI 4.39-9.99) among participants not receiving social grants.

**Conclusions:** While social grant support made a great difference in lowering the effect of income decrease on difficulty accessing food, it was insufficient to fully protect youth from those difficulties. In post-pandemic recovery efforts, there is a critical need to support youth through economic empowerment programming and food schemes.
INTRODUCTION

The COVID-19 pandemic has had a negative, sustained impact on the global food system, disrupting food production, supply, and access (1). Prior to, and since, the COVID-19 pandemic, geopolitical instability and climate change continue to disrupt access to adequate, sufficient and nutritious food (2). It is estimated that the COVID-19 pandemic led to an additional 137 million people suffering from food insecurity in 2020 (3). People experienced food shortages, resulting in uncertainty about their ability to obtain food. They were forced to compromise on the quality and/or quantity of the food they consume, and many went days without eating. The increase in food insecurity since the COVID-19 pandemic is worrying as food access and healthy nutritional intake play a major role on general health and well-being, both in the short and long-term (4), and are key factors of adolescent physical, cognitive and social development (5). Extensive literature has documented the role of food insecurity on affecting mental health outcomes (6) and on increasing gender-based violence (7).

Individuals who face the greatest difficulties accessing food are more frequently those with lower educational level and poor socioeconomic backgrounds, whatever the country income group (8). In South Africa, the majority of the population lives under the poverty line, with a 32.7% unemployment rate in the country in 2022 (9). South Africa has also one of the highest HIV prevalence rates in the world, and people living with HIV commonly experience high rates of food insecurity and malnutrition (10), that reflect their socio-economic vulnerability. In this context, with multiple existing threats that could lead to food insecurity, the COVID-19 pandemic and the public health mitigation measures implemented to contain the pandemic constitutes an additional burden to access to food.

While Sub-Saharan Africa may have reported lower COVID-19 mortality rates than higher income settings (11, 12), this region experienced tremendous indirect social, economic and health consequences of the COVID-19 public health mitigation measures, with major access disruptions to healthcare, education and workplaces (12-14). The pandemic also contributed to increases in gender-base violence (15) as well as mental health issues, globally and in sub-Saharan Africa (16). Among sub-Saharan Africa countries, South Africa has reported the highest number of COVID-19 cases (an estimated 4 million by July 2023) and deaths (an estimated
## INTRODUCTION

The COVID-19 pandemic has had a negative, sustained impact on the global food system, disrupting food production, supply, and access (1). Prior to, and since, the COVID-19 pandemic, geopolitical instability and climate change continue to disrupt access to adequate, sufficient and nutritious food (2). It is estimated that the COVID-19 pandemic led to an additional 137 million people suffering from food insecurity in 2020 (3). People experienced food shortages, resulting in uncertainty about their ability to obtain food. They were forced to compromise on the quality and/or quantity of the food they consume, and many went days without eating. The increase in food insecurity since the COVID-19 pandemic is worrying as food access and healthy nutritional intake play a major role on general health and well-being, both in the short and long-term (4), and are key factors of adolescent physical, cognitive and social development (5). Extensive literature has documented the role of food insecurity on affecting mental health outcomes (6) and on increasing gender-based violence (7).

Individuals who face the greatest difficulties accessing food are more frequently those with lower educational level and poor socioeconomic backgrounds, whatever the country income group (8). In South Africa, the majority of the population lives under the poverty line, with a 32.7% unemployment rate in the country in 2022 (9). South Africa has also one of the highest HIV prevalence rates in the world, and people living with HIV commonly experience high rates of food insecurity and malnutrition (10), that reflect their socio-economic vulnerability. In this context, with multiple existing threats that could lead to food insecurity, the COVID-19 pandemic and the public health mitigation measures implemented to contain the pandemic constitutes an additional burden to access to food.

While Sub-Saharan Africa may have reported lower COVID-19 mortality rates than higher income settings (11, 12), this region experienced tremendous indirect social, economic and health consequences of the COVID-19 public health mitigation measures, with major access disruptions to healthcare, education and workplaces (12-14). The pandemic also contributed to increases in gender-based violence (15) as well as mental health issues, globally and in sub-Saharan Africa (16). Among sub-Saharan Africa countries, South Africa has reported the highest number of COVID-19 cases (an estimated 4 million by July 2023) and deaths (an estimated
102,000 by July 2023) (17). A national lockdown was declared in South Africa between March 27th and May 1st 2020, which was considered the most restrictive lockdown in sub-Saharan Africa, and also one of the most restrictive worldwide (18). This lockdown included a stay-at-home order, gathering restrictions, alcohol and tobacco sale bans, as well as travel restrictions, unless for essential reasons, with movements between provinces and districts prohibited. South Africans were confined to their homes and all forms of public transport were prohibited. Exceptions were possible only when seeking essential services, emergency or chronic medical attention, for funeral services, or for collecting a social grant or pension, with capacity limits. All non-essential businesses were ordered to close and retail stores selling essential goods were prohibited from selling any other goods. The National School Nutrition Programme (NSNP), which provides 9 million meals per day for learners was interrupted (19, 20). These circumstances have been most impactful on the financial security and food access of South Africa's poorest communities, leading to riots, protests and confrontations with police (18, 21). After this first lockdown period, South Africa started to ease the restrictions as it moved through five lockdown levels (22), but, for many, the disruptions on education, employment, access to care and food remain (23). Few studies have described the difficulties to accessing food during and after the restrictions or the role of the related mitigation measures that led to work disruptions and economic loss.

Adolescents and young adults have been among those most affected by social and economic disruptions related to the COVID-19 pandemic, with school closures and lack of job opportunities during a crucial time of their career development. However, little is known about the impacts of the COVID-19 pandemic on this population in South Africa (24, 25). Despite food access and healthy nutritional intake being crucial components of their physical, cognitive and social development (26), specific experiences of youth related to food access during the COVID-19 pandemic are lacking. Food insecurity and hunger were two of the main concerns reported in a qualitative survey among South African youth in April 2020 regarding their COVID-19 experiences (20), showing that COVID-19 was already perceived as a major threat for food access.
102,000 by July 2023) (17). A national lockdown was declared in South Africa between March 27th and May 1st 2020, which was considered the most restrictive lockdown in sub-Saharan Africa, and also one of the most restrictive worldwide (18). This lockdown included a stay-at-home order, gathering restrictions, alcohol and tobacco sale bans, as well as travel restrictions, unless for essential reasons, with movements between provinces and districts prohibited. South Africans were confined to their homes and all forms of public transport were prohibited. Exceptions were possible only when seeking essential services, emergency or chronic medical attention, for funeral services, or for collecting a social grant or pension, with capacity limits. All non-essential businesses were ordered to close and retail stores selling essential goods were prohibited from selling any other goods. The National School Nutrition Programme (NSNP), which provides 9 million meals per day for learners was interrupted (19, 20). These circumstances have been most impactful on the financial security and food access of South Africa's poorest communities, leading to riots, protests and confrontations with police (18, 21). After this first lockdown period, South Africa started to ease the restrictions as it moved through five lockdown levels (22), but, for many, the disruptions on education, employment, access to care and food remain (23). Few studies have described the difficulties to accessing food during and after the restrictions or the role of the related mitigation measures that led to work disruptions and economic loss.

Adolescents and young adults have been among those most affected by social and economic disruptions related to the COVID-19 pandemic, with school closures and lack of job opportunities during a crucial time of their career development. However, little is known about the impacts of the COVID-19 pandemic on this population in South Africa (24, 25). Despite food access and healthy nutritional intake being crucial components of their physical, cognitive and social development (26), specific experiences of youth related to food access during the COVID-19 pandemic are lacking. Food insecurity and hunger were two of the main concerns reported in a qualitative survey among South African youth in April 2020 regarding their COVID-19 experiences (20), showing that COVID-19 was already perceived as a major threat for food access.
Difficulties in accessing food during the pandemic in South Africa have been reported by the National Income Dynamics Study-Coronavirus Rapid Mobile Survey (NIDS-CRAM), a nationally-representative panel survey conducted between April 2020 and May 2021 (27). In April 2020, 47% of households reported “having run out of money to buy food”, which was twice as high as in 2017, with one-third (35%) continuing to experience this problem in March 2021. In May 2021, household hunger (17%) and child hunger (14%) remained high, with significant, sustained increases among households who experienced job loss due to the COVID-19 lockdown (28). Thus, over a year after the beginning of the COVID-19 pandemic and the implementation of control measures, many South African households remained economically vulnerable and severely food insecure (29).

To tackle the socio-economic effects of the COVID-19 pandemic through mitigation measures, the South African government extended its social grants program to include a range of revised and new social support grants. A special COVID-19 Social Relief of Distress (SRD) grant was introduced in April 2020, giving the equivalent of R350 (about USD21 in 2020) per month for working age adults >18 years old who were unemployed and not receiving any other grant, until April 2021 (30). There were also top-ups for households receiving the Child Support Grant (R480 per month + top-up of R240), received by over 7 million caregivers, and top-ups of R250 for the Old Age Pension for people over 60 years of age (R1990 per month), the Disability Grant (maximum R2080 per month) and the Foster Care Grant (R1070 per month). Several studies have analysed the role of these social grants in reducing household and child hunger, with varying results (28, 31). However, few studies have focused on the social and economic impacts of the COVID-19 pandemic among adolescents and young adults (24, 25).

We described the increased difficulty accessing food since the COVID-19 pandemic for South African youth and investigated how changes in income since the COVID-19 pandemic affected access to food and if receiving social grant moderates the relationship between income change and increased difficulty accessing food. We hypothesized that the COVID-19 pandemic and associated public health mitigation measures led to further difficulties in accessing food among youth, especially through economic disruptions. A secondary hypothesis was that financial
Difficulties in accessing food during the pandemic in South Africa have been reported by the National Income Dynamics Study-Coronavirus Rapid Mobile Survey (NIDS-CRAM), a nationally-representative panel survey conducted between April 2020 and May 2021 (27). In April 2020, 47% of households reported “having run out of money to buy food”, which was twice as high as in 2017, with one-third (35%) continuing to experience this problem in March 2021. In May 2021, household hunger (17%) and child hunger (14%) remained high, with significant, sustained increases among households who experienced job loss due to the COVID-19 lockdown (28). Thus, over a year after the beginning of the COVID-19 pandemic and the implementation of control measures, many South African households remained economically vulnerable and severely food insecure (29).

To tackle the socio-economic effects of the COVID-19 pandemic through mitigation measures, the South African government extended its social grants program to include a range of revised and new social support grants. A special COVID-19 Social Relief of Distress (SRD) grant was introduced in April 2020, giving the equivalent of R350 (about USD21 in 2020) per month for working age adults >18 years old who were unemployed and not receiving any other grant, until April 2021 (30). There were also top-ups for households receiving the Child Support Grant (R480 per month + top-up of R240), received by over 7 million caregivers, and top-ups of R250 for the Old Age Pension for people over 60 years of age (R1990 per month), the Disability Grant (maximum R2080 per month) and the Foster Care Grant (R1070 per month). Several studies have analysed the role of these social grants in reducing household and child hunger, with varying results (28, 31). However, few studies have focused on the social and economic impacts of the COVID-19 pandemic among adolescents and young adults (24, 25).

We described the increased difficulty accessing food since the COVID-19 pandemic for South African youth and investigated how changes in income since the COVID-19 pandemic affected access to food and if receiving social grant moderates the relationship between income change and increased difficulty accessing food. We hypothesized that the COVID-19 pandemic and associated public health mitigation measures led to further difficulties in accessing food among youth, especially through economic disruptions. A secondary hypothesis was that financial
support from the government may have contributed to moderate the detrimental effects of these
economic disruptions on the difficulty accessing food.

METHODS

Study design and population

AYAZAZI RIGHTS (Rapid Investigation of Gendered Health outcomes in the Time of SARS-CoV-2) was a cross-sectional survey examining South African youth experiences during the COVID-19 public health response. This online survey took place in the eThekwini District, in KwaZulu-Natal, a province that have been especially affected by the COVID-19 pandemic, with the higher proportion of youth in the country, and the highest average household size (4.4 people in 2022) (32). Among the 1 125 765 households censused in 2016, 3001 were headed by youth under 18 years old (33). The survey was conducted from the 21st of December 2021 to the 31st of May 2022, a time period when South Africa experienced a fourth COVID-19 wave, due to the newly discovered Omicron variant, with a level 1 alert (including mandatory mask indoor and capacity limits for gatherings). The National State of Disaster was lifted on April 15th, 2022. Inclusion criteria included: youth aged 16-24 years; residing in the eThekwini district, Durban, South Africa; ability to read in English and/or isiZulu and have access to the internet via a mobile phone, tablet, or computer. For this analysis, we restricted the analytic sample to participants with non-missing data regarding access to food, income change and covariates.

