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• Published: 19 October 2016

Prevalence and assessment of malnutrition among children attending the Reproductive and Child Health clinic at Bagamoyo District Hospital, Tanzania

• Omar Ali Juma 1 ,
• Zachary Obinna Enumah 2 ,
• Hannah Wheatley 1 ,
• Mohamed Yunus Rafiq 3 ,
• Seif Shekalaghe 1 ,
• Ali Ali 1 ,
• Shishira Mgonia 4 &
• Salim Abdulla 1  

BMC Public Health volume  16 , Article number:  1094 ( 2016 ) Cite this article

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Malnutrition has long been associated with poverty, poor diet and inadequate access to health care, and it remains a key global health issue that both stems from and contributes to ill-health, with 50 % of childhood deaths due to underlying undernutrition. The purpose of this study was to determine the prevalence of malnutrition among children under-five seen at Bagamoyo District Hospital (BDH) and three rural health facilities ranging between 25 and 55 km from Bagamoyo: Kiwangwa, Fukayosi, and Yombo.

A total of 63,237 children under-five presenting to Bagamoyo District Hospital and the three rural health facilities participated in the study. Anthropometric measures of age, height/length and weight and measurements of mid-upper arm circumference were obtained and compared with reference anthropometric indices to assess nutritional status for patients presenting to the hospital and health facilities.

Overall proportion of stunting, underweight and wasting was 8.37, 5.74 and 1.41 % respectively. Boys were significantly more stunted, under weight and wasted than girls ( p -value < 0.05). Children aged 24–59 months were more underweight than 6–23 months ( p -value = <0.0001). But, there was no statistical significance difference between the age groups for stunting and wasting. Children from rural areas experienced increased rates of stunting, underweight and wasting than children in urban areas ( p -value < 0.05). The results of this study concur with other studies that malnutrition remains a problem within Tanzania; however our data suggests that the population presenting to BDH and rural health facilities presented with decreased rates of malnutrition compared to the general population.

Conclusions

Hospital and facility attending populations of under-five children in and around Bagamoyo suffer moderately high rates of malnutrition. Current nutrition programs focus on education for at risk children and referral to regional hospitals for malnourished children. Even though the general population has even greater malnutrition than the population presenting at the hospital, in areas of high malnutrition, hospital-based interventions should also be considered as centralized locations for reaching thousands of malnourished children under-five.

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Malnutrition has long been associated with poor diet and inadequate access to health and sanitation services. Malnutrition remains a major public health problem particularly in the developing countries where it accounts for more than 90 % of all nutritional related conditions with two third of all cases originating from Sub Saharan Africa, and morbidity and mortality due to malnutrition is high among children under 5 years of age [ 1 ]. Several studies have reported that poverty, inadequate access to a balance diet and underlying diseases (tuberculosis, malaria, diarrhea, etc.) contribute to high levels of malnutrition [ 2 – 4 ]. Death and disease in developing countries are often primarily a result of malnutrition (Rice [ 5 ]), and malnutrition remains the underlying cause of one out of every two such deaths [ 5 – 7 ]. A recent study by the World Health Organization (WHO) also demonstrates that child death and malnutrition have a substantial unequal, global distribution [ 8 ].

Malnutrition remains a key global health issue and a nutritional related condition in Tanzania. It is often assessed through anthropometric analyses that examine weight, stunting and wasting. For the purposes of this paper, the UNICEF definitions were applied as follows. ‘Underweight’ was defined as either moderate or severe, with moderate being below two standard deviations from median weight for age of reference population and severe being below three standard deviations from median weight for age reference population. ‘Wasting’ can be either moderate or severe and is defined as being below two standard deviations from median weight for height of reference population. Finally, ‘stunting’ can be either moderate or severe and is defined as being two standards deviations from median height for age of the reference population.

More importantly, though, there is currently a gap in literature on malnutrition in Tanzania examining populations presenting to hospitals and facilities. All information found for Pwani, Tanzania on malnutrition were household surveys providing only a statistical average for the region. Where the Integrated Management of Childhood Illness (IMCI) program has been well established in Tanzania since 1996 throughout the majority of districts, it is clear that malnutrition remains an issue within Tanzania. However, there is still limited, if any, information for sub-regional data populations and how those populations differ from the aggregated regional population in terms of malnutrition. The objective of this study was to examine the status of malnutrition among male and female children aged 6–59 months in rural and urban areas of Bagamoyo District, Tanzania, specifically that population presenting to the Reproductive and Child Health (RCH) clinic at BDH and surrounding facilities at Kiwangwa (55 km), Fukayosi (45 km), and Yombo (25 km) from Bagamoyo. Populations were presenting mainly for well-child visits, illnesses, and a malaria vaccine trial being conducted by the Ifakara Health Institute. At BDH, a child’s weight measurement is charted according to the child’s age, and his or her progress is marked as one of three categories: green = normal progress; yellow = alert - child at risk; and red = danger – child needs referral. Each child is provided a map of his/her growth. At BDH and surrounding facilities, the nutritional intervention for those children at risk is limited to counselling that advises the caregivers to provide a balanced diet for the child. Culturally appropriate examples of a balanced diet, including porridge with peanuts, rice with meat and or vegetables and fruits, is provided for caregivers. If the child is labelled as “red,” the child is referred to Muhimbili National Hospital in Dar es Salaam, which has a Nutritional Rehabilitation Unit where the child is given additional nutritional supplementation.

