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The burden of childhood stunting in Tanzania is persistently high, even in high food-producing regions. This calls for a paradigm shift in Child Growth Monitoring (CGM) to a multi-dimensional approach that also includes the contextual information of an individual child and her/his caregivers. To contribute to the further development of CGM to reflect local contexts, we engaged the Capability Framework for Child Growth (CFCG) to identify maternal capabilities for ensuring healthy child growth. Ethnographic fieldwork was conducted in Southeastern Tanzania using in-depth interviews, key informant interviews, participant observation, and focus group discussions with caregivers for under-fives. Three maternal capabilities for healthy child growth emerged: (1) being able to feed children, (2) being able to control and make decisions on farm products and income, and (3) being able to ensure access to medical care. Mothers’ capability to feed children was challenged by being overburdened by farm and domestic work, and gendered patterns in childcare. Patriarchal cultural norms restricted women’s control of farm products and decision-making on household purchases. The CFCG could give direction to the paradigm shift needed for child growth monitoring, as it goes beyond biometric measures, and considers mothers’ real opportunities for achieving healthy child growth.
This paper draws on data gathered during three months of ethnographic fieldwork conducted in Malangali, a rural village in Kilosa District, Southeastern Tanzania. The principal investigator, accompanied by a research assistant, both women with a background in medical sociology, lived in the village for three months (in two separate periods) to conduct the fieldwork. From July to September 2015, the researchers conducted a household census, collected anthropometric measurements of under-five children, and conducted 19 focus group discussions. From August to September 2016, we conducted 30 in-depth interviews and five key informant interviews. Participant observations were made throughout the fieldwork period. The findings in this paper are mainly drawn from data collected through participant observations, focus group discussions, and in-depth interviews with biological mothers and fathers of under-five children, irrespective of their nutritional status, and key informant interviews with community health workers (CHWs) and traditional birth attendants (TBAs). As defined by the World Health Organization, the TBAs are persons who assists the mothers during childbirth, and have initially acquired their skills by delivering babies themselves or through apprenticeship to other traditional birth attendants [23]. The fieldwork setting of this research has been described elsewhere [24], but, in short, Morogoro region is considered one of Tanzania’s “food baskets”—i.e., high food-producing regions—but has a relatively high prevalence of stunting (33%) among under-five children [4]. The rural location of Kilosa District, which has a high prevalence of infant malnutrition and anemia in a context of plenty, make it an appealing choice for examining the capabilities that contribute to healthy child growth. The major income-generating activity of residents in this district is small-scale farming. Others engage in petty trade, formal/skilled employment, and self-employment through different forms of unskilled manual labor. While most of the agricultural activities we observed were conducted by men and women alike with a shared aim of feeding the family, harvesting and storing the harvests were depicted as male responsibilities. Threshing maize (kupukuchua mahindi), taking care of children, and doing household chores were characterized as female tasks. Recruitment of participants for key informant interviews: Key informants included community health workers (CHWs) and Traditional Birth Attendants (TBAs). Both CHWs and TBAs are important local health experts, consulted by parents about health and growth issues of their child. In the study village—just like in other villages in Tanzania—there are two CHWs; they are involved in routine child growth monitoring services in the village, and are linked to a dispensary. TBAs are consulted by mothers in relation to maternal issues. The two CHWs were recruited through the village chairman’s support. The CHWs were then requested to link the researcher with TBAs, the second group of key informants in this research. Recruitment of participants for in-depth interviews and focus group discussions: The participants in in-depth interviews and focus group discussions were recruited through the help of CHWs and local leaders, and through the researcher’s social networks. Given their role in providing growth monitoring services to under-five children in the community, and thus having good knowledge of parents with under-five children, CHWs facilitated the identification of some mothers and fathers of under-five children for IDIs from the wider community. Some of the participants for IDIs were identified by the researcher from the wider community through individual social networks developed while living in the field, while others were identified from the clinics’ attendees at the child growth monitoring clinic during participant observation. In this case, during her visits to the growth monitoring clinics, the researcher—in consultation with the CHW—explained the purpose of her presence at the clinic to mothers, and identified mothers for in-depth interviews after their children’s growth was assessed. Furthermore, the participants in the focus group were purposively recruited from the community with the help of the local leaders and other relevant gatekeepers. The researcher requested the local leaders to mobilize a number of potential individuals for recruitment for participation in the focus group discussions. As the principal researcher was living in the community, she visited the individuals in their settings, asking them about their children, and used screening questions to determine the individual’s eligibility for participation. The screening ensured that each participant had a biological child under five years old and is a permanent resident of the village. To avoid recruiting people of the same social network, different entry points were used. After it was established that the individuals met the study’s eligibility criteria, the person was given detailed information about the study, and was asked whether she/he was willing to take part. For individuals who expressed interest and willingness to participate, appointments for discussion were made based on their availability. During data collection, there reached a time when further probing in the interviews and FGDs did not reveal new codes. At this stage, data saturation was reached and we decided to stop recruitment. We conducted in-depth interviews to gain insight into caregivers’ personal views and experiences of the capabilities and contexts underlying the growth of