Recruitment

A multi-pronged recruitment strategy was used to enrol participants. First, we approached
participants from previous youth studies led by the University of the Witwatersrand MatCH
Research Unit (Wits MRU, based in Durban), who agreed to be recontacted for other research
projects via text messages. Secondly, we engaged with the Wits MRU Adolescent Community
Advisory Board (ACAB), the adult Wits MRU's Community Advisory Board (CAB), and other
community-based and youth-led organisations serving youth across eThekwini District to share
information about the study via e-mails and through their social networks. Thirdly, we
distributed recruitment flyers in areas highly frequented by youth such as commercial retail
settings, transit areas, and health care facilities. The survey link was also displayed on the Wits
MRU website as a pop-up message and was posted on social media platforms of youth-led
organisations, including a not-for-profit company located in Durban that specializes in media
support from the government may have contributed to moderate the detrimental effects of these
economic disruptions on the difficulty accessing food.

METHODS

**Study design and population**

AYAZAZI RIGHTS (Rapid Investigation of Gendered Health outcomes in the Time of SARS-CoV-2) was a cross-sectional survey examining South African youth experiences during the COVID-19 public health response. This online survey took place in the eThekwini District, in KwaZulu-Natal, a province that have been especially affected by the COVID-19 pandemic, with the higher proportion of youth in the country, and the highest average household size (4.4 people in 2022) (32). Among the 1 125 765 households censused in 2016, 3001 were headed by youth under 18 years old (33). The survey was conducted from the 21st of December 2021 to the 31st of May 2022, a time period when South Africa experienced a fourth COVID-19 wave, due to the newly discovered Omicron variant, with a level 1 alert (including mandatory mask indoor and capacity limits for gatherings). The National State of Disaster was lifted on April 15th, 2022. Inclusion criteria included: youth aged 16-24 years; residing in the eThekwini district, Durban, South Africa; ability to read in English and/or isiZulu and have access to the internet via a mobile phone, tablet, or computer. For this analysis, we restricted the analytic sample to participants with non-missing data regarding access to food, income change and covariates.

Recruitment

A multi-pronged recruitment strategy was used to enrol participants. First, we approached
participants from previous youth studies led by the University of the Witwatersrand MatCH
Research Unit (Wits MRU, based in Durban), who agreed to be recontacted for other research
projects via text messages. Secondly, we engaged with the Wits MRU Adolescent Community
Advisory Board (ACAB), the adult Wits MRU's Community Advisory Board (CAB), and other
community-based and youth-led organisations serving youth across eThekwini District to share
information about the study via e-mails and through their social networks. Thirdly, we
distributed recruitment flyers in areas highly frequented by youth such as commercial retail
settings, transit areas, and health care facilities. The survey link was also displayed on the Wits
MRU website as a pop-up message and was posted on social media platforms of youth-led
organisations, including a not-for-profit company located in Durban that specializes in media
communication access for vulnerable communities in South Africa. Participants also had the
opportunity to share the link and the QR code of the survey with their eligible peers and family
members. To further promote the survey, a prize draw to win cash prizes of R100 (CAD$ 8.50)
was offered for participants providing their mobile phone number at the end of the survey (and
unlinked with survey responses). Overall, a total of 269 cash prizes were given out,
corresponding to a 10% chance of winning over the enrolment period. Participants could enter
and complete the mobile health survey via a free web link provided via the #datafree Moya
Messenger App.

Data collection and analytic sample

The questionnaire was auto-administered and structured with close-ended questions across four
survey sections: demographics; COVID-19 experiences (including COVID-19 vaccine uptake
and perceptions, changes in income, work disruptions, access to food and social grants); sexual
and reproductive health, care, and behaviours; and mental health, care, and substance use. The
questionnaire was created in English and translated in isiZulu, with back translation into English
to ensure accuracy. The questionnaire was programmed into REDCap (Research Electronic Data
Capture) (34) and piloted with youth and topical experts with revisions integrated prior to the
study launch. Overall, the median time of completion was 15 minutes (Interquartile Range
[IQR]=8-26). Participants who completed the whole questionnaire in less than 4.5 minutes were
subsequently excluded from the analyses as this was considered as a too short time to fully read,
understand, and complete it. Overall, 2694 youth accessed the online survey. Among them, 303
(11%) did not consent to participate and 142 (6%) did not complete the whole survey. Among
the 2249 participants that completed the whole survey, we excluded 154 (7%) who completed it
in less than 4.5 minutes. Subsequently, we excluded 149 (7%) participants with missing data on
food access difficulty, then 204 (10%) with missing data on income change, 58 (3%) with
missing data on receiving social grant, and finally 64 (4%) participants with missing data on
covariates (including gender, ethnicity, household structure, HIV status), leading to a final study
population of 1620 (Figure 1).
communication access for vulnerable communities in South Africa. Participants also had the
opportunity to share the link and the QR code of the survey with their eligible peers and family
members. To further promote the survey, a prize draw to win cash prizes of R100 (CAD$ 8.50)
was offered for participants providing their mobile phone number at the end of the survey (and
unlinked with survey responses). Overall, a total of 269 cash prizes were given out,
corresponding to a 10% chance of winning over the enrolment period. Participants could enter
and complete the mobile health survey via a free web link provided via the #datafree Moya
Messenger App.

Data collection and analytic sample

The questionnaire was auto-administered and structured with close-ended questions across four
survey sections: demographics; COVID-19 experiences (including COVID-19 vaccine uptake
and perceptions, changes in income, work disruptions, access to food and social grants); sexual
and reproductive health, care, and behaviours; and mental health, care, and substance use. The
questionnaire was created in English and translated in isiZulu, with back translation into English
to ensure accuracy. The questionnaire was programmed into REDCap (Research Electronic Data
Capture) (34) and piloted with youth and topical experts with revisions integrated prior to the
study launch. Overall, the median time of completion was 15 minutes (Interquartile Range
[IQR]=8-26). Participants who completed the whole questionnaire in less than 4.5 minutes were
subsequently excluded from the analyses as this was considered as a too short time to fully read,
understand, and complete it. Overall, 2694 youth accessed the online survey. Among them, 303
(11%) did not consent to participate and 142 (6%) did not complete the whole survey. Among
the 2249 participants that completed the whole survey, we excluded 154 (7%) who completed it
in less than 4.5 minutes. Subsequently, we excluded 149 (7%) participants with missing data on
food access difficulty, then 204 (10%) with missing data on income change, 58 (3%) with
missing data on receiving social grant, and finally 64 (4%) participants with missing data on
covariates (including gender, ethnicity, household structure, HIV status), leading to a final study
population of 1620 (Figure 1).
Measures

The primary outcome was difficulty accessing food during the COVID-19 pandemic, measured using the following question: “Since the COVID-19 pandemic, did your access to sufficient, quality food change?” with four response options: “It was more difficult to access food”, “It has not changed”, “It was easier to access food”, and “Prefer not to answer”. Responses were dichotomized to enable comparison between participants who reported increased difficulty accessing food vs. participants who did not, as less than 1% of the whole sample reporting that their access to food was easier. Those who responded “Prefer not to answer” were not included. Additionally, we descriptively explored other aspects of difficulty accessing food, by collecting further information about work disruptions among those employed and about suggested factors limiting food access using multiple-choice questions.

The primary exposure of interest hypothesized to affect food access was COVID-19-related economic disruptions. Economic disruptions were assessed by measuring income change since the COVID-19 pandemic, categorized as “Decreased a lot”, “Decreased slightly”, “Unchanged”, “Increased slightly” and “Increased a lot”. Due to small cell count for the last two categories (<5%), there were combined with the “Unchanged” group, into one reference category, for further analyses.

The interaction term of interest was receiving any social grant from the government since the COVID-19 pandemic, whether personally or for their household. Additionally, information about the type of social grant received was asked, i.e., whether the grant was for child support, old age pension, disability grant, foster child grant, or another purpose. The “other” category was subsequently recoded as all participants specified that “other grant” referred to the COVID-19 SRD grant. Changes in social grant support since the COVID-19 pandemic, (i.e. increased, stayed the same, decreased, or do not know), were also reported.

Potential confounders were identified based on previously published literature (35) as socio-
demographic factors known to be associated with food insecurity and difficulty to access food.
Gender was described in three categories: boy/man, girl/woman, and gender non-conforming (i.e
self-identifying as non-binary or not identifying with any gender). Ethnicity was categorized
Measures

The primary outcome was difficulty accessing food during the COVID-19 pandemic, measured using the following question: “Since the COVID-19 pandemic, did your access to sufficient, quality food change?” with four response options: “It was more difficult to access food”, “It has not changed”, “It was easier to access food”, and “Prefer not to answer”. Responses were dichotomized to enable comparison between participants who reported increased difficulty accessing food vs. participants who did not, as less than 1% of the whole sample reporting that their access to food was easier. Those who responded “Prefer not to answer” were not included. Additionally, we descriptively explored other aspects of difficulty accessing food, by collecting further information about work disruptions among those employed and about suggested factors limiting food access using multiple-choice questions.

The primary exposure of interest hypothesized to affect food access was COVID-19-related economic disruptions. Economic disruptions were assessed by measuring income change since the COVID-19 pandemic, categorized as “Decreased a lot”, “Decreased slightly”, “Unchanged”, “Increased slightly” and “Increased a lot”. Due to small cell count for the last two categories (<5%), there were combined with the “Unchanged” group, into one reference category, for further analyses.

The interaction term of interest was receiving any social grant from the government since the COVID-19 pandemic, whether personally or for their household. Additionally, information about the type of social grant received was asked, i.e., whether the grant was for child support, old age pension, disability grant, foster child grant, or another purpose. The “other” category was subsequently recoded as all participants specified that “other grant” referred to the COVID-19 SRD grant. Changes in social grant support since the COVID-19 pandemic, (i.e. increased, stayed the same, decreased, or do not know), were also reported.

Potential confounders were identified based on previously published literature (35) as socio-demographic factors known to be associated with food insecurity and difficulty to access food. Gender was described in three categories: boy/man, girl/woman, and gender non-conforming (i.e self-identifying as non-binary or not identifying with any gender). Ethnicity was categorized
using the official population groups from South Africa Census (33): Black African, Coloured, White, Indian, and Asian (In the South African Context, Coloured refers to “any person of ‘mixed blood’ as well as descendants from Black-White, Black-Asian, White-Asian, and Black-Colored unions”(36). Classifications of Black African and Colored are not racial but rather social constructs of South African historical apartheid origin (37). In addition, we accounted for income level (under or above R800 [about USD48 in 2020] per month), being enrolled at school and/or employed (if no to both, participants were defined as Neither in Education, Employment or Training [NEET](38)), the structure of the household including the number of children (age 0-17 years), adults (18-59) and seniors (from age 60) living in the household (reported as numerical variables by participants and described as binary variables for each category), having children (none, one, two or more), and self-reported HIV status (positive, negative, unsure of HIV-status or prefer not to say).

## Statistical Analyses

Characteristics of the study population were described overall and stratified by the outcome variable (increased difficulty accessing food). Characteristics were also compared between the population included and the population excluded due to missing data. Additionally, social grant support (received or not, type and change) was described overall and stratified by income change. These descriptions were further stratified by gender: men, women, and gender non-conforming (Supplementary tables). Multivariable logistic regression models estimated the association between income decrease (whether a lot or slightly) and increased difficulty accessing food during the COVID-19 pandemic, adjusted by the covariates listed above. To assess potential modification of the effect of an income decrease on the difficulty accessing food by receipt of social grant support, an interaction term was included for income change by social grant receipt. Subgroup analyses by gender were also conducted. Data analyses were performed using SAS® OnDemand for Academics, © 2022 SAS Institute Inc.
using the official population groups from South Africa Census (33): Black African, Coloured, White, Indian, and Asian (In the South African Context, Coloured refers to “any person of ‘mixed blood’ as well as descendants from Black-White, Black-Asian, White-Asian, and Black-Colored unions”(36). Classifications of Black African and Colored are not racial but rather social constructs of South African historical apartheid origin (37). In addition, we accounted for income level (under or above R800 [about USD48 in 2020] per month), being enrolled at school and/or employed (if no to both, participants were defined as Neither in Education, Employment or Training [NEET](38)), the structure of the household including the number of children (age 0-17 years), adults (18-59) and seniors (from age 60) living in the household (reported as numerical variables by participants and described as binary variables for each category), having children (none, one, two or more), and self-reported HIV status (positive, negative, unsure of HIV-status or prefer not to say).