It is important, therefore, to further understand and classify the prevalence and status of malnutrition in hospital and facility-based populations, as studies focusing on community prevalence cannot provide us with sub-population data allowing us to determine whether hospital and facility-based nutrition interventions would reach malnourished children. Where larger data sets examine district wide rates of malnutrition (e.g. Tanzania Demographic and Health Survey), this study investigated how rates of malnutrition remain higher than desired even within hospital and facility-presenting populations, which suggests increased nutrition efforts at centralized hospital and facilities locations could benefit overall population nutrition efforts.

Study area and study population

The study was conducted at the Reproductive and Child Health (RCH) clinic at Bagamoyo District Hospital (BDH) and surrounding facilities at Kiwangwa (55 km), Fukayosi (45 km), and Yombo (25 km) from Bagamoyo. BDH is located at the center of Bagamoyo District and serves a population of more than 200,000 people. Major services at BDH include primary care, reproductive health, immunizations and nutritional counselling. Bagamoyo is a district located on the coast Tanzania, approximately 60 km north of Dar es Salaam, the economic and social capital of Tanzania. The accessibility from Dar es Salaam is adequate. Approximately 73 % of Bagamoyo residents own pieces of land of which only 20 % are titled. Literacy for women and men in Bagamoyo is approximately 71 and 60 %, respectively. Average household size was 4.7 persons per household. Rural households were found to have an average household size of 5.0 persons per household, which is relatively larger than urban households (4.2 persons per household). The Zaramo, Kwere, Doe and Zigua comprise the major ethnic groups in the area. Most residents are self-employed in cultivation and fishing activities, which comprise 95 % of total employment; the remaining residents (5 %) are employed by public sectors and engage in other activities such as transportation, woodwork, and small business. Most families live on under $2/day [ 9 , 10 ].

Recruitments and consenting

The study population included children aged 6–59 months attending RCH clinic from January 1, 2009 to December 31, 2009. Children presenting for routine well-child check-ups, specific pathologies, and a malaria vaccine trial being conducted by Ifakara Health Institute were included in the study through the Bagamoyo Morbidity Surveillance System (BMSS). Consent was obtained from participants’ caretakers prior to being enrolled in the study, and research clearance was granted through the Tanzanian Commission on Sciences and Technology (COSTECH).

Data collection and analysis

All children were examined by a nurse and a doctor. Thereafter, the following information was collected: social demographic, anthropometric measures of age, height/length (measured by laying the child down horizontally) and weight. This study used the Mid-Upper Arm Circumference (MUAC) to classify the children, although typically malnutrition is accessed using height and weight. Typically, the nurse or medical attendant would lay a child down on a table with a tape measure attached to the table. Then, without clothes, the child is weighed. Data were entered by two independent data clerks using Data Management Software for clinical trials SigmaSoft. The two data entries were compared and inconsistencies corrected accordingly. Data was first cleaned to remove or correct values that were unrealistic, such as a height of 10 cm or a weight of 100 kg. Anthropometric indices were used to assess the nutritional status. Anthropometric values were compared across individuals in relation of a reference population according to the World Health Organization 2007 Reference Population. Z-scores were used to compare the children who attended Bagamoyo District Hospital to the reference population. Formula used to calculate Z-Score was as follows:

Z-scores use an application of statistical theory to describe the relationship of a child’s anthropometric index to the median index from a reference population. Z-scores were assigned as “missing” to children with missing age, weight for age, weight for height, or height for age. Any values of z-scores considered biologically implausible based on WHO recommendation (flexible exclusion range) were treated as out of range and were excluded in the estimation of proportion of malnutrition. Chi-squared test was used to compare the proportion of stunting, underweight and wasting between the groups. Cut-off point of below −2 Z-score was used to classify children as malnourished, as per definitions out stunting, undernutrition and wasting outlined above. Data analysis was done using Stata11 (Stata Corporation, Texas, USA). Standard editions and significant level was kept at 5 %. Samples were divided into 6–23 and 24–59 months categories in accordance with WHO macro to calculate Z-scores [ 11 ].

The study population consisted of 63,237 children under the age of five. The study population was divided primarily into two age group of 6–23 months and 24 to 59 months, all of whom attended the RCH clinic in Bagamoyo District Hospital and surrounding facilities at Kiwangwa (55 km), Fukayosi (45 km), and Yombo (25 km) from Bagamoyo. The minimum age was 6 months and maximum age was 59.93 months with mean of 23.50 months and standard deviation 14.01 months. The minimum and maximum height was 50 cm and 125 cm respectively with mean of 80.05 cm and standard deviation of 10.85. Minimum weight was 3.5 and maximum was 25 kg with mean of 10.60 kg and standard deviation of 2.68 kg.

There were more boys (53.6 %) compared to girls with a sex ratio of boys/girls was 1.2:1. The majority of children were aged 6–23 months (see Table  1 ).

The hospital and facility attendance rate was higher among boys between ages of 6–23 months (see Table  1 ). The mean z-scores for boys were lower compared to girls at 6–23 months age group (see Table  1 ). With the exception of stunting, girls aged 24–59 months have lower z-scores value than boys (see Table  1 ).

Anthropometric analysis

Overall proportion of stunting, underweight and wasting was 8.4, 5.7 and 1.4 % respectively. Boys were significantly more stunted, underweight and wasted than girls ( p -value < 0.05) Table  2 .

Children aged 24–59 months were more underweight than 6–23 months ( p -value = <0.0001). No statistical significance difference was determined between the age groups for stunting and wasting when examining age alone. On the other hand, boys in either age group were more stunted than girls of the same age group. Children living in rural area were more malnourished than children living in urban areas (see Table  2 ).