their individual children. The focus Group Discussions aimed to capture general opinions on parents’ capabilities contributing to healthy growth in their under-five children. For interviews and focus-group discussions, topic guides with open-ended questions and probes that covered various topics, including perceptions of child growth, contextual factors underlying child growth, child feeding practices, and experiences with growth monitoring services, were developed using the CFCG and piloted. The issues related to parental capabilities, conversion factors, and agency relevant to healthy child growth were captured using questions on the parents’ daily responsibilities in the family, perceived qualities of a good mother/father in relation to her/his child, mothers’ and fathers’ roles in promoting healthy growth, what parents can do to make their children grow well, what parents think they would need to make their children grow well, the environments that contribute to parents’ ability and/or inability to provide good care for their children, and stories about moments when they wanted to take care of their children but could not. All focus group discussions and in-depth interviews were conducted in Swahili, audio-recorded using a digital recorder, and later transcribed verbatim. Most interviews were arranged in the participants’ homes at times convenient to them. The focus group discussions were conducted in different venues, including school classrooms (after school hours), and the principal researcher’s and participants’ home compounds. In order to gain insights into the socio-cultural and economic contexts in which parents/caregivers and their children live, the principal researcher set up a household and lived in the study community for the entire period of the fieldwork. While in the field, she took part in the village life and participated in daily activities. Passive participant observation was conducted during day-to-day activities such as visiting and chatting with neighbours at their homes, attending village meetings, churches and burial ceremonies. More active participant observation involved cooking with women, participating in the intimate household level child care activities such as feeding and carrying the baby around, accompanying mothers to the child growth monitoring clinic, to the market for groceries, joining women to fetching water from the boreholes, accompanying them to pick greens from gardens near their house and to the farms at a few hours walking distance. Walking around between the houses/neighbourhoods allowed the researcher to observe the daily preparation of food, timing of feeding, whether people preferred or avoided certain types of food, eating arrangements, and groups of men and women busy in farms, et cetera. The researcher’s house location, in particular, placed her in a setting where she could easily meet and observe villagers—particularly early in the morning, and in the evening—as they passed to and from their farms. Furthermore, living and working in the field while pregnant and later together with her newborn, narrowed the distance between the researcher and the women who participated in the research, something that motivated them to freely share their stories. Additionally, her stay in the field and the fact that most of the in-depth interviews were conducted in participants’ homes enabled her to witness the poor condition that some of children and their parents were living in and thus contributed to her understanding of the construction of healthy child growth in this context. Throughout the fieldwork, the researcher wrote fieldnotes on day-to-day encounters, and kept a reflective diary. Data analysis started in the field, as the researchers documented the themes that emerged from day-to-day encounters. This enabled researchers to go deeper into the subsequent focus group discussions/interviews. As Strauss and Corbin [25] emphasize, in ethnography, data collection and analysis are not distinct phases, as an initial analysis of the information gathered in the early phases of fieldwork shapes the future course of the work in a reiterative process. To preserve linguistic authenticity, all transcripts were analyzed in Swahili. The analysis took place at two levels. In the first circle of coding, the inductive and deductive codes were developed. First, a series of inductive codes was developed based on the principles of Grounded Theory [25], whereby theoretical insights emerge from the data rather than being pre-specified. Inductive codes were determined through a close reading and re-reading of transcripts. Second, the deductive coding was performed based on theoretical components of the capability approach that informed the data collection topic guides and maternal capabilities could be identified. The inductive and deductive codes were discussed and refined by the researcher and the fourth author. In the next circle of coding, the codes were categorized into groups of themes—as described in Hennink, Hutter, and Bailey [26]—which reflected maternal capabilities for healthy child growth. All transcripts were imported to and coded using NVivo 11 software (QSR International Pty Ltd., Doncaster, Australia). Additional data from field notes were used to clarify and expand the perspectives of the caregivers in relation to maternal capabilities for healthy child growth. The researcher was a mother and was pregnant at the time of the first round of fieldwork. During the second round, she had two children, and the newborn was with her in the field. The researcher’s role as a mother encouraged the women to trust her and to share their stories about how they navigate the challenges they face in ensuring the healthy growth of their children. Although the researcher and the research assistant were younger than some of the participants, the principal investigator being a mother masked the disadvantage of appearing young to some of the participants, as it brought them into the peer group of adults who were able to empathize with the caregivers’ stories. The study was approved by the Research Ethics Committee at the Faculty of Spatial Sciences of the University of Groningen in Groningen, the Netherlands and the Tanzanian Ministry of Health, Community Development, Gender, Elderly and Children through the Medical Research Coordinating Committee (MRCC) in Dar es Salaam, Tanzania (NIMR/HQ/R.8a/Vol.IX/1974). Additionally, permission was granted by the regional, district, and village leaderships prior to the commencement of the research activities. Full information was provided to participants verbally and as a written copy in Swahili, and written/thumbprint consent was obtained. Participants’ confidentiality and anonymity were ensured by conducting the discussions/interviews in private locations, and removing all identifiers from the interview transcripts prior to data analysis. In the quotations in this paper, pseudonyms are used to protect the participants’ identities.
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