## Statistical Analyses

Characteristics of the study population were described overall and stratified by the outcome variable (increased difficulty accessing food). Characteristics were also compared between the population included and the population excluded due to missing data. Additionally, social grant support (received or not, type and change) was described overall and stratified by income change. These descriptions were further stratified by gender: men, women, and gender non-conforming (Supplementary tables). Multivariable logistic regression models estimated the association between income decrease (whether a lot or slightly) and increased difficulty accessing food during the COVID-19 pandemic, adjusted by the covariates listed above. To assess potential modification of the effect of an income decrease on the difficulty accessing food by receipt of social grant support, an interaction term was included for income change by social grant receipt. Subgroup analyses by gender were also conducted. Data analyses were performed using SAS® OnDemand for Academics, © 2022 SAS Institute Inc.
# RESULTS

## Participant characteristics

Among the 1620 participants, median age was 22 years (IQR 19-24); 53% were women, 5% gender non-conforming, and 76% were Black-African. Median size of the household was 7 people (IQR 5-9), 19% of participants were living with two or more seniors in their household, 41% were living with three or more children. Only 1% of participants were living by themselves. Overall, 476 (29%) participants reported that it was more difficult to access food since the COVID-19 pandemic. Since the COVID-19 pandemic, 18% reported their income had decreased a lot and 14% reported their income had decreased slightly; 68% had no income change. Overall, 35% reported having received, personally and/or by someone else in their household, social grants from the government. Among participants who reported increased difficulty accessing food, 34% reported that their income decreased a lot, and 53% of them were receiving social grant support (Table 1a). When comparing the included population with the excluded population due to missing data (n=475), no differences were found in the distribution for the main exposure, interaction terms and covariates. However, a higher rate of participants in the excluded population reported that it was more difficult to access food since the COVID-19 pandemic (38%).

Receiving social grant support differed by income change: among participants reporting that their income decreased a lot, 50% received social grant support, while among participants reporting that their income decreased slightly, they were 39% to receive social grant support. Among participants who received social grant support, 76% of them were receiving child support grant, and 48% were receiving old age pension. Only 3% of participants reported having received the COVID-19 SRD grant. Furthermore, among participants who received social grant support, 49% of them saw their support increased since the COVID-19 pandemic, while 31% did not know if this support has changed (Table 1b).
# RESULTS

## Participant characteristics

Among the 1620 participants, median age was 22 years (IQR 19-24); 53% were women, 5% gender non-conforming, and 76% were Black-African. Median size of the household was 7 people (IQR 5-9), 19% of participants were living with two or more seniors in their household, 41% were living with three or more children. Only 1% of participants were living by themselves. Overall, 476 (29%) participants reported that it was more difficult to access food since the COVID-19 pandemic. Since the COVID-19 pandemic, 18% reported their income had decreased a lot and 14% reported their income had decreased slightly; 68% had no income change. Overall, 35% reported having received, personally and/or by someone else in their household, social grants from the government. Among participants who reported increased difficulty accessing food, 34% reported that their income decreased a lot, and 53% of them were receiving social grant support (Table 1a). When comparing the included population with the excluded population due to missing data (n=475), no differences were found in the distribution for the main exposure, interaction terms and covariates. However, a higher rate of participants in the excluded population reported that it was more difficult to access food since the COVID-19 pandemic (38%).

Receiving social grant support differed by income change: among participants reporting that their income decreased a lot, 50% received social grant support, while among participants reporting that their income decreased slightly, they were 39% to receive social grant support. Among participants who received social grant support, 76% of them were receiving child support grant, and 48% were receiving old age pension. Only 3% of participants reported having received the COVID-19 SRD grant. Furthermore, among participants who received social grant support, 49% of them saw their support increased since the COVID-19 pandemic, while 31% did not know if this support has changed (Table 1b).
## Effects of income change on difficulty accessing food

The crude estimated odds ratio (OR) for the effect of a large income decrease ("Decreased a lot"), compared with no change in income, on difficulty accessing food was 3.83 (95% confidence interval [CI] 2.93-5.00), and the covariate-adjusted odds ratio (aOR) was 3.63 (95%CI 2.70-4.88). The strength of this association was slightly higher for men (aOR 5.05, 95%CI 3.10-8.22) than women (aOR 3.29, 95%CI 2.19-4.93). The crude OR for a slight income decrease ("Decreased slightly"), compared with no change in income, on difficulty accessing food was 1.18 (95%CI 0.85-1.64) overall, and the aOR was 1.37 (95%CI 0.95-1.96). Similarly, the strength of this association was higher for men (aOR 2.18, 95%CI 1.26-3.76) than women (aOR 1.14, 95%CI 0.67-1.92) (Table 2).

When looking at the effect of income change on difficulty accessing food according to receiving social grants, the aOR for the effect of a large income decrease, compared with no change in income, on difficulty accessing food was 1.49 (95%CI 0.98-2.28) among participants receiving social grants, and 6.63 (95%CI 4.39-9.99) among participants not receiving social grants. The aOR for the effect of a slight income decrease was 0.57 (95%CI 0.33-1.01) among participants receiving social grants, and 2.31 (95%CI 1.45-3.67) among participants not receiving social grant (Figure 2). Similar modification effects of receiving social grants were found by gender (Appendix 2).

## Limiting factors to access food and work disruptions

When asking for factors that may have limited their food access during the COVID-19 pandemic, 44% of participants declared it was because of insufficient income, 34% because transport to go get food was limited, 30% because food markets, stores or school feeding schemes were either closed or running out of food, and 19% because they could not leave their household due to personal or family responsibilities. Participants who faced any of these limiting factors were more likely to report increased difficulties accessing food during the COVID-19 pandemic (between 42% and 52%) (Figure 3). Among those who were employed (n=409), multiple experiences of work disruptions and employee challenges since the onset of the COVID-19 pandemic were reported, such as workplace closures (59%). Additionally, 53% reported not feeling safe to go to their workplace, 36% were ill or under quarantine, 32% could
## Effects of income change on difficulty accessing food

The crude estimated odds ratio (OR) for the effect of a large income decrease ("Decreased a lot"), compared with no change in income, on difficulty accessing food was 3.83 (95% confidence interval [CI] 2.93-5.00), and the covariate-adjusted odds ratio (aOR) was 3.63 (95%CI 2.70-4.88). The strength of this association was slightly higher for men (aOR 5.05, 95%CI 3.10-8.22) than women (aOR 3.29, 95%CI 2.19-4.93). The crude OR for a slight income decrease ("Decreased slightly"), compared with no change in income, on difficulty accessing food was 1.18 (95%CI 0.85-1.64) overall, and the aOR was 1.37 (95%CI 0.95-1.96). Similarly, the strength of this association was higher for men (aOR 2.18, 95%CI 1.26-3.76) than women (aOR 1.14, 95%CI 0.67-1.92) (Table 2).

When looking at the effect of income change on difficulty accessing food according to receiving social grants, the aOR for the effect of a large income decrease, compared with no change in income, on difficulty accessing food was 1.49 (95%CI 0.98-2.28) among participants receiving social grants, and 6.63 (95%CI 4.39-9.99) among participants not receiving social grants. The aOR for the effect of a slight income decrease was 0.57 (95%CI 0.33-1.01) among participants receiving social grants, and 2.31 (95%CI 1.45-3.67) among participants not receiving social grant (Figure 2). Similar modification effects of receiving social grants were found by gender (Appendix 2).

## Limiting factors to access food and work disruptions

When asking for factors that may have limited their food access during the COVID-19 pandemic, 44% of participants declared it was because of insufficient income, 34% because transport to go get food was limited, 30% because food markets, stores or school feeding schemes were either closed or running out of food, and 19% because they could not leave their household due to personal or family responsibilities. Participants who faced any of these limiting factors were more likely to report increased difficulties accessing food during the COVID-19 pandemic (between 42% and 52%) (Figure 3). Among those who were employed (n=409), multiple experiences of work disruptions and employee challenges since the onset of the COVID-19 pandemic were reported, such as workplace closures (59%). Additionally, 53% reported not feeling safe to go to their workplace, 36% were ill or under quarantine, 32% could
not get transport to work, 16% needed to care for children or relatives and 10% were fired. All of
these experiences were related to increased difficulty to access food, especially being fired (63%)
and not getting transport to work (64%) **(Figure 4)**.

DISCUSSION

In this cross-sectional study, we found that one-third of South-African youth surveyed, of all genders, experienced increased difficulty to access sufficient, quality food since the onset of the COVID-19 pandemic in March 2020. These results were partially explained by the indirect effects of the COVID-19 pandemic on the economy, with those youth experiencing income loss having higher odds of experiencing greater difficulty accessing food during the COVID-19 pandemic. This was especially the case for youth who did not receive any social grants, who had over six times higher odds of having difficulty accessing food when experiencing a large income decrease. While receiving social grants partly mitigated the association between income loss and increased difficulty accessing food, there were still 49% higher odds of difficulty in accessing food due to a large income decrease.

Previous studies have described the limited effects of social grant support in mitigating the
economic impacts of the COVID-19 pandemic on outcomes such as mental health in Canada and
France (39) or severe food insecurity in Nigeria (40). In South Africa, within the NIDS-CRAM
study, having received a social grant (either the Child support grant, the SRD grant or the Old
Age pension grant) (41) was associated with a decrease in household and child hunger by 17-
24% (29, 41). A substantial decline in the prevalence of hunger was recorded between May and
August 2020, a time when a greater relaxation of lockdown restrictions was observed, but also a
period when the government social grants programme increased as part of the pandemic response
(42). Studies point out that this government social grants programme was inadequate, with top-
ups and special grants implemented during COVID-19 lockdowns being insufficient to reduce
household and especially child hunger. In particular it was reported that the social grant
programme did not adequately target women, partly because women who already received child
grants could not apply for the SRD grant (30). In our survey, only one-third of participants
reported receiving social grants, and only 50% of those who experienced large income loss
received social grant support. Most of the social grant support came from child support or old
not get transport to work, 16% needed to care for children or relatives and 10% were fired. All of
these experiences were related to increased difficulty to access food, especially being fired (63%)
and not getting transport to work (64%) **(Figure 4)**.

DISCUSSION

In this cross-sectional study, we found that one-third of South-African youth surveyed, of all genders, experienced increased difficulty to access sufficient, quality food since the onset of the COVID-19 pandemic in March 2020. These results were partially explained by the indirect effects of the COVID-19 pandemic on the economy, with those youth experiencing income loss having higher odds of experiencing greater difficulty accessing food during the COVID-19 pandemic. This was especially the case for youth who did not receive any social grants, who had over six times higher odds of having difficulty accessing food when experiencing a large income decrease. While receiving social grants partly mitigated the association between income loss and increased difficulty accessing food, there were still 49% higher odds of difficulty in accessing food due to a large income decrease.

Previous studies have described the limited effects of social grant support in mitigating the
economic impacts of the COVID-19 pandemic on outcomes such as mental health in Canada and
France (39) or severe food insecurity in Nigeria (40). In South Africa, within the NIDS-CRAM
study, having received a social grant (either the Child support grant, the SRD grant or the Old
Age pension grant) (41) was associated with a decrease in household and child hunger by 17-
24% (29, 41). A substantial decline in the prevalence of hunger was recorded between May and
August 2020, a time when a greater relaxation of lockdown restrictions was observed, but also a
period when the government social grants programme increased as part of the pandemic response
(42). Studies point out that this government social grants programme was inadequate, with top-
ups and special grants implemented during COVID-19 lockdowns being insufficient to reduce
household and especially child hunger. In particular it was reported that the social grant
programme did not adequately target women, partly because women who already received child
grants could not apply for the SRD grant (30). In our survey, only one-third of participants
reported receiving social grants, and only 50% of those who experienced large income loss
received social grant support. Most of the social grant support came from child support or old
age pension grants. These youth were likely living in households that receive social grants, but
did not receive these grants themselves.