The results of this study suggest that malnutrition remains a problem within Bagamoyo and surrounding areas. While our results focus on only one district hospital and three surrounding health facilities in Tanzania, they agree with national household surveys that rural populations have higher rates of malnutrition than urban populations within Tanzania. More importantly, though, there is currently a gap in literature on malnutrition in hospital and facility-based populations under-five. The objective of this study was to examine the status of malnutrition among male and female children aged 6–59 months in rural and urban areas of Bagamoyo District, Tanzania, specifically that population presenting to the RCH clinic at BDH and selected surrounding rural facilities.

As malnutrition has been widely documented in resource-poor settings [ 12 – 14 ], it is extremely important given its links to morbidity, mortality and disease. Our study confirmed that malnutrition remains an issue within and surrounding Bagamoyo. Across the axes of gender and geographical location (i.e. urban v. rural), our findings indicate a concerning level of malnutrition as assess by stunting, underweight, and wasting in both groups aged 6–23 months and 24–59 months (see Table  2 ). Similarly, as Table  2 indicates, our study also confirms a significant difference of malnourishment between urban and rural populations [ 15 – 17 ], even among children with access to hospital and facility services.

Beyond analysing the prevalence and assessing levels of malnutrition along anthropometric criteria, the risk factors and underlying conditions that contribute to malnutrition must be discussed. Among other factors, high birth rates, poverty, lack of education, disease prevalence [ 18 ], have a long history of correlation and/or causation to malnutrition levels. Our data substantiated Smith’s [ 16 ] claim that urban children have better nutrition due to overall more favourable socioeconomic factors in urban areas to rural such as market for fish and variety of food options.

Similarly, a number of studies have shown a relationship between education and malnutrition [ 19 – 22 ]. Arguably, educational differences contribute to the unequal distribution of malnutrition among urban and rural residents. We suggest, however, that among children presenting to BDH, malnutrition remains an issues even within the hospital-presenting population. Where access and availability of the hospital and its services may demonstrate lower than national averages, this study concluded that malnutrition remains a problem even within hospital-based settings.

Interventions – What was done? What else is needed?

In light of MDG1 and MDG4, malnutrition in resource poor settings has been a major focus of both governmental and non-governmental interventions. Where our study was conducted at just over the halfway point of the MDG timeline (2009), these findings contribution to assessing the current trend of poverty, malnutrition and child health in Tanzania. The National Poverty Eradication Strategy, the Tanzania Development Vision 2025, The Tanzania Mini-Tiger Plan, The Poverty Reduction Strategy Paper, and the National Strategy for Growth and Reduction of Poverty are major strategies focused on drastically reducing poverty and creating high quality livelihoods for Tanzanians. Rooted in neoliberalism, many of these policies focus on reducing poverty as a means to improving quality of life, such as nutritional status.

Our study suggested that malnutrition rates among patients presented to BDH are lower than average for the Pwani Region according to the 2010 Demographic and Household Survey; data collection for the 2010 DHS overlapped with this study. While Bagamoyo may be unique in its urban and rural population distribution, the difference is also do to the population studied. Although those attending BDH resided within Pwani Region, they are not a representative sample of the region whereas the DHS sampling techniques lead to a regionally representative average. According to WHO, the right to health must be available, accessible, acceptable, and of good quality. As an inclusive right, the right to health also demands access to safe and potable water and adequate sanitation, an adequate supply of safe food, nutrition and housing, occupational health, environmental conditions, and access to health-related education and information. Given the more urban setting of BDH compared to the entire Pwani Region, many of these determinants of quality healthcare are present to a much higher degree within the BDH RCH clinic. Thus, the very notion that patients have access to BDH accounts for part of the difference in malnutrition rates in our study population compared to Pwani Region. However, the data also suggested that even with these increased resources, the presenting population remains malnourished.

Implications

Bagamoyo District Hospital encounters a unique population of children under-five from both urban and rural areas. Given the large population of patients that present for both well child checks and immunizations, as well as patients presenting with other pathologies (e.g. malaria, infection, pneumonia, etc.), unique approaches can be taken to curb the malnutrition rates. As stated above, it is imperative to develop a deeper understanding of food, agricultural and fishing changes, and the ways in which these economic changes affect nutritional status of children. In developing a deeper sensibility of poverty’s interaction with malnutrition in Bagamoyo, additional interventions can be targeted to improve both immediate and generational malnutrition rates. Hospital-based nutrition interventions should be considered alongside community-based intervention. Hospital-based interventions can focus on interventions that take advantage of reaching large groups of caregivers and children at one time. Basic nutritional education is currently only provided to at-risk children for weight/age ratio at BDH. The nutritional education comes primarily in the form of verbal instructions to provide the child with a balanced diet. Due to multiple contributing factors to malnutrition, verbal instructions to caregivers about providing a balanced diet are unlikely to be very effective in addressing malnutrition. In addition, because MUAC measurements are not being regularly used, many at-risk children are being missed. However, the large number of caregivers (approximately100 caregivers present five days a week) at RCH at BDH provides a unique opportunity to reach thousands of at-risk children in a centralized location. By providing additional educational workshops on cooking preparation and food preservation demonstrations, breastfeeding support and access to fortified staples at RCH clinics, many at-risk children in high malnutrition areas could be reached with relatively small increases in staff and resources.

