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Objectives: Stunting remains a prevalent issue in Tanzania. The consequences of stunting include reduced height, greater susceptibility to disease, and diminished cognitive ability throughout the lifespan. Lack of psychosocial stimulation is associated with increased stunting, particularly in terms of its cognitive impact. The Addressing Stunting in Tanzania Early (ASTUTE) program was a large social and behavior change communication (SBCC) intervention that aimed to reduce childhood stunting in the region by targeting early childhood development (ECD) behaviors. The purpose of this study is to report on the extent to which exposure to ASTUTE might be related to ECD behaviors. Methods: ASTUTE disseminated program messages via a mass media campaign and interpersonal communication (IPC). Logistic regression models were used to explore the relationship between exposure to TV, radio, IPC messages, and key ECD behaviors of female primary caregivers and male heads of household. Results: Among primary caregivers, IPC was positively associated with all ECD behaviors measured. Radio was associated with all behaviors except drawing with their child. TV was associated with all behaviors except playing with their child. Among heads of household, only the radio was positively associated with the ECD behaviors measured. Conclusions for practice: Findings indicate that SBCC interventions that include mass media and IPC components may be effective at promoting parental engagement in ECD behaviors. Significance: We know that ECD is important for a child’s development. We know that parents play a critical role in promoting ECD behaviors. We are still exploring ways to influence parents so that they are more involved in ECD behaviors. The results presented here provide evidence for successful mass media and IPC efforts to improve parents’ ECD behaviors. We hope this study will add more evidence for large interventions such as these to the literature, and we are very hopeful that governments and large international NGOs will prioritize SBCC approaches in the future, especially in locations where face-to-face interventions may be challenging.
Addressing Stunting in Tanzania Early (ASTUTE) involved a large SBCC nutrition project that included mass media communications and IPC interventions focused on improving children’s nutrition and development indicators before a child reaches the age of 2 in order to decrease stunting. IMA World Health led the implementation of this program with funding from UK Aid and the Foreign, Commonwealth & Development Office (FCDO). ECD was a key theme of the program. The theory-based radio spots were broadcast a total of 70,000 times, and each ended with a consistent tagline. TV spots were aired before and during the evening news on national and regional stations for a total of 1198 times. The IPC component of the intervention was implemented by community health workers (CHW) during 30-minute in-home visits. The CHWs counseled mothers an average of 3.6 times in-home and referred children with faltering growth to health facilities for treatment while also educating and supporting mothers to engage in stimulation-related behaviors such as drawing, playing, naming objects, and talking with children. More details about the mass media communications and IPC interventions can be found elsewhere [24]. A total of 4996 mothers, hereafter known as primary caregivers, and 3082 corresponding fathers, hereafter known as male heads of the household, were surveyed across the Lake Zone region of Tanzania, which includes the five regions of Geita, Kagera, Kigoma, Mwanza, and Shinyanga. Only households with a child under the age of 2 years were eligible to participate. A stratified, multi-stage random sample design was used to select questionnaire participants. Within the five participating regions, 243 villages were selected, and participants were randomly sampled within each village. Participant demographics are presented in Table 1. Participant Demographics. * Categories are not mutually exclusive. The questionnaire was administered to participants following the mass media campaign. Questionnaire items were directed at the female caregiver of the youngest child in the home and the male head of household if available and applicable. The research firm IPSOS collected data and used a field team that consisted of 10 supervisors and 50 enumerators. In total, 25% of records were quality-checked by conducting revisits and phone checks. IRB approval was granted by Development Media International’s (DMI) internal IRB and Tanzania’s National Institute for Medical Research. Participation was voluntary, and informed consent was collected before the survey began. Respondents were told that they could stop the survey at any time. Questionnaire items were written in English and then translated into Swahili. The Swahili items were then checked by DMI and IPSOS to ensure that original intent was retained. The questionnaire was piloted and adjusted before being given to participants. The questionnaire contained 169 questions and required approximately 50–60 min to complete. Data were collected on participant demographic characteristics, reported exposure to the intervention, and engagement in key ECD practices. Wealth. Household wealth was estimated using a calculated composite variable comprising multiple questionnaire items that were adapted from a previously validated index [25]. The index comprised two sub-indices, including access to services and ownership of consumer durables. Access to services pertains to the availability of safe drinking water sources (e.g., protected wells and a public standpipe) and safe sanitation (e.g., a flush toilet). For this study, pit latrines were not counted as safe sanitation. Consumer durables included ownership of seven items: a radio, TV, bicycle, motorcycle, mobile phone, boat, or animal-drawn cart. An average of the two indices was used to calculate an overall wealth score, with possible values ranging between 0 and 1. Higher wealth scores indicate higher socioeconomic status. SBCC Intervention Exposure. A separate exposure score was calculated for each of the radio, TV, and IPC intervention components. Exposure to radio was coded “yes” if respondents reported yes to hearing the example spots that endwith a laughing baby sound, or if they reported hearing messages on the radio that advised about maternal/child health/child developments. Exposure to TV was coded “yes” if respondents reported yes to seeing the example image frame(s) on TV or “reported seeing messages on the TV that advised about maternal/child health/child development.” IPC exposure was coded “yes” if respondents reported that they had received an in-home visit from a (community) health worker that advised about maternal/child health/child developments. Exposure to radio, TV, and IPC was estimated for female primary caregivers. IPC targeted females only, so male respondents responded only to questions about exposure to radio and TV and not IPC. ECD Behaviors. Eight items were used to measure female primary caregivers’ ECD behaviors. Four items pertained to talking to children. Examples included “In the last week, have you talked to [your child] about other people in your family?” and “In the past week, have you spoken to [your child] even if they were unable to respond?” Given their thematic similarity, items that pertained to talking were combined into a cumulative talking measure with scores ranging from 0 (answered “no” to all four talking items) to 4 (answered “yes” to all four talking items). The remaining items asked primary caregivers about their practices related to drawing (“In the last week, have you done any drawing with [your child]?”), counting (“In the last week, have you counted things in front of [your child]?”), naming objects (“In the last week, when you have been with [your child], have you named the objects around you so that your baby starts learning words?”), and playing (“In the last week, have you spent time playing with [your child]? (e.g., chasing, playing a game, playing with a toy)”) with their child. Item responses were dichotomized, with the “don’t know” response option coded as missing. Two items were used to measure male heads of households’ ECD behaviors: “In the last week, have you spent time playing with [your child]? (e.g., chasing, playing a game, playing with a toy)” and “When you are holding [your child], do you name the objects around you? (e.g., cow, house, sister, tree).” Item responses were dichotomized, with the “don’t know” response option coded as missing. To ensure that data remained confidential, they were deidentified and shared only with study personnel. The dataset with survey results was cleaned and re-coded in STATA version 16. Further data analysis was performed in SAS 9.4. Frequency statistics were calculated for key demographic variables, intervention exposures, and ECD indicators. Logistic regression was conducted for the ECD variables with each of the exposure variables. All models were adjusted for respondent age, education, and household wealth. Each model was examined for goodness-of-fit and each met acceptable standards.
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