Very few participants declared receiving the COVID-19 SRD grant, which may be partly
explained by the lack of a specific response option for this grant. Rather, survey respondents
specified receipt of the SRD as an “Other” grant response. A report from the Department of
Social Development in South Africa, assessing the implementation and utilisation of the SRD
grant, found that this grant was mostly used to purchase food (30). However, this report also
highlights the difficulties to access this grant for people in need, as there were a lot of grant’s
criteria to fulfill, considered as exclusionary and disadvantageous. The application for this grant
was to be completed online, excluding people without access to online services and with a low
level of digital literacy. Others have described that the communication on how to access and
apply to this grant was considered insufficient and not enough targeted for people in need (30).
In this context, many youth who could have been eligible to this grant did not apply, due to lack
of means, limited internet access, and/or knowledge. Therefore, youth may not have received the
adequate financial support to mitigate the socioeconomic impacts of the pandemic, such as the
impact on food access. The lockdown measures limited youth from moving about and earning
additional sources of income for themselves and their families (e.g., informal markets, day
labour, etc) that could have helped mitigate the insufficient social grant support and food access
difficulties. Youth living in households with younger children had also to deal with the
interruption of the NSNP during the lockdown, with the additional challenge to feed those
children who did not get access to meals at school during this period (43).

Our study also provides a description of the multiple work disruptions encountered by South
African youth who were employed at the onset of the COVID-19 pandemic, such as workplace
closures, transport disturbances and not feeling safe to go to work because of COVID-19.
Among this minority of youth who were employed, the pandemic had devastating effects on their
ability to maintain their employment and sufficiently provide for themselves and their families,
with work disruptions having highly affected their ability to access food. As the baseline level of
unemployment was already excessively high among youth (58% among 15-24 years in 2019)
(44), the COVID-19 pandemic has emphasized and worsen the existing challenges faced by
South-African youth in getting non-precarious jobs (45). In our study, youth who experience
work disruptions were particularly affected by increased difficulty accessing food, which is in
age pension grants. These youth were likely living in households that receive social grants, but
did not receive these grants themselves.

Very few participants declared receiving the COVID-19 SRD grant, which may be partly
explained by the lack of a specific response option for this grant. Rather, survey respondents
specified receipt of the SRD as an “Other” grant response. A report from the Department of
Social Development in South Africa, assessing the implementation and utilisation of the SRD
grant, found that this grant was mostly used to purchase food (30). However, this report also
highlights the difficulties to access this grant for people in need, as there were a lot of grant’s
criteria to fulfill, considered as exclusionary and disadvantageous. The application for this grant
was to be completed online, excluding people without access to online services and with a low
level of digital literacy. Others have described that the communication on how to access and
apply to this grant was considered insufficient and not enough targeted for people in need (30).
In this context, many youth who could have been eligible to this grant did not apply, due to lack
of means, limited internet access, and/or knowledge. Therefore, youth may not have received the
adequate financial support to mitigate the socioeconomic impacts of the pandemic, such as the
impact on food access. The lockdown measures limited youth from moving about and earning
additional sources of income for themselves and their families (e.g., informal markets, day
labour, etc) that could have helped mitigate the insufficient social grant support and food access
difficulties. Youth living in households with younger children had also to deal with the
interruption of the NSNP during the lockdown, with the additional challenge to feed those
children who did not get access to meals at school during this period (43).

Our study also provides a description of the multiple work disruptions encountered by South
African youth who were employed at the onset of the COVID-19 pandemic, such as workplace
closures, transport disturbances and not feeling safe to go to work because of COVID-19.
Among this minority of youth who were employed, the pandemic had devastating effects on their
ability to maintain their employment and sufficiently provide for themselves and their families,
with work disruptions having highly affected their ability to access food. As the baseline level of
unemployment was already excessively high among youth (58% among 15-24 years in 2019)
(44), the COVID-19 pandemic has emphasized and worsened the existing challenges faced by
South-African youth in getting non-precarious jobs (45). In our study, youth who experience
work disruptions were particularly affected by increased difficulty accessing food, which is in
line with the challenges reported by a similar population of youth in a 2020 qualitative study (20).

Difficulties in accessing food during the COVID-19 pandemic increased equally for men, women, and gender non-conforming participants in our survey, but this does not exclude that the baseline level of food insecurity prior to the COVID-19 pandemic response in March 2020 may have been different by gender. The NIDS-CRAM survey described a higher level of food insecurity among South African women compared to men during the COVID-19 pandemic (42). This may be due to women having been especially affected by the socio-economic impacts of the COVID-19 pandemic (46), representing two of the three million of job losses recorded in April 2020 by NIDS-CRAM (47). Studies conducted prior the COVID-19 pandemic showed higher level of food insecurity for South African women compared to men, especially for women-headed households (48). This can be explained by the socio-economic challenges faced by women in South Africa, where gender norms, roles and behaviours remain strongly marked (49), and women are disproportionately represented in informal employment (50). Few studies have focused on food insecurity among South African youth while exploring gender differences. A previous survey conducted between 2014 and 2016 among youth living in Soweto and Durban found similar food insecurity rates for young men and woman (35).

This study has limitations. The cross-sectional study design limits the interpretation and the assessment of the causality between large income decrease and increased difficulty accessing food. Data collection occurred over an extended period of time during the COVID-19 pandemic (March 2020-May 2022), which went across several different alert levels. Survey distribution took place during a level 1 alert period, which may have led to participants omitting some of their experiences over those last two years, or only shared the most recent or difficult ones. This change in alert levels may have influenced participants' responses in reporting difficulty accessing food. Responses may have, therefore, been subject to recall bias. Because participants who were excluded from the analysis due to missing data reported a higher rate of increased difficulty accessing food than the study population (38% vs 29%), it is important to consider the possibility of selection bias and underestimation of the importance of food insecurity in this context. Furthermore, it is also possible that responses may have been subject to social desirability bias. However, such bias may have been minimized by the use of an anonymous
line with the challenges reported by a similar population of youth in a 2020 qualitative study (20).

Difficulties in accessing food during the COVID-19 pandemic increased equally for men, women, and gender non-conforming participants in our survey, but this does not exclude that the baseline level of food insecurity prior to the COVID-19 pandemic response in March 2020 may have been different by gender. The NIDS-CRAM survey described a higher level of food insecurity among South African women compared to men during the COVID-19 pandemic (42). This may be due to women having been especially affected by the socio-economic impacts of the COVID-19 pandemic (46), representing two of the three million of job losses recorded in April 2020 by NIDS-CRAM (47). Studies conducted prior the COVID-19 pandemic showed higher level of food insecurity for South African women compared to men, especially for women-headed households (48). This can be explained by the socio-economic challenges faced by women in South Africa, where gender norms, roles and behaviours remain strongly marked (49), and women are disproportionately represented in informal employment (50). Few studies have focused on food insecurity among South African youth while exploring gender differences. A previous survey conducted between 2014 and 2016 among youth living in Soweto and Durban found similar food insecurity rates for young men and woman (35).

This study has limitations. The cross-sectional study design limits the interpretation and the assessment of the causality between large income decrease and increased difficulty accessing food. Data collection occurred over an extended period of time during the COVID-19 pandemic (March 2020-May 2022), which went across several different alert levels. Survey distribution took place during a level 1 alert period, which may have led to participants omitting some of their experiences over those last two years, or only shared the most recent or difficult ones. This change in alert levels may have influenced participants' responses in reporting difficulty accessing food. Responses may have, therefore, been subject to recall bias. Because participants who were excluded from the analysis due to missing data reported a higher rate of increased difficulty accessing food than the study population (38% vs 29%), it is important to consider the possibility of selection bias and underestimation of the importance of food insecurity in this context. Furthermore, it is also possible that responses may have been subject to social desirability bias. However, such bias may have been minimized by the use of an anonymous
online survey format. Comparisons with other studies are limited due to the use of non-
standardised questions, especially for the study outcome of food insecurity. More robust
measures, that better take into account the complexity of food security, consisting in scoring
multiple questions, exist (such as the 9-item Household Food Insecurity Access Scale, or the 3-
item Household Hunger Scale but were not used for our study due to the necessity to keep the
survey questionnaire short, as well as the fact that these measures are especially designed to
assess current food insecurity profiles (i.e in the last month), and not necessarily for an extended
period of time like in our study (i.e March 2020 – May 2022). We were, however, able to adjust
our analyses on a range of relevant sociodemographic characteristics which are known
confounders of the association between economic hardship and food insecurity. Information
regarding the modalities of food access for youth (i.e responsible for purchasing their own food
or not, or purchasing for their household) could have been of additional value for this study.
Despite using a convenience sample, we developed a multi-pronged recruitment approach,
including working in collaboration with community partners, to capture a large and diverse
sample of South-African youth living in the eThekwini district in Durban, a district that has been
especially affected by the COVID-19 pandemic. A key strength is that this survey represents to
our knowledge one of the few large quantitative surveys focusing on youth living in sub-Saharan
Africa during the COVID-19 pandemic (51).

In conclusion, South African youth have been highly affected by the COVID-19 pandemic,
facing socio-economic challenges which were associated with increased difficulty to access food.
Few were able to access to social grant support. Our results highlight that regardless of whether
youth received social grants, we observed that youth whose incomes decreased a lot during the
pandemic had significantly reduced ability to access food during the pandemic. The critically
high effect among those not receiving social grants signals a need to support youth in accessing
financial supports during ongoing and future public health crises. While social grant support
made a great difference in lowering the effect of income decrease on difficulty accessing food, it
was insufficient to fully protect youth from those difficulties. Our data highlight the need to
develop adapted financial and non-financial support for this underserved group, especially in the
event of further public health crises. In light of the continued recovery from the pandemic and
online survey format. Comparisons with other studies are limited due to the use of non-
standardised questions, especially for the study outcome of food insecurity. More robust
measures, that better take into account the complexity of food security, consisting in scoring
multiple questions, exist (such as the 9-item Household Food Insecurity Access Scale, or the 3-
item Household Hunger Scale but were not used for our study due to the necessity to keep the
survey questionnaire short, as well as the fact that these measures are especially designed to
assess current food insecurity profiles (i.e in the last month), and not necessarily for an extended
period of time like in our study (i.e March 2020 – May 2022). We were, however, able to adjust
our analyses on a range of relevant sociodemographic characteristics which are known
confounders of the association between economic hardship and food insecurity. Information
regarding the modalities of food access for youth (i.e responsible for purchasing their own food
or not, or purchasing for their household) could have been of additional value for this study.
Despite using a convenience sample, we developed a multi-pronged recruitment approach,
including working in collaboration with community partners, to capture a large and diverse
sample of South-African youth living in the eThekwini district in Durban, a district that has been
especially affected by the COVID-19 pandemic. A key strength is that this survey represents to
our knowledge one of the few large quantitative surveys focusing on youth living in sub-Saharan
Africa during the COVID-19 pandemic (51).

In conclusion, South African youth have been highly affected by the COVID-19 pandemic,
facing socio-economic challenges which were associated with increased difficulty to access food.
Few were able to access to social grant support. Our results highlight that regardless of whether
youth received social grants, we observed that youth whose incomes decreased a lot during the
pandemic had significantly reduced ability to access food during the pandemic. The critically
high effect among those not receiving social grants signals a need to support youth in accessing
financial supports during ongoing and future public health crises. While social grant support
made a great difference in lowering the effect of income decrease on difficulty accessing food, it
was insufficient to fully protect youth from those difficulties. Our data highlight the need to
develop adapted financial and non-financial support for this underserved group, especially in the
event of further public health crises. In light of the continued recovery from the pandemic and
for future pandemic responses, there is a critical need to support youth through economic empowerment programming and food security policy and planning.

**Financial Support:** AYAZAZI RIGHTS is funded by the Centre for International Child Health (CICH) through the generous support of the British Columbia Children's Hospital Foundation, Canada.

The work reported herein for Janan Dietrich was made possible through funding by the South African Medical Research Council through its Division of Research Capacity Development under the Early Investigators Programme from funding received from the South African National Treasury as well as the CIPHER GROWING THE LEADERS OF TOMORROW grant from the International AIDS Society. The content hereof is the sole responsibility of the authors and do not necessarily represent the official views of the SAMRC. Kalysha Closson is supported by a Canadian Institutes for Health Research Banting Postdoctoral Fellowship.