Limitations

Limitations might influence the results and conclusions from this study. One limitation is that measurements of children’s height by laying the child down may always have a source of human error. Additionally, another limitation that could be improved in future studies is to assess malnutrition at multiple points in time. In doing so, one could investigate whether or not interventions (e.g. such as nutritional counselling) have been effective. Data in our study was limited to a single point in time.

In our study of 63,276 children, hospital and facility-attending populations of children under-five still remain at risk for higher than expected malnutrition rates in Bagamoyo, Tanzania. General malnutrition programs focus on community and household interventions, which are needed as the general population has even greater malnutrition than the population presenting at the hospital. In areas of high malnutrition, however, hospital-based interventions should also be considered as centralized locations for reaching thousands of malnourished children under-five, such as those presenting to Bagamoyo District Hospital.

Abbreviations

Bagamoyo District Hospital

Bagamoyo Morbidity Surveillance System

Community health workers

Tanzanian Commission for Science and Technology

Demographic and Household Survey

Human immunodeficiency virus / Acquired immune deficiency syndrome

Millennium Development Goals

Non-governmental organizations

Reproductive and Child Health

United Nations Children’s Fund

World Health Organization

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Acknowledgements

The authors would like to acknowledge several individuals without whom this project would not have been possible. First, we would like to thank The Tanzanian Commission on Science and Technology (COSTECH) for facilitating the research, as well as the Ifakara Health Institute. We would also like to extend our sincere gratitude to the RCH staff, Ifakara Health Institute field staff, and medical officers.

The research conducted was funded by the Ifakara Health Institute.

Availability of data and materials

The data used to generate the results of this study may contain restrictions. However, the data used in this report are available from the corresponding author upon reasonable request.

Authors’ contributions

OJ served as lead investigator for the study. ZOE, HW, MYR helped draft the manuscript. AA performed data analysis. SS works under Ifakara Health Institute, and SM helped execute the research at Bagamoyo District Hospital. SA oversees RCH clinic where study gathered participant data. All authors read and approved the final manuscript.

Competing interests

The authors declare that they have no competing interest.

Consent for publication

Not applicable.

Ethics approval and consent to participate

Consent for this study was obtained from the patient’s caregivers. The study was approved through the Tanzania Commission on Science and Technology.

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Ifakara Health Institute, Bagamoyo Branch, PO BOX 74, Bagamoyo, Tanzania

Omar Ali Juma, Hannah Wheatley, Seif Shekalaghe, Ali Ali & Salim Abdulla

Johns Hopkins University School of Medicine, Baltimore, USA

Zachary Obinna Enumah

Department of Anthropology, Brown University, Providence, USA

Mohamed Yunus Rafiq

Bagamoyo District Hospital, Bagamoyo, Tanzania

Shishira Mgonia

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Juma, O.A., Enumah, Z.O., Wheatley, H. et al. Prevalence and assessment of malnutrition among children attending the Reproductive and Child Health clinic at Bagamoyo District Hospital, Tanzania. BMC Public Health 16 , 1094 (2016). https://doi.org/10.1186/s12889-016-3751-0

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Published : 19 October 2016

DOI : https://doi.org/10.1186/s12889-016-3751-0

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Addressing child undernutrition in Tanzania with the ASTUTE program

• E Beckstead 1 ,
• G Mulokozi 2 ,
• M Jensen 1 ,
• J Smith 1 ,
• M Baldauf 1 ,
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• M. Linehan 2 ,
• S. Torres 2 ,
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BMC Nutrition volume  8 , Article number:  29 ( 2022 ) Cite this article

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Optimal infant and young child feeding practices (IYCFP) reduce childhood stunting and are associated with additional health benefits. In Tanzania, IYCFP are far from optimal where 32% of children under the age of 5 years are stunted. The purpose of this study was to examine whether behavior change communication focused on reducing child undernutrition was associated with improved IYCFP in Tanzania.

A cross-sectional survey was administered to approximately 10,000 households with children under the age of 2 at baseline and endline. Bivariate analyses and logistic regression was used to examine the relationship between exposure to behavior change communication and timely initiation of breastfeeding, exclusive breastfeeding, continued breastfeeding at one year, timely complementary feeding (CF), minimum meal frequency (MMF), minimum dietary diversity (MDD), and minimum acceptable diet (MAD).

Mothers who heard a radio spot about IYCFP were more likely than mothers who had not heard a radio spot about IYCFP to begin complementary foods at six months. Their children were also more likely to achieve MMF, MDD, and MAD with odds ratios of 2.227 ( p  = 0.0061), 1.222 ( p  = 0.0454), 1.618 ( p  =  < .0001), and 1.511 ( p  = 0.0002), respectively. Mothers who saw a TV spot about IYCFP were more likely to have greater odds of knowing when to begin complementary feeding, feeding their child a minimally diverse diet (4 food groups or more), and serving a minimum acceptable diet with odds ratios of 1.335 ( p  = 0.0081),

1.360 ( p  = 0.0003), and 1.268 ( p  = 0.0156), respectively.

Exposure to behavior change communication in Tanzania was generally associated with some increased knowledge of optimal IYCFP as well as practicing IYCF behaviors. Behavior change communication planners and implementers may want to consider conducting similar campaigns as an important component of behavior change to reduce undernutrition and poor health outcomes in developing settings.