**Conflicts of interest:** None. The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.

**Authorship:** JJ analysed the data. JJ wrote the first draft of the paper, with critical inputs from all co-authors. AK, JD, and MB secured funding for this study. JJ, BZ, KC, TP, JD, MB and AK designed the survey. BZ led the recruitment of participants, developed the database and online tools. JJ coordinated the survey and performed data quality checks. All authors reviewed and approved the final version of the manuscript.

**Ethical Standards Disclosure:** This study was conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures involving research study participants were approved by the Simon Fraser University Research Ethics Board and the UBC Behavioral Research Ethics Board (Ref: H21-02027), as well as by the University of the Witwatersrand Human Research Ethics Committee (Wits HREC-Medical) in South Africa (REB number: M210863). Participants were provided with an electronic consent letter, detailing the purpose of the survey, benefits and risk for participation, and key contacts for further question prior to accessing to the questionnaire. Parental consent was not required for youth aged 16 and 17 years, in agreement with the REBC and the Wits HREC-Medical, both of them considering that the research risk of the survey was low. A list of resources including online and in-person local support services such as for mental health and sexual and reproductive health care was provided at the end of the questionnaire.
for future pandemic responses, there is a critical need to support youth through economic empowerment programming and food security policy and planning.

**Financial Support:** AYAZAZI RIGHTS is funded by the Centre for International Child Health (CICH) through the generous support of the British Columbia Children's Hospital Foundation, Canada.

The work reported herein for Janan Dietrich was made possible through funding by the South African Medical Research Council through its Division of Research Capacity Development under the Early Investigators Programme from funding received from the South African National Treasury as well as the CIPHER GROWING THE LEADERS OF TOMORROW grant from the International AIDS Society. The content hereof is the sole responsibility of the authors and do not necessarily represent the official views of the SAMRC. Kalysha Closson is supported by a Canadian Institutes for Health Research Banting Postdoctoral Fellowship.

**Conflicts of interest:** None. The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.

**Authorship:** JJ analysed the data. JJ wrote the first draft of the paper, with critical inputs from all co-authors. AK, JD, and MB secured funding for this study. JJ, BZ, KC, TP, JD, MB and AK designed the survey. BZ led the recruitment of participants, developed the database and online tools. JJ coordinated the survey and performed data quality checks. All authors reviewed and approved the final version of the manuscript.

**Ethical Standards Disclosure:** This study was conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures involving research study participants were approved by the Simon Fraser University Research Ethics Board and the UBC Behavioral Research Ethics Board (Ref: H21-02027), as well as by the University of the Witwatersrand Human Research Ethics Committee (Wits HREC-Medical) in South Africa (REB number: M210863). Participants were provided with an electronic consent letter, detailing the purpose of the survey, benefits and risk for participation, and key contacts for further question prior to accessing to the questionnaire. Parental consent was not required for youth aged 16 and 17 years, in agreement with the REBC and the Wits HREC-Medical, both of them considering that the research risk of the survey was low. A list of resources including online and in-person local support services such as for mental health and sexual and reproductive health care was provided at the end of the questionnaire.
References

1. Saboori B, Radmehr R, Zhang YY, et al. A new face of food security: A global perspective of the COVID-19 pandemic. Prog Disaster Sci. 2022;16:100252.

2. Cole MB, Augustin MA, Robertson MJ, et al. The science of food security. NPJ Sci Food. 2018;2:14.

3. World Food Programme. WFP Global Update on COVID-19: November 2020. Growing needs, response to date and what's to come in 2021 [Internet]. Rome, Italy: World Food Programme; 2020 [cited 2024 March 6]. Available from: https://reliefweb.int/sites/reliefweb.int/files/resources/WFP-0000121038.pdf.

4. Antwi J, Appiah B, Oluwakuse B, et al. The Nutrition-COVID-19 Interplay: a Review. Curr Nutr Rep. 2021;10(4):364-74.

5. Patton GC, Sawyer SM, Santelli JS, et al. Our future: a Lancet commission on adolescent health and wellbeing. Lancet. 2016;387(10036):2423-78.

6. Jones AD. Food Insecurity and Mental Health Status: A Global Analysis of 149 Countries. Am J Prev Med. 2017;53(2):264-73.

7. Gibbs A, Jewkes R, Willan S, et al. Associations between poverty, mental health and substance use, gender power, and intimate partner violence amongst young (18-30) women and men in urban informal settlements in South Africa: A cross-sectional study and structural equation model. PLoS One. 2018;13(10):e0204956.

8. Belachew T, Lindstrom D, Gebremariam A, et al. Predictors of chronic food insecurity among adolescents in Southwest Ethiopia: a longitudinal study. BMC Public Health. 2012;12:604.

9. Statistics South Africa. P0211 - Quarterly Labour Force Survey (QLFS), 4th Quarter 2022 [Internet]. Pretoria, South Africa: Republic of South Africa; 2023 [cited 2024 March 6]. Available from: https://www.statssa.gov.za/publications/P0211/P02114thQuarter2022.pdf

10. Nigusso FT, Mavhandu-Mudzusi AH. High magnitude of food insecurity and malnutrition among people living with HIV/AIDS in Ethiopia: A call for integration of food and nutrition security with HIV treatment and care Programme. Nutr Health. 2021;27(2):141-50.

11. Wamai RG, Hirsch JL, Van Damme W, et al. What Could Explain the Lower COVID-19 Burden in Africa despite Considerable Circulation of the SARS-CoV-2 Virus? Int J Environ Res Public Health. 2021;18(16).
References

1. Saboori B, Radmehr R, Zhang YY, et al. A new face of food security: A global perspective of the COVID-19 pandemic. Prog Disaster Sci. 2022;16:100252.

2. Cole MB, Augustin MA, Robertson MJ, et al. The science of food security. NPJ Sci Food. 2018;2:14.

3. World Food Programme. WFP Global Update on COVID-19: November 2020. Growing needs, response to date and what's to come in 2021 [Internet]. Rome, Italy: World Food Programme; 2020 [cited 2024 March 6]. Available from:

https://reliefweb.int/sites/reliefweb.int/files/resources/WFP-0000121038.pdf.

4. Antwi J, Appiah B, Oluwakuse B, et al. The Nutrition-COVID-19 Interplay: a Review. Curr Nutr Rep. 2021;10(4):364-74.

5. Patton GC, Sawyer SM, Santelli JS, et al. Our future: a Lancet commission on adolescent health and wellbeing. Lancet. 2016;387(10036):2423-78.

6. Jones AD. Food Insecurity and Mental Health Status: A Global Analysis of 149 Countries. Am J Prev Med. 2017;53(2):264-73.

7. Gibbs A, Jewkes R, Willan S, et al. Associations between poverty, mental health and substance use, gender power, and intimate partner violence amongst young (18-30) women and men in urban informal settlements in South Africa: A cross-sectional study and structural equation model. PLoS One. 2018;13(10):e0204956.

8. Belachew T, Lindstrom D, Gebremariam A, et al. Predictors of chronic food insecurity among adolescents in Southwest Ethiopia: a longitudinal study. BMC Public Health. 2012;12:604.

9. Statistics South Africa. P0211 - Quarterly Labour Force Survey (QLFS), 4th Quarter 2022 [Internet]. Pretoria, South Africa: Republic of South Africa; 2023 [cited 2024 March 6]. Available from: https://www.statssa.gov.za/publications/P0211/P02114thQuarter2022.pdf

10. Nigusso FT, Mavhandu-Mudzusi AH. High magnitude of food insecurity and malnutrition among people living with HIV/AIDS in Ethiopia: A call for integration of food and nutrition security with HIV treatment and care Programme. Nutr Health. 2021;27(2):141-50.

11. Wamai RG, Hirsch JL, Van Damme W, et al. What Could Explain the Lower COVID-19 Burden in Africa despite Considerable Circulation of the SARS-CoV-2 Virus? Int J Environ Res Public Health. 2021;18(16).
12. Bwire G, Ario AR, Eyu P, et al. The COVID-19 pandemic in the African continent. BMC Med. 2022;20(1):167.

13. Formenti B, Gregori N, Crosato V, et al. The impact of COVID-19 on communicable and non-communicable diseases in Africa: a narrative review. Infez Med. 2022;30(1):30-40.

14. Mbunge E. Effects of COVID-19 in South African health system and society: An explanatory study. Diabetes Metab Syndr. 2020;14(6):1809-14.

15. Mahlangu P, Gibbs A, Shai N, et al. Impact of COVID-19 lockdown and link to women and children's experiences of violence in the home in South Africa. BMC Public Health. 2022;22(1):1029.

16. Kola L, Kohrt BA, Hanlon C, et al. COVID-19 mental health impact and responses in low-income and middle-income countries: reimagining global mental health. Lancet Psychiatry. 2021;8(6):535-50.

17. South African National Department of Health. COVID-19 South African Coronavirus News And Information [Internet] Pretoria, South Africa: Republic of South Africa; 2023 [cited 2024 March 6]. Available from: https://sacoronavirus.co.za/.

18. Stiegler N, Bouchard JP. South Africa: Challenges and successes of the COVID-19 lockdown. Ann Med Psychol (Paris). 2020;178(7):695-8.

19. Section 27 - Catalyst for social justice. National School Nutrition Programme – the campaign for #SchoolMealsNow [Internet] [cited 2024 March 6]. Available from: https://section27.org.za/national-school-nutrition-programme/.

20. Gittings L, Toska E, Medley S, et al. 'Now my life is stuck!': Experiences of adolescents and young people during COVID-19 lockdown in South Africa. Glob Public Health. 2021:1-17.

21. Carlitz RD, Makhura MN. Life under lockdown: Illustrating tradeoffs in South Africa's response to COVID-19. World Dev. 2021;137:105168.

22. South African Government. COVID-19 / Coronavirus 2023 [Internet]. Pretoria, South Africa: Republic of South Africa [cited 2024 March 6]. Available from: https://www.gov.za/Coronavirus

23. Moonasar D, Pillay A, Leonard E, et al. COVID-19: lessons and experiences from South Africa's first surge. BMJ Glob Health. 2021;6(2).

24. Duby Z, Bunce B, Fowler C, et al. Intersections between COVID-19 and socio-economic mental health stressors in the lives of South African adolescent girls and young women. Child Adolesc Psychiatry Ment Health. 2022;16(1):23.
12. Bwire G, Ario AR, Eyu P, et al. The COVID-19 pandemic in the African continent. BMC Med. 2022;20(1):167.

13. Formenti B, Gregori N, Crosato V, et al. The impact of COVID-19 on communicable and non-communicable diseases in Africa: a narrative review. Infez Med. 2022;30(1):30-40.

14. Mbunge E. Effects of COVID-19 in South African health system and society: An explanatory study. Diabetes Metab Syndr. 2020;14(6):1809-14.

15. Mahlangu P, Gibbs A, Shai N, et al. Impact of COVID-19 lockdown and link to women and children's experiences of violence in the home in South Africa. BMC Public Health. 2022;22(1):1029.

16. Kola L, Kohrt BA, Hanlon C, et al. COVID-19 mental health impact and responses in low-income and middle-income countries: reimagining global mental health. Lancet Psychiatry. 2021;8(6):535-50.

17. South African National Department of Health. COVID-19 South African Coronavirus News And Information [Internet] Pretoria, South Africa: Republic of South Africa; 2023 [cited 2024 March 6]. Available from: https://sacoronavirus.co.za/.

18. Stiegler N, Bouchard JP. South Africa: Challenges and successes of the COVID-19 lockdown. Ann Med Psychol (Paris). 2020;178(7):695-8.

19. Section 27 - Catalyst for social justice. National School Nutrition Programme – the campaign for #SchoolMealsNow [Internet] [cited 2024 March 6]. Available from: https://section27.org.za/national-school-nutrition-programme/.

20. Gittings L, Toska E, Medley S, et al. 'Now my life is stuck!': Experiences of adolescents and young people during COVID-19 lockdown in South Africa. Glob Public Health. 2021:1-17.

21. Carlitz RD, Makhura MN. Life under lockdown: Illustrating tradeoffs in South Africa's response to COVID-19. World Dev. 2021;137:105168.

22. South African Government. COVID-19 / Coronavirus 2023 [Internet]. Pretoria, South Africa: Republic of South Africa [cited 2024 March 6]. Available from: https://www.gov.za/Coronavirus

23. Moonasar D, Pillay A, Leonard E, et al. COVID-19: lessons and experiences from South Africa's first surge. BMJ Glob Health. 2021;6(2).

24. Duby Z, Bunce B, Fowler C, et al. Intersections between COVID-19 and socio-economic mental health stressors in the lives of South African adolescent girls and young women. Child Adolesc Psychiatry Ment Health. 2022;16(1):23.
25. Porter C, Hittmeyer A, Favara M, et al. The evolution of young people's mental health during COVID-19 and the role of food insecurity: Evidence from a four low-and-middle-income-country cohort study. Public Health Pract (Oxf). 2022;3:100232.

26. Barker ME, Hardy-Johnson P, Weller S, et al. How do we improve adolescent diet and physical activity in India and sub-Saharan Africa? Findings from the Transforming Adolescent Lives through Nutrition (TALENT) consortium. Public Health Nutr. 2020;1-9.

27. National Income Dynamics Study – Coronavirus Rapid Mobile Survey (NIDS-CRAM). NIDS-CRAM Wave 5 Reports [Internet] [cited 2024 March 6]. Available from: https://cramsurvey.org/reports/.

28. Gelo D, Dikgang J. Implications of COVID-19 labour market shock for child and household hungers in South Africa: Do social protection programs protect?'. PLoS One. 2022;17(7):e0269848.

29. Van der Berg S, Patel L, Bridgman G. Food insecurity in South Africa: Evidence from NIDS-CRAM Wave 5. 2021.

30. Department of Social Development, South Africa. The Rapid Assessment of the Implementation and Utilisation of the Special COVID-19 SRD Grant. 2021. [Internet] Pretoria, South Africa: Republic of South Africa [cited 2023 Aug 11]. Available from: https://www.dsd.gov.za/index.php/component/jdownloads/?task=download.send&id=316:the-rapid-assessment-of-the-implementation-and-utilisation-of-the-special-covid-19-srd-grant&catid=7&m=0&Itemid=101

31. Hart TG, Davids YD, Rule S, et al. The COVID-19 pandemic reveals an unprecedented rise in hunger: The South African Government was ill-prepared to meet the challenge. Sci Afr. 2022;16:e01169.

32. Statistics South Africa. Community Survey 2016 – Statistical release P031 [Internet]. Pretoria, South Africa: Republic of South Africa; 2023 [cited 2024 March 6]. Available from: http://cs2016.statssa.gov.za/wp-content/uploads/2016/07/NT-30-06-2016-RELEASE-for-CS-2016-Statistical-releas_1-July-2016.pdf

33. Statistics South Africa. Census 2022 – Statistical release P0301.4 [Internet]. Pretoria, South Africa: Republic of South Africa; 2023 [cited 2024 March 6]. Available from: https://census.statssa.gov.za/assets/documents/2022/P03014_Census_2022_Statistical_Release.pdf
25. Porter C, Hittmeyer A, Favara M, et al. The evolution of young people's mental health during COVID-19 and the role of food insecurity: Evidence from a four low-and-middle-income-country cohort study. Public Health Pract (Oxf). 2022;3:100232.

26. Barker ME, Hardy-Johnson P, Weller S, et al. How do we improve adolescent diet and physical activity in India and sub-Saharan Africa? Findings from the Transforming Adolescent Lives through Nutrition (TALENT) consortium. Public Health Nutr. 2020;1-9.

27. National Income Dynamics Study – Coronavirus Rapid Mobile Survey (NIDS-CRAM). NIDS-CRAM Wave 5 Reports [Internet] [cited 2024 March 6]. Available from: https://cramsurvey.org/reports/.

28. Gelo D, Dikgang J. Implications of COVID-19 labour market shock for child and household hungers in South Africa: Do social protection programs protect?'. PLoS One. 2022;17(7):e0269848.

29. Van der Berg S, Patel L, Bridgman G. Food insecurity in South Africa: Evidence from NIDS-CRAM Wave 5. 2021.

30. Department of Social Development, South Africa. The Rapid Assessment of the Implementation and Utilisation of the Special COVID-19 SRD Grant. 2021. [Internet] Pretoria, South Africa: Republic of South Africa [cited 2023 Aug 11]. Available from: https://www.dsd.gov.za/index.php/component/jdownloads/?task=download.send&id=316:the-rapid-assessment-of-the-implementation-and-utilisation-of-the-special-covid-19-srd-grant&catid=7&m=0&Itemid=101

31. Hart TG, Davids YD, Rule S, et al. The COVID-19 pandemic reveals an unprecedented rise in hunger: The South African Government was ill-prepared to meet the challenge. Sci Afr. 2022;16:e01169.

32. Statistics South Africa. Community Survey 2016 – Statistical release P031 [Internet]. Pretoria, South Africa: Republic of South Africa; 2023 [cited 2024 March 6]. Available from: http://cs2016.statssa.gov.za/wp-content/uploads/2016/07/NT-30-06-2016-RELEASE-for-CS-2016-Statistical-releas_1-July-2016.pdf

33. Statistics South Africa. Census 2022 – Statistical release P0301.4 [Internet]. Pretoria, South Africa: Republic of South Africa; 2023 [cited 2024 March 6]. Available from: https://census.statssa.gov.za/assets/documents/2022/P03014_Census_2022_Statistical_Release.pdf
34. Harris PA, Taylor R, Thielke R, et al. Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377-81.

35. Jesson J, Dietrich J, Beksinska M, et al. Food insecurity and depression: a cross-sectional study of a multi-site urban youth cohort in Durban and Soweto, South Africa. Tropical medicine & international health: TM & IH. 2021;26(6).

36. Brown K. Coloured and black relations in South Africa: The burden of racialized hierarchy. Macalester Int. 2000;9:198-207.

37: Adhikari M. ‘God made the white man, God made the black man…’: Popular racial stereotyping of Coloured people in apartheid South Africa. S. Afr. Hist. J. 2006;55:142–164.

38. OECD Data. Youth not in employment, education or training (NEET) (indicator) 2023 [Internet]. Paris, France : OECD [cited 2024 March 6] Available from: https://data.oecd.org/youthinac/youth-not-in-employment-education-or-training-neet.htm.

39. Coulaud PJ, Salway T, Jesson J, et al. Moderation of the association between COVID-19-related income loss and depression by receipt of financial support: Repeated cross-sectional surveys of young adults in Canada and France (2020-2021). SSM Popul Health. 2023;21:101340.

40. Balana BB, Ogunniyi A, Oyeyemi M, et al. COVID-19, food insecurity and dietary diversity of households: Survey evidence from Nigeria. Food Secur. 2023;15(1):219-41.

41. Nwosu CO, Kollamparambil U, Oyenubi A. Food insecurity and health outcomes during the coronavirus pandemic in South Africa: a longitudinal study. Health Econ Rev. 2022;12(1):32.

42. Delbiso TD, Kotecho MG, Asfaw FM. Effects of COVID-19 imposed school closure on school feeding program in Addis Ababa, Ethiopia. Soc Sci Humanit Open. 2021;4(1):100185.

43. Statistics South Africa. Quarterly Labour Force Survey (QLFS), 4th Quarter 2019 [Internet]. Pretoria, South Africa: Republic of South Africa; 2020 [cited 2024 March 6]. Available from: https://www.statssa.gov.za/?p=12948#:~:text=An%20increase%20of%2045%20000,and%20Utilities%20(14%20000).

44. Mokofe WM. From precarity to pandemic: How the Covid-19 pandemic has exacerbated poverty, unemployment, and inequality in South Africa. Law Democracy & Development. 2023;26(1):395-424.
34. Harris PA, Taylor R, Thielke R, et al. Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377-81.

35. Jesson J, Dietrich J, Beksinska M, et al. Food insecurity and depression: a cross-sectional study of a multi-site urban youth cohort in Durban and Soweto, South Africa. Tropical medicine & international health: TM & IH. 2021;26(6).

36. Brown K. Coloured and black relations in South Africa: The burden of racialized hierarchy. Macalester Int. 2000;9:198-207.

37: Adhikari M. ‘God made the white man, God made the black man…’: Popular racial stereotyping of Coloured people in apartheid South Africa. S. Afr. Hist. J. 2006;55:142–164.

38. OECD Data. Youth not in employment, education or training (NEET) (indicator) 2023 [Internet]. Paris, France : OECD [cited 2024 March 6] Available from: https://data.oecd.org/youthinac/youth-not-in-employment-education-or-training-neet.htm.

39. Coulaud PJ, Salway T, Jesson J, et al. Moderation of the association between COVID-19-related income loss and depression by receipt of financial support: Repeated cross-sectional surveys of young adults in Canada and France (2020-2021). SSM Popul Health. 2023;21:101340.

40. Balana BB, Ogunniyi A, Oyeyemi M, et al. COVID-19, food insecurity and dietary diversity of households: Survey evidence from Nigeria. Food Secur. 2023;15(1):219-41.

41. Nwosu CO, Kollamparambil U, Oyenubi A. Food insecurity and health outcomes during the coronavirus pandemic in South Africa: a longitudinal study. Health Econ Rev. 2022;12(1):32.

42. Delbiso TD, Kotecho MG, Asfaw FM. Effects of COVID-19 imposed school closure on school feeding program in Addis Ababa, Ethiopia. Soc Sci Humanit Open. 2021;4(1):100185.

43. Statistics South Africa. Quarterly Labour Force Survey (QLFS), 4th Quarter 2019 [Internet]. Pretoria, South Africa: Republic of South Africa; 2020 [cited 2024 March 6]. Available from: https://www.statssa.gov.za/?p=12948#:~:text=An%20increase%20of%2045%20000,and%20Utilities%20(14%20000).

44. Mokofe WM. From precarity to pandemic: How the Covid-19 pandemic has exacerbated poverty, unemployment, and inequality in South Africa. Law Democracy & Development. 2023;26(1):395-424.
45. Gavrilovic M, Rubio M, Bastagli F, et al. Gender-responsive social protection post-COVID-19. Science. 2022;375(6585):1111-3.

46. Spaull N, Ardington C, Bassier I, et al. The NIDS-CRAM Team. Overview and findings: NIDS-CRAM synthesis report wave 1. 2021.

47. Mthethwa S, Wale E. Household Vulnerability to Food Insecurity in Rural South Africa: Evidence from a Nationally Representative Survey Data. Int J Environ Res Public Health. 2021;18(4).

48. Shepherd DL. Food insecurity, depressive symptoms, and the salience of gendered family roles during the COVID-19 pandemic in South Africa. Soc Sci Med. 2022;301:114830.

49. Statistics South Africa. Quarterly Labour Force Survey (QLFS), 1st Quarter 2019 [Internet]. Pretoria, South Africa: Republic of South Africa; 2020 [cited 2023 Aug 11]. Available from: https://www.statssa.gov.za/?p=12115.

50. Pinchoff J, Austrian K, Rajshekhar N, et al. Gendered economic, social and health effects of the COVID-19 pandemic and mitigation policies in Kenya: evidence from a prospective cohort survey in Nairobi informal settlements. BMJ Open. 2021;11(3):e042749.
45. Gavrilovic M, Rubio M, Bastagli F, et al. Gender-responsive social protection post-COVID-19. Science. 2022;375(6585):1111-3.

46. Spaull N, Ardington C, Bassier I, et al. The NIDS-CRAM Team. Overview and findings: NIDS-CRAM synthesis report wave 1. 2021.

47. Mthethwa S, Wale E. Household Vulnerability to Food Insecurity in Rural South Africa: Evidence from a Nationally Representative Survey Data. Int J Environ Res Public Health. 2021;18(4).

48. Shepherd DL. Food insecurity, depressive symptoms, and the salience of gendered family roles during the COVID-19 pandemic in South Africa. Soc Sci Med. 2022;301:114830.

49. Statistics South Africa. Quarterly Labour Force Survey (QLFS), 1st Quarter 2019 [Internet]. Pretoria, South Africa: Republic of South Africa; 2020 [cited 2023 Aug 11]. Available from: https://www.statssa.gov.za/?p=12115.