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Evidence-based Infant and Young Child Feeding Practices (IYCFP) are defined as essential nutritional behaviors for children under the age of 2 and are an effective intervention used to improve children’s health [ 1 ]. These practices include breastfeeding within the first hour of life, breastfeeding exclusively for the first six months of life, beginning complementary feeding at 6–8 months, feeding children diverse diets, and feeding children at least the minimum number of times per day (minimum meal frequency, MMF) [ 2 ].

Sub-optimal IYCFP presents significant challenges and is a public health concern in Tanzania. Chronic undernutrition under the age of 5 is associated with less schooling, late entry into starting school, and between 22 to 45% less income throughout a lifetime [ 3 ]. Tanzania has faced low rates of optimal IYCFP for many years. One study indicates that only 46.1% of mothers in Tanzania initiated breastfeeding within the first hour, and 41% to 49.9% of infants under the age of 6 months were exclusively breastfed [ 4 , 5 ]. Additionally, about half (49.3%) of children 6 to 23 months of age had MDD, 70.3% met the standard for MMF [ 4 ], and 30.1% received a MAD [ 6 ]. MDD is defined as the consumption of foods from at least 4 food groups within a period of 24 h [ 7 ].

Failure to provide a child with optimal IYCFP is associated with stunting and severe illness [ 1 ]. Stunting in children is illustrated by low-height-for-age; stunted individuals are much shorter than their healthy peers, even years later [ 1 ]. Other long-term effects of stunting include permanently reduced cognitive and motor development, increased risk of degenerative diseases, premature death, poor performance in school, and decreased economic productivity [ 8 , 9 , 10 ]. About 32% of children under the age of 5 in Tanzania are stunted [ 6 ]. Tanzania’s National Nutrition plan aims to reduce stunting to 28% by 2021 [ 6 ]. By 2019, substantial progress had been made towards this goal, though an estimated 2,700,000 children under 5 years remained stunted [ 6 ].

While integrated communication and capacity building programs are a strategy often utilized to disseminate information, shape norms, and influence a mother's nutrition and feeding practices [ 11 ], media-based efforts are often used to create awareness of local issues and generate attention from the community [ 11 ]. Literature indicates that programs which incorporate various communication strategies play a central role in addressing the nutrition of young children in Tanzania [ 12 ]. While not in Tanzania, one study analyzed the combined impact of integrated programs using capacity building, mass media interventions, community mobilization, and interpersonal communication (IPC) on breastfeeding and complementary feeding (CF) practices [ 7 ]. This large-scale study conducted in Vietnam, Ethiopia and Bangladesh found that CF indicators improved over time among both groups: those exposed to all 3 interventions (IPC, mass media, community mobilization), and those exposed to standard IPC but less intensive mass media and community mobilization [ 7 ]. However, there was no differential improvement among the group that was more intensively exposed to mass media and community mobilization [ 7 ]. Specifically relating to Tanzania, studies have confirmed the association between dietary diversity and reduction of undernutrition among children and others have suggested that behavioral change communication strategies may help reduce rates of undernutrition. However, studies using large-scale data from Tanzania to examine the direct association between mass media and IYCFP have not been identified in literature [ 12 , 13 ].

The purpose of this study was to examine the relationship between behavior change communication and critical child nutrition and health behaviors in Tanzania. Specific research questions included:

Did parental knowledge about and behaviors of IYCFP change over time before and after the behavior change communication was implemented?

Is communication campaign exposure associated with increased parental knowledge about IYCFP?

Is communication campaign exposure associated with increased infant and young child feeding practices? (i.e. MMF, diet diversity, initiation of breastfeeding within 24 h, exclusive breastfeeding for the first 6 months, complementary feedings starting at 6–8 months)

Study design

From 2015–2020, IMA World Health (IMA) implemented the Department for International Development-funded “Scaling up Growth: Addressing Stunting in Tanzania Early (in the under 5’s)” (ASTUTE). The project was designed in close collaboration with the Tanzanian Ministry of Health. ASTUTE was specifically designed to support the Tanzania’s nutrition strategy, including a mandate to build the capacity of District Nutrition Officers (DNuOs) to manage and coordinate, at the district level, the nine nutrition-relevant government sectors through Council Multisectoral Steering Committees for Nutrition (CMSCN), mirroring the coordination at the national level by the High Level Steering Committee on Nutrition (HLSCN). The National Institute for Medical Research provided ethical clearance.

The behavior change communication was implemented in five regions of the Lake Zone in Tanzania (see Fig.  1 ). These are Geita, Kagera, Kigoma, Mwanza, and Shinyanga with a collective population of 10.2 million and over 750,000 stunted children. These regions were selected for their documented high prevalence of stunting and anemia and poor infant and child feeding. The behavior change communication focused on three major objectives:

Building capacity of the local government to implement and manage high quality nutrition-specific and nutrition-sensitive activities to reduce childhood stunting, including facility-based nutrition services and community out-reach by community health workers (CHWs), through joint planning, skill training, on-going mentoring and performance monitoring interventions to prioritize and allocate district resources for coordinated nutrition activities, supplies, and messages.

Increasing the knowledge of mothers and caregivers to develop a new understanding of what children need to eat to thrive, and to adopt and support improved child feeding practices. This was implemented by CHWs and volunteers working with community-based organizations who mobilized communities and conducted home visits using the negotiating for behavior change strategy; carried out support groups for mothers, male head of households, and other caregivers; and implemented the positive deviance/hearth approach to rehabilitating malnourished children. Additionally, ASTUTE increased mothers’ and caregivers’ knowledge through large-scale radio and TV campaigns implemented for the duration of the project. Messaging for all activities revolved around stunting prevention practices including early and exclusive breastfeeding, appropriate complementary feeding, hand hygiene and sanitation, early childhood development, and men’s support for women during pregnancy and post-delivery.