50. Pinchoff J, Austrian K, Rajshekhar N, et al. Gendered economic, social and health effects of the COVID-19 pandemic and mitigation policies in Kenya: evidence from a prospective cohort survey in Nairobi informal settlements. BMJ Open. 2021;11(3):e042749.
<figure><img src="image_4.png" /><figcaption>**Figure 1: Selection of the study population – AYAZAZI RIGHTS 2022**</figcaption></figure>
<figure><img src="image_3.png" /><figcaption>**Figure 1: Selection of the study population – AYAZAZI RIGHTS 2022**</figcaption></figure>
<figure><img src="image_5.png" /></figure>

**Figure 2:** Estimated adjusted Odds ratio between income change and increased difficulty accessing food, according to receiving social grant support. Multivariable logistic regression model. RIGHTS online survey. eThekwini District. South Africa. 2022. **Abbreviations:** AOR= Adjusted Odds Ratio, CI= 95% Confidence Interval

**Notes:** Outcome was difficulty accessing food during the COVID-19 pandemic, defined as increased vs unchanged or easier, the main exposure was income change since the COVID-19 pandemic, defined in three categories: decreased a lot, decreased slightly and unchanged as the comparison group (including increased a lot and increased slightly). Model is adjusted for age group, gender, ethnicity, having children, current occupation, income level, household structure (number of adults, children and seniors living in the same household), and HIV status.
<figure><img src="image_4.png" /></figure>

**Figure 2:** Estimated adjusted Odds ratio between income change and increased difficulty accessing food, according to receiving social grant support. Multivariable logistic regression model. RIGHTS online survey. eThekwini District. South Africa. 2022. **Abbreviations:** AOR= Adjusted Odds Ratio, CI= 95% Confidence Interval

**Notes:** Outcome was difficulty accessing food during the COVID-19 pandemic, defined as increased vs unchanged or easier, the main exposure was income change since the COVID-19 pandemic, defined in three categories: decreased a lot, decreased slightly and unchanged as the comparison group (including increased a lot and increased slightly). Model is adjusted for age group, gender, ethnicity, having children, current occupation, income level, household structure (number of adults, children and seniors living in the same household), and HIV status.
<figure><img src="image_6.png" /></figure>

**Figure 3:** Factors limiting food access since the COVID-19 pandemic (N=1620). overall and according to increased difficulty accessing food. AYAZAZI RIGHTS online survey. eThekwini District. South Africa. 2022.
<figure><img src="image_5.png" /></figure>

**Figure 3:** Factors limiting food access since the COVID-19 pandemic (N=1620). overall and according to increased difficulty accessing food. AYAZAZI RIGHTS online survey. eThekwini District. South Africa. 2022.
<figure><img src="image_7.png" /><figcaption>**Figure 4:** Experiences of work disruptions for those employed (N=409). overall and according to increased difficulty accessing food. AYAZAZI RIGHTS online survey. eThekwini District. South Africa. 2022.</figcaption></figure>
<figure><img src="image_6.png" /><figcaption>**Figure 4:** Experiences of work disruptions for those employed (N=409). overall and according to increased difficulty accessing food. AYAZAZI RIGHTS online survey. eThekwini District. South Africa. 2022.</figcaption></figure>
<table><caption>**Table 1a:** Characteristics of the study population according to the increased difficulty to access food since the COVID-19 pandemic. AYAZAZI RIGHTS online survey, eThekwini District, South Africa, 2022</caption><thead><tr><th rowspan="2">Variables</th><th rowspan="2">Overall<br>N=1620</th><th colspan="2">Increased difficulty accessing<br>food</th></tr><tr><th>Yes, N= 476</th><th>No, N= 1144</th></tr></thead><tbody><tr><td colspan="4"><strong>Main exposure variables</strong></td></tr><tr><td><strong>Income change since the COVID-19<br>pandemic</strong></td><td></td><td></td><td></td></tr><tr><td>Decreased a lot</td><td>297</td><td>18.3%</td><td>160 33.6%</td><td>137 12.0%</td></tr><tr><td>Decreased slightly</td><td>219</td><td>13.5%</td><td>58 12.2%</td><td>161 14.1%</td></tr><tr><td>Unchanged or increased</td><td>1104</td><td>68.1%</td><td>258 54.2%</td><td>846 74.0%</td></tr><tr><td><strong>Received social grant support</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>Yes</td><td>565</td><td>34.9%</td><td>250 52.5%</td><td>315 27.5%</td></tr><tr><td>No</td><td>1055</td><td>65.1%</td><td>226 47.5%</td><td>829 72.5%</td></tr><tr><td colspan="4"><strong>Covariates</strong></td></tr><tr><td><strong>Gender</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>Man</td><td>681</td><td>42.0%</td><td>178 37.4%</td><td>503 44.0%</td></tr><tr><td>Woman</td><td>861</td><td>53.1%</td><td>276 58.0%</td><td>585 51.1%</td></tr><tr><td>Non-conforming</td><td>78</td><td>4.8%</td><td>22 4.6%</td><td>56 4.9%</td></tr><tr><td><strong>Age groups (years)</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>16-18</td><td>405</td><td>25.0%</td><td>76 16.0%</td><td>329 28.8%</td></tr><tr><td>19-24</td><td>1215</td><td>75.0%</td><td>400 84.0%</td><td>815 71.2%</td></tr><tr><td><strong>Ethnicity</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>Black African</td><td>1233</td><td>76.1%</td><td>372 78.2%</td><td>861 75.3%</td></tr><tr><td>Coloured, Indian or Asian</td><td>318</td><td>19.6%</td><td>91 19.1%</td><td>227 19.8%</td></tr><tr><td>White</td><td>69</td><td>4.3%</td><td>13 2.7%</td><td>56 4.9%</td></tr><tr><td><strong>Having children</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>None</td><td>1046</td><td>64.6%</td><td>239 50.2%</td><td>807 70.5%</td></tr><tr><td>One</td><td>463</td><td>28.6%</td><td>179 37.6%</td><td>284 24.8%</td></tr><tr><td>Two or more</td><td>111</td><td>6.9%</td><td>58 12.2%</td><td>53 4.6%</td></tr><tr><td><strong>Current occupation, part-time or full<br>time</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>At school and employed</td><td>86</td><td>5.3%</td><td>31 6.5%</td><td>55 4.8%</td></tr><tr><td>At school only</td><td>744</td><td>45.9%</td><td>158 33.2%</td><td>586 51.2%</td></tr><tr><td>Employed only</td><td>323</td><td>19.9%</td><td>116 24.4%</td><td>207 18.1%</td></tr><tr><td>Neither at school or employed</td><td>467</td><td>28.8%</td><td>171 35.9%</td><td>296 25.9%</td></tr><tr><td><strong>Income level</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>No income -R800</td><td>695</td><td>42.9%</td><td>239 50.2%</td><td>456 39.9%</td></tr><tr><td>R800 or more</td><td>925</td><td>57.1%</td><td>237 49.8%</td><td>688 60.1%</td></tr><tr><td><strong>Number of adults living in household</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>None to 3</td><td>657</td><td>40.6%</td><td>203 42.6%</td><td>454 39.7%</td></tr><tr><td>4 or more</td><td>963</td><td>59.4%</td><td>273 57.4%</td><td>690 60.3%</td></tr><tr><td><strong>Number of seniors living in household</strong></td><td></td><td></td><td></td><td></td></tr></tbody></table>
<table><caption>**Table 1a:** Characteristics of the study population according to the increased difficulty to access food since the COVID-19 pandemic. AYAZAZI RIGHTS online survey, eThekwini District, South Africa, 2022</caption><thead><tr><th rowspan="2">Variables</th><th rowspan="2">Overall<br>N=1620</th><th colspan="2">Increased difficulty accessing<br>food</th></tr><tr><th>Yes, N=476</th><th>No, N=1144</th></tr></thead><tbody><tr><td colspan="4"><strong>Main exposure variables</strong></td></tr><tr><td><strong>Income change since the COVID-19<br>pandemic</strong></td><td></td><td></td><td></td></tr><tr><td>Decreased a lot</td><td>297</td><td>18.3%</td><td>160 33.6%</td><td>137 12.0%</td></tr><tr><td>Decreased slightly</td><td>219</td><td>13.5%</td><td>58 12.2%</td><td>161 14.1%</td></tr><tr><td>Unchanged or increased</td><td>1104</td><td>68.1%</td><td>258 54.2%</td><td>846 74.0%</td></tr><tr><td><strong>Received social grant support</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>Yes</td><td>565</td><td>34.9%</td><td>250 52.5%</td><td>315 27.5%</td></tr><tr><td>No</td><td>1055</td><td>65.1%</td><td>226 47.5%</td><td>829 72.5%</td></tr><tr><td colspan="4"><strong>Covariates</strong></td></tr><tr><td><strong>Gender</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>Man</td><td>681</td><td>42.0%</td><td>178 37.4%</td><td>503 44.0%</td></tr><tr><td>Woman</td><td>861</td><td>53.1%</td><td>276 58.0%</td><td>585 51.1%</td></tr><tr><td>Non-conforming</td><td>78</td><td>4.8%</td><td>22 4.6%</td><td>56 4.9%</td></tr><tr><td><strong>Age groups (years)</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>16-18</td><td>405</td><td>25.0%</td><td>76 16.0%</td><td>329 28.8%</td></tr><tr><td>19-24</td><td>1215</td><td>75.0%</td><td>400 84.0%</td><td>815 71.2%</td></tr><tr><td><strong>Ethnicity</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>Black African</td><td>1233</td><td>76.1%</td><td>372 78.2%</td><td>861 75.3%</td></tr><tr><td>Coloured, Indian or Asian</td><td>318</td><td>19.6%</td><td>91 19.1%</td><td>227 19.8%</td></tr><tr><td>White</td><td>69</td><td>4.3%</td><td>13 2.7%</td><td>56 4.9%</td></tr><tr><td><strong>Having children</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>None</td><td>1046</td><td>64.6%</td><td>239 50.2%</td><td>807 70.5%</td></tr><tr><td>One</td><td>463</td><td>28.6%</td><td>179 37.6%</td><td>284 24.8%</td></tr><tr><td>Two or more</td><td>111</td><td>6.9%</td><td>58 12.2%</td><td>53 4.6%</td></tr><tr><td><strong>Current occupation, part-time or full<br>time</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>At school and employed</td><td>86</td><td>5.3%</td><td>31 6.5%</td><td>55 4.8%</td></tr><tr><td>At school only</td><td>744</td><td>45.9%</td><td>158 33.2%</td><td>586 51.2%</td></tr><tr><td>Employed only</td><td>323</td><td>19.9%</td><td>116 24.4%</td><td>207 18.1%</td></tr><tr><td>Neither at school or employed</td><td>467</td><td>28.8%</td><td>171 35.9%</td><td>296 25.9%</td></tr><tr><td><strong>Income level</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>No income -R800</td><td>695</td><td>42.9%</td><td>239 50.2%</td><td>456 39.9%</td></tr><tr><td>R800 or more</td><td>925</td><td>57.1%</td><td>237 49.8%</td><td>688 60.1%</td></tr><tr><td><strong>Number of adults living in household</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>None to 3</td><td>657</td><td>40.6%</td><td>203 42.6%</td><td>454 39.7%</td></tr><tr><td>4 or more</td><td>963</td><td>59.4%</td><td>273 57.4%</td><td>690 60.3%</td></tr><tr><td><strong>Number of seniors living in household</strong></td><td></td><td></td><td></td><td></td></tr></tbody></table>
<table><tbody><tr><td>None or 1</td><td>1310</td><td>80.9%</td><td>343</td><td>72.1%</td><td>967</td><td>84.5%</td></tr><tr><td>2 or more</td><td>310</td><td>19.1%</td><td>133</td><td>27.9%</td><td>177</td><td>15.5%</td></tr><tr><td><strong>Number or children 0-17 years living in household</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>None, 1 or 2</td><td>954</td><td>58.9%</td><td>223</td><td>46.8%</td><td>731</td><td>63.9%</td></tr><tr><td>3 or more</td><td>666</td><td>41.1%</td><td>253</td><td>53.2%</td><td>413</td><td>36.1%</td></tr><tr><td><strong>HIV status</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>HIV-positive</td><td>86</td><td>5.3%</td><td>44</td><td>9.2%</td><td>42</td><td>3.7%</td></tr><tr><td>HIV-negative</td><td>1077</td><td>66.5%</td><td>267</td><td>56.1%</td><td>810</td><td>70.8%</td></tr><tr><td>Unsure of HIV-status or prefer not to say</td><td>457</td><td>28.2%</td><td>165</td><td>34.7%</td><td>292</td><td>25.5%</td></tr></tbody></table>
<table><tbody><tr><td>None or 1</td><td>1310</td><td>80.9%</td><td>343</td><td>72.1%</td><td>967</td><td>84.5%</td></tr><tr><td>2 or more</td><td>310</td><td>19.1%</td><td>133</td><td>27.9%</td><td>177</td><td>15.5%</td></tr><tr><td><strong>Number or children 0-17 years living in household</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>None, 1 or 2</td><td>954</td><td>58.9%</td><td>223</td><td>46.8%</td><td>731</td><td>63.9%</td></tr><tr><td>3 or more</td><td>666</td><td>41.1%</td><td>253</td><td>53.2%</td><td>413</td><td>36.1%</td></tr><tr><td><strong>HIV status</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>HIV-positive</td><td>86</td><td>5.3%</td><td>44</td><td>9.2%</td><td>42</td><td>3.7%</td></tr><tr><td>HIV-negative</td><td>1077</td><td>66.5%</td><td>267</td><td>56.1%</td><td>810</td><td>70.8%</td></tr><tr><td>Unsure of HIV-status or prefer not to say</td><td>457</td><td>28.2%</td><td>165</td><td>34.7%</td><td>292</td><td>25.5%</td></tr></tbody></table>
<table><caption>**Table 1b:** Social grant support received, overall and according to income change. AYAZAZI RIGHTS online survey. eThekwini District. South Africa. 2022</caption><thead><tr><th rowspan="2">Social grant support</th><th rowspan="2">Total (n=1620)</th><th colspan="3">According to income change</th></tr><tr><th>Decreased a lot (n=297)</th><th>Decreased slightly (n=219)</th><th>Unchanged or increased (n=1104)</th></tr></thead><tbody><tr><td><strong>Have you or your household received any social grants from the government since the COVID-19 pandemic?</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>Yes</td><td>565</td><td>34.9%</td><td>149</td><td>50.2%</td><td>85</td><td>38.8%</td><td>331</td><td>30.0%</td></tr><tr><td>No</td><td>1055</td><td>65.1%</td><td>148</td><td>49.8%</td><td>134</td><td>61.2%</td><td>773</td><td>70.0%</td></tr><tr><td><strong>If yes, what social grants did you receive?</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Child support</td><td>429</td><td>75.9%</td><td>109</td><td>73.2%</td><td>55</td><td>64.7%</td><td>265</td><td>80.1%</td></tr><tr><td>Old age pension</td><td>269</td><td>47.6%</td><td>39</td><td>26.2%</td><td>40</td><td>47.1%</td><td>190</td><td>57.4%</td></tr><tr><td>Disability grant</td><td>53</td><td>9.4%</td><td>15</td><td>10.1%</td><td>8</td><td>9.4%</td><td>30</td><td>9.1%</td></tr><tr><td>Foster child grant</td><td>39</td><td>6.9%</td><td>11</td><td>7.4%</td><td>4</td><td>4.7%</td><td>24</td><td>7.3%</td></tr><tr><td>COVID-19 Social Relief of Distress grant</td><td>14</td><td>2.5%</td><td>4</td><td>2.7%</td><td>1</td><td>1.2%</td><td>9</td><td>2.7%</td></tr><tr><td><strong>If yes, did your social grants support from the government change since the COVID-19 pandemic?</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Support increased</td><td>276</td><td>48.8%</td><td>69</td><td>46.3%</td><td>29</td><td>34.1%</td><td>178</td><td>53.8%</td></tr><tr><td>Support stayed the same</td><td>73</td><td>12.9%</td><td>18</td><td>12.1%</td><td>18</td><td>21.2%</td><td>37</td><td>11.2%</td></tr><tr><td>Support decreased</td><td>36</td><td>6.4%</td><td>20</td><td>13.4%</td><td>11</td><td>12.9%</td><td>5</td><td>1.5%</td></tr><tr><td>I don't know</td><td>174</td><td>30.8%</td><td>42</td><td>28.2%</td><td>27</td><td>31.8%</td><td>105</td><td>31.7%</td></tr><tr><td>Missing data</td><td>6</td><td>1.1%</td><td>0</td><td>0.0%</td><td>0</td><td>0.0%</td><td>6</td><td>1.8%</td></tr></tbody></table>
<table><caption>**Table 1b:** Social grant support received, overall and according to income change. AYAZAZI RIGHTS online survey. eThekwini District. South Africa. 2022</caption><thead><tr><th rowspan="2">Social grant support</th><th rowspan="2">Total (n=1620)</th><th colspan="3">According to income change</th></tr><tr><th>Decreased a lot (n=297)</th><th>Decreased slightly (n=219)</th><th>Unchanged or increased (n=1104)</th></tr></thead><tbody><tr><td><strong>Have you or your household received any social grants from the government since the COVID-19 pandemic?</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>Yes</td><td>565</td><td>34.9%</td><td>149</td><td>50.2%</td><td>85</td><td>38.8%</td><td>331</td><td>30.0%</td></tr><tr><td>No</td><td>1055</td><td>65.1%</td><td>148</td><td>49.8%</td><td>134</td><td>61.2%</td><td>773</td><td>70.0%</td></tr><tr><td><strong>If yes, what social grants did you receive?</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Child support</td><td>429</td><td>75.9%</td><td>109</td><td>73.2%</td><td>55</td><td>64.7%</td><td>265</td><td>80.1%</td></tr><tr><td>Old age pension</td><td>269</td><td>47.6%</td><td>39</td><td>26.2%</td><td>40</td><td>47.1%</td><td>190</td><td>57.4%</td></tr><tr><td>Disability grant</td><td>53</td><td>9.4%</td><td>15</td><td>10.1%</td><td>8</td><td>9.4%</td><td>30</td><td>9.1%</td></tr><tr><td>Foster child grant</td><td>39</td><td>6.9%</td><td>11</td><td>7.4%</td><td>4</td><td>4.7%</td><td>24</td><td>7.3%</td></tr><tr><td>COVID-19 Social Relief of Distress grant</td><td>14</td><td>2.5%</td><td>4</td><td>2.7%</td><td>1</td><td>1.2%</td><td>9</td><td>2.7%</td></tr><tr><td><strong>If yes, did your social grants support from the government change since the COVID-19 pandemic?</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Support increased</td><td>276</td><td>48.8%</td><td>69</td><td>46.3%</td><td>29</td><td>34.1%</td><td>178</td><td>53.8%</td></tr><tr><td>Support stayed the same</td><td>73</td><td>12.9%</td><td>18</td><td>12.1%</td><td>18</td><td>21.2%</td><td>37</td><td>11.2%</td></tr><tr><td>Support decreased</td><td>36</td><td>6.4%</td><td>20</td><td>13.4%</td><td>11</td><td>12.9%</td><td>5</td><td>1.5%</td></tr><tr><td>I don't know</td><td>174</td><td>30.8%</td><td>42</td><td>28.2%</td><td>27</td><td>31.8%</td><td>105</td><td>31.7%</td></tr><tr><td>Missing data</td><td>6</td><td>1.1%</td><td>0</td><td>0.0%</td><td>0</td><td>0.0%</td><td>6</td><td>1.8%</td></tr></tbody></table>
<table><caption>**Table 2:** Estimated adjusted Odds Ratio between income change and increased difficulty accessing food, overall and by gender. Logistic regression models. RIGHTS online survey. eThekwini District. South Africa. 2022.</caption><thead><tr><th rowspan="2">Analyses</th><th colspan="2">Total sample<br>(N=1620)</th><th colspan="2">Men<br>(n=681)</th><th colspan="2">Women<br>(n=861)</th><th colspan="2">Gender non-<br>conforming (n=78)</th></tr><tr><th>(a)OR</th><th>95% CI</th><th>(a)OR</th><th>95% CI</th><th>(a)OR</th><th>95% CI</th><th>aOR</th><th>95% CI</th></tr></thead><tbody><tr><td><strong>Crude estimated Odds Ratio</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Income decreased a lot<br>vs Unchanged or increased</td><td>3.83</td><td>(2.93-5.00)</td><td>5.71</td><td>(3.69-8.84)</td><td>2.84</td><td>(1.99-4.05)</td><td>4.89</td><td>(1.46-16.36)</td></tr><tr><td>Income decreased slightly<br>vs Unchanged or increased</td><td>1.18</td><td>(0.85-1.64)</td><td>2.03</td><td>(1.24-3.34)</td><td>0.79</td><td>(0.49-1.27)</td><td>1.04</td><td>(0.24-4.44)</td></tr><tr><td><strong>Covariate-adjusted<br>estimated Odds Ratio</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Income decreased a lot<br>vs Unchanged or increased</td><td>3.63</td><td>(2.70-4.88)</td><td>5.05</td><td>(3.10-8.22)</td><td>3.29</td><td>(2.19-4.93)</td><td>5.98</td><td>(1.38-25.80)</td></tr><tr><td>Income decreased slightly<br>vs Unchanged or increased</td><td>1.37</td><td>(0.95-1.96)</td><td>2.18</td><td>(1.26-3.76)</td><td>1.14</td><td>(0.67-1.92)</td><td>1.15</td><td>(0.25-5.35)</td></tr></tbody></table>

**Abbreviations:** (a)OR=(adjusted) Odds Ratio, CI= 95% Confidence Interval

**Notes:** Covariate-adjusted models for the total sample, men and women are adjusted for age group, gender (except for models stratified by gender) ethnicity, having children, current occupation, income level, household structure (number of adults, children and seniors living in the same household), and HIV status. Covariate-adjusted model for gender non-conforming participants adjusted only on age group, current occupation, income level and household structure to ensure model fit.
<table><caption>**Table 2:** Estimated adjusted Odds Ratio between income change and increased difficulty accessing food, overall and by gender. Logistic regression models. RIGHTS online survey. eThekwini District. South Africa. 2022.</caption><thead><tr><th rowspan="2">Analyses</th><th colspan="2">Total sample<br>(N=1620)</th><th colspan="2">Men<br>(n=681)</th><th colspan="2">Women<br>(n=861)</th><th colspan="2">Gender non-<br>conforming (n=78)</th></tr><tr><th>(a)OR</th><th>95% CI</th><th>(a)OR</th><th>95% CI</th><th>(a)OR</th><th>95% CI</th><th>aOR</th><th>95% CI</th></tr></thead><tbody><tr><td><strong>Crude estimated Odds Ratio</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Income decreased a lot<br>vs Unchanged or increased</td><td>3.83</td><td>(2.93-5.00)</td><td>5.71</td><td>(3.69-8.84)</td><td>2.84</td><td>(1.99-4.05)</td><td>4.89</td><td>(1.46-16.36)</td></tr><tr><td>Income decreased slightly<br>vs Unchanged or increased</td><td>1.18</td><td>(0.85-1.64)</td><td>2.03</td><td>(1.24-3.34)</td><td>0.79</td><td>(0.49-1.27)</td><td>1.04</td><td>(0.24-4.44)</td></tr><tr><td><strong>Covariate-adjusted<br>estimated Odds Ratio</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Income decreased a lot<br>vs Unchanged or increased</td><td>3.63</td><td>(2.70-4.88)</td><td>5.05</td><td>(3.10-8.22)</td><td>3.29</td><td>(2.19-4.93)</td><td>5.98</td><td>(1.38-25.80)</td></tr><tr><td>Income decreased slightly<br>vs Unchanged or increased</td><td>1.37</td><td>(0.95-1.96)</td><td>2.18</td><td>(1.26-3.76)</td><td>1.14</td><td>(0.67-1.92)</td><td>1.15</td><td>(0.25-5.35)</td></tr></tbody></table>

**Abbreviations:** (a)OR=(adjusted) Odds Ratio, CI= 95% Confidence Interval

**Notes:** Covariate-adjusted models for the total sample, men and women are adjusted for age group, gender (except for models stratified by gender) ethnicity, having children, current occupation, income level, household structure (number of adults, children and seniors living in the same household), and HIV status. Covariate-adjusted model for gender non-conforming participants adjusted only on age group, current occupation, income level and household structure to ensure model fit.