Increasing the knowledge of adolescent girls, reproductive age women, mothers, caregivers, households and community decision makers through facility-based health promotion and community and household-based

Map of intervention area. This map was provided by the ASTUTE program and is used with permission

In the designated regions, an evidence-based communication campaign was implemented between June 2017 and March 2020, which included radio and TV campaigns (17.6 million reached), mobile outreach (8.4 million reached through direct messaging), and IPC in the form of home visits (6.4 million reached). The radio spots were theory-based and lasted 60 s. They were broadcast 10 times a day for a total of 70,000 times. TV spots were also 60 s and aired a total of 1, 198 times. They aired on three different national/regional stations before and during the news.

A mother’s knowledge about IYCFP, as well as environmental and social influences are important determinants of her nutrition related behaviors. Social Cognitive Theory (SCT) is a well-established theoretical approach that may be utilized to address parental feeding practices and to inform behavior change communication development [ 14 ]. The constructs of SCT are cognitive influences, environmental influences, and supporting behavioral factors such as self-efficacy [ 15 ]. Many communication campaigns utilize techniques from SCT by modeling desired behaviors on television using actors that are culturally or ethnically similar to the audience [ 11 ]. When done correctly, behavior change strategies can help increase the self-efficacy of the audience, and can address inappropriate cultural or social practices that adversely affect childhood nutrition status [ 11 , 12 ]. The use of SCT allows for a more thorough understanding of nutrition-related behaviors [ 16 , 17 ].

The ASTUTE program utilized a cross-sectional survey that was distributed to 5,000 households before the behavior change communication was implemented and an additional 4,996 households after the behavior change communication was implemented. Inclusion criteria included having a child under two years (0–23 months) of age and living in the regions where the campaign took place. Respondents who did not meet these criteria were excluded from the study. Survey questions were directed to the female caregiver of the youngest child in the household, and if available, to the male head of household. Consent was received before the survey was administered, and participants understood that their participation was voluntary, they could stop at any time, and the potential risks and benefits associated with their participation. The survey was developed in English, and then translated to Swahili. It was piloted and edited, and ultimately included 169 questions which aimed to measure participants’ exposure to the communication campaign and other outcomes.

Data were collected by a field team consisting of 50 enumerators and 10 supervisors. All field team members received a two-week training prior to participant recruitment and data collection. Their goal was to recruit 5,000 households during three rounds of surveys. Survey participants were selected using a stratified, multi-stage random sample design. During the baseline round, 243 villages were included and participants were randomly sampled within each village. During the following two rounds of surveys the same villages were used, but participants were again randomly selected. Interviews were conducted in the participants’ homes and lasted on average 50–60 min. Data were collected digitally using smartphones and PDAs (personal digital assistants).

At baseline, 5,000 female caregivers and 1,114 male heads of household were surveyed from January to February 2017. At endline, 4,993 female caregivers and 3,084 male heads of household were surveyed from January to February 2020. While the survey used in this study was not validated as part of this work, it was largely based on previously validated instruments such as the Demographic and Health Surveys and was pilot tested in the field before baseline data were collected. Behavior change communication objectives analyzed during the study included the reach and exposure of the campaign, change of key indicators, and the association between exposure and key indicators.

Authorization for this research and intervention was obtained from the Ministry of Health in Tanzania and Development Media International’s (DMI) internal IRB. Data quality was checked by 11 controllers, and if the quality of a previously completed interview could not be validated, a new interview was conducted. Additionally, raw data was checked for outliers and invalid answers.

Measurement

Female caregivers provided demographic and household information in the survey to understand the distribution in each sample group. Before data analysis occurred, a single binary definition was created for each variable of the campaign. Primary and secondary outcome variables were also defined for each campaign message theme.

A wealth index variable was created to estimate relative household income. This variable was based on the index created by Briones [ 18 ]. It includes household access to services such as safe water and sanitation as well as ownership of goods including radio, TV, bicycle, motorcycle, automobile, mobile phone, boat, and animal-drawn cart. The score is the average of the services and goods scores. Values range between 0 and 1, with wealth increasing as the value gets closer to 1.

Two female and two male media exposure variables were created. Female exposure to radio was defined as ‘yes’ if women reported recalling a radio message that discussed maternal nutrition, exclusive breastfeeding, or child nutrition after six months. Female exposure to TV was defined as ‘yes’ if women reported recalling a TV message about maternal nutrition, exclusive breastfeeding, or child nutrition after six months. TV and radio variables were also created for males using the same methodology.

A variable was created to measure overall exposure to the behavior change communication. This variable, which only includes responses from mothers, assesses whether the respondent had no exposure to the behavior change communication, heard or watched any behavior change messages (media only), had any IPC-related interactions (IPC only), or both media and IPC.

Seven variables measuring feeding practices were used, in alignment with World Health Organization (WHO) standards for IYCF indicators [ 10 ]. They included timely initiation of breastfeeding, exclusive breastfeeding, continued breastfeeding at one year, timely complementary feeding (CF), minimum meal frequency (MMF), minimum dietary diversity (MDD), and minimum acceptable diet (MAD). These variables are described below.

Timely initiation of breastfeeding

Timely initiation of breastfeeding, as defined by the WHO, means beginning breastfeeding within the first hour of life [ 10 ]. Putting baby to breast immediately or within the first hour was considered timely. The question used to create this variable was “how long after birth did you first put (name) to breast?”.

Exclusive breastfeeding

For exclusive breastfeeding, the primary outcome was defined as “proportion of mothers of children 0–6 months who are currently breastfeeding and report they haven’t given the child any other food/liquids.” This was assessed by asking participants whether they are breastfeeding and to select food and drinks they had fed their infant within the last 24 h.

Continued breastfeeding at one year

Continued breastfeeding at one year was assessed by asking mothers of infants ages 12–15 months whether they are “still breastfeeding (name).”

Timely Complementary Feeding (CF)

For complementary feeding, mothers of children ages 6–8 months were asked: “Have you introduced (name) any other fluids or foods besides breast milk?” “How old was (name) when he/she was first fed something other than breast milk?”.

Minimum Meal Frequency (MMF)

MMF is defined by the WHO as being fed 2 times per day for breastfed infants 6–8 months, 3 times for breastfed children 9–23 months, and 4 times for non-breastfed children 6–23 months [ 2 ]. Based on these standards, participants were asked the age of their child and whether they are breastfed. They were then asked if the child ate anything when they woke up in the morning, anything between then and lunch, anything at lunch, anything between lunch and dinner, anything at dinner, and anything after dinner.

Minimum Dietary Diversity (MDD)

This variable measured how many food groups were represented in the child’s (6–23 months) diet in the previous day. Participants were asked to select whether their child had eaten specific types of grains, legumes, dairy, flesh, eggs, and fruit/vegetables. Children who ate from four or more of these groups were coded as having MDD.

Minimum Acceptable Diet (MAD)

If children ages 6–23 months achieved MDD and MMF, then they were coded as having a MAD.

The raw data were cleaned, recoded if necessary, and analyzed using SAS version 9.4. The baseline data were first compared to the endline data to determine change for the key indicators.

A chi-square test was conducted to determine whether these differences in key indicators.

between baseline and endline were statistically different. A multiple logistic regression model was built to determine the relationship between exposure to the media campaign and increased IYCFP among female caregivers. The model controlled for maternal and male head of household age, education, child age, and wealth.

There were 9,996 female survey participants (combining those at baseline and at endline) who answered questions (see Table 1 ). Demographic characteristics were relatively consistent from baseline to endline. Most respondents reported living in a rural setting (86%) with crop farming as the main occupation (70.77%). Most were Christian (83.32%) and were in a monogamous marriage (74.02%). All questions regarding feeding practices related to those who had children between 0 and 24 months with the average age of child in that demographic being 9.5 months.

While baseline data were not available for all variables, at the end of the campaign, nearly all reported behaviors had increased at endline (see Table 2 ). Endline data demonstrate compliance was high for timely initiation of breastfeeding (83.62%), exclusive breastfeeding (83.25%), timely complementary feeding (77.62%) and continued breastfeeding through 1 year of age (90.79%).

Mothers who recalled hearing a radio ad about IYCFP were more likely to practice key IYCFP behaviors and have knowledge than those who had not heard radio ads (see Table 3 ). For example, mothers who recalled hearing a radio ad about IYCFP had greater odds of achieving timely initiation of CF at six months, MMF, MDD, and MAD.

Male head of household exposure to radio ads was not as often associated with higher knowledge or behaviors as was maternal exposure (see Table 4 ). Specifically, male heads of household who recalled hearing a radio ad about IYCFP had greater odds of the mother knowing when to initiate CF and practicing timely initiation of breastfeeding.

Maternal exposure to TV ads focused on key child messages was associated with greater knowledge and behavior in a few instances (see Table 5 ). Examples include knowledge of CF, feeding children a diverse diet (4 food groups or more), and serving a MAD.

Similar to maternal exposure, when male heads of household reported exposure to these TV advertisements their child had greater odds of having a diverse diet and a MAD. However, male heads of household who recalled seeing these messages had lower odds of the mother knowing when to begin breastfeeding (see Table 6 ).

The association between overall behavior change communication exposure, and/or IPC, and knowledge and behaviors of mothers related to IYCFP showed mixed results (see Table 7 ).

Knowledge of when to initiate breastfeeding was significantly lower for those who had IPC only or IPC plus media exposure compared to those with no behavior change communication exposure. Inversely, MAD was significantly higher for those with IPC only or IPC plus media exposure compared to those with none.

This study examined the impact of a comprehensive capacity-building and communication campaign designed to improve IYCFP in Tanzania. Results indicated that households in the study area generally experienced improved IYCFP knowledge and behaviors over time. Further, households with mothers and male heads of household who heard nutrition-specific communication messages through mass media were often associated with higher IYCFP. Lastly, overall exposure as measured using general ASTUTE messages and IPC through clinics and other similar venues was not consistently associated with higher levels of IYCFP.

Radio exposure

Mothers who remembered hearing at least one IYCFP radio ad were more likely to provide timely CF, provide MMF, provide MDD for the child and provide MAD, when compared to mothers who did not hear a radio ad. This positive association is consistent with other studies that report a 14.7% increase in MMF, 16.3% increase in MDD, and 22% increase in MAD after being exposed to both IPC and a media campaign  [ 19 ]. MAD showed the greatest association with mother’s radio exposure. In contrast, MMF practices showed the smallest association. A similar study conducted in Ethiopia reported that mothers who recalled hearing at least three radio spots had 1.06 and 2.9 times the odds of achieving MMF and MAD [ 20 ]. The Ethiopian study, however, deviates from the current study’s findings in that MMF was not associated with media exposure in Ethiopia [ 20 ]. Interestingly, mothers who were exposed to a radio ad were less likely to know when to initiate breastfeeding compared to mothers who did not hear a radio ad. This finding was inconsistent with a similar study which reported an increase of 3.01 in the mean regression score and an 8.5% increase in mothers from the intervention group who knew when to initiate breastfeeding [ 21 , 22 ]. This result is unexpected and could be due to a confounder that was not accounted for in the study. One potential confounding factor is inadequate promotion of early initiation of breastfeeding at health facilities and among traditional birth attendants. Radio exposure among male heads of household varied slightly, with fewer significant associations.

When the male head of household recalled hearing a radio ad, mothers had greater odds of knowing when to initiate breastfeeding, and were more likely to achieve timely initiation of breastfeeding compared to when the male head of household had not heard a radio ad. No other studies were found that related a male head of household hearing an ad to the mother’s knowledge of when to initiate breastfeeding and achieving timely initiation of breastfeeding.

TV exposure

Mothers who saw at least one TV ad were more likely to feed their child a MAD, achieve MDD for their child, and know when to begin CF, compared to mothers who did not recall seeing a TV ad. Other studies had similar results, such as a 44.78% increase in CF knowledge among tribal mothers in India after viewing a video related to breastfeeding and CF practices [ 23 ], an increase in complementary feeding practices for mothers who were exposed to mass media [ 19 ], and a 2.7% increase in knowledge about when to initiate CF [ 22 ]. Another study in India found that exposure to a video about IYCFP was associated with an increase in MDD by 6.67% [ 23 ]. Furthermore, mothers were more likely to achieve MAD and provide MDD for their child when the male head of household had seen at least one TV ad compared to mothers with a male head of household who did not see a TV ad [ 23 ]. Not all studies have found positive significant associations between TV ads and IYCFP. A study in Bangladesh found exposure to TV ads did not significantly impact the amount of MAD and MDD in the population [ 19 ], though this trend was not true of radio ad exposure.

Mass media exposure

The value of mass media campaigns has been demonstrated in previous studies [ 24 , 25 , 26 ]. A large-scale television campaign in Vietnam reported that exposure increased a mother’s likelihood of exclusive breastfeeding and concluded that mass media should be part of a comprehensive program [ 26 ]. Another review article analyzed the outcomes of various mass media campaigns and determined that mass media does have the capacity to influence positive behavior changes while preventing negative changes which impact health on a large scale [ 24 ]. Our results are consistent with these findings. While media exposure was not positively associated with improvements among all IYCFP, TV and radio exposure was generally associated with several important changes in IYCF knowledge and behaviors.

Limitations

A few limitations need to be considered when generalizing the results from this study. Most importantly, this study did not include a control group. While comparisons over time showed positive trends, respondents or communities without the intervention would have been helpful in controlling for a host of other possible influencing factors. Hence, much of the analysis considered self-reported intervention exposure. Additionally, since the ASTUTE program implemented various social behavior change campaigns apart from this behavior change communication, other program elements may have played a role in impacting IYCFP. While still subject to several limitations, the current study benefited from a robust sample and strong measures with results suggesting the intervention was associated with a number of positive outcomes.

Future research

Future IYCFP research would benefit from strong study design strategies. Further, future studies should evaluate cost considerations associated with mass media and IPC campaigns to assess which elements are the most cost effective.

The findings from this study suggest that a large, integrated behavior change communication inclusive of strategic communication strategies and approaches may help improve key child health behaviors. These findings further reinforce the value of targeted mass media campaigns which use TV and radio to influence health. Ultimately, the behavior change communication in Tanzania provides evidence to support similar comprehensive campaigns to reduce undernutrition and poor health outcomes in developing settings.

Availability of data and materials

The data that support the findings of this study are available from IMA World Health but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data is however available from the authors upon reasonable request and with permission of IMA World Health. Contact Benjamin Crookston if you would like to request data from this study.

Abbreviations

Scaling up Growth: Addressing Stunting in Tanzania Early (in the under 5’s)

• Infant and young child feeding practices

Complementary feeding

Minimum meal frequency

Minimum dietary diversity

Minimum acceptable diet

Interpersonal communication

IMA World Health

District Nutrition Offices

Council Multisectoral Steering Committees for Nutrition

High Level Steering Committee on Nutrition

Community health workers

Social cognitive theory

Personal digital assistants

Development Media International

World Health Organization

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Acknowledgements

The authors would like to acknowledge the work of IMA Health and their collaboration on this project.

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EB, MJ, and BC analyzed and interpreted data. EB and MJ prepared tables. JS, MB, MJ, and EB drafted the main manuscript text. GM, KD, ST, ML, JW, JG, PCH and BC provided substantial revisions. All authors reviewed the manuscript. The author(s) read and approved the final manuscript.

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The data used for this paper was collected under IRB approval from Development Media International’s (DMI) internal IRB. The study was conducted in compliance with DMI’s ethical guidelines. Participants in Tanzania were informed that participation was voluntary and informed consent was received before beginning the survey. All the participants were 18 years of age or older. Information collected about children was collected through the parents/guardians. Participants were allowed to stop the survey at any time.

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Beckstead, E., Mulokozi, G., Jensen, M. et al. Addressing child undernutrition in Tanzania with the ASTUTE program. BMC Nutr 8 , 29 (2022). https://doi.org/10.1186/s40795-022-00511-0

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