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Suboptimal breastfeeding practices, early initiation of complementary feeding, and monotonous cereal-based diets have been implicated as contributors to continuing high rates of child undernutrition in sub-Saharan Africa. Nutrition-sensitive interventions, including agricultural programs that increase access to nutrient-rich vegetables, legumes, and animal-source foods, have the potential to achieve sustainable improvements in children’s diets. In the quest to evaluate the efficacy of such programs in improving growth and development in the first 2 years of life, there is a role for mixed methods research to better understand existing infant and young child feeding practices. This analysis forms part of a longitudinal study assessing the impact of improvements to poultry health and crop production on diets and growth of 503 randomly selected children from eight rural communities in Manyoni District in central Tanzania. Using an explanatory sequential design, the quantitative phase of data collection was conducted between May 2014 and May 2016, comprising six monthly structured questionnaires, four monthly household-level documentation of chicken and egg consumption, and fortnightly records of children’s breastfeeding status. The subsequent qualitative phase involved in-depth interviews with a subset of 39 mothers in October 2016. Breastfeeding was almost universal (96.8%) and of long duration (mean = 21.7 months, SD = 3.6), but early initiation of complementary feeding was also common (74.4%; mean = 4.0 months, SD = 1.8), overwhelmingly driven by maternal perceptions of insufficient milk supply (95.0%). Chicken and eggs were infrequently eaten, but close associations between maternal and child consumption patterns (p <.001) suggest the potential for strategies that increase household-level consumption to bring nutritional benefits to young children.
This paper presents longitudinal findings from a study of 503 children from eight rural villages in Sanza and Majiri Wards, Manyoni District, Singida Region, in the semi‐arid central zone of Tanzania. Project sites were selected in consultation with government partners at national, regional, and district levels, guided by the prevalence of childhood stunting and the absence of existing nutritional interventions. One third (34%) of Tanzanian children under the age of 5 years were reported as stunted in the most recent national survey (i.e., HAZ greater than two standard deviations below the median of the WHO, 2006, reference population), with a regional stunting prevalence of 29% in Singida and 37% in the adjacent Dodoma Region (Ministry of Health, Community Development, Gender, Elderly and Children et al., 2016). Ninety‐seven per cent of rural households in Tanzania cultivate crops, with combined agricultural activities (crop, livestock, and labour) estimated to generate 70% of income (Covarrubias, Nsiima, & Zezza, 2012). Agriculture in Tanzania is predominantly rain fed and consequently is highly susceptible to adverse weather patterns (Kubik & Maurel, 2016). A unimodal pattern of rainfall is seen in the study area, with long‐term mean annual rainfall of 624 mm and a mean of 49 rain days reported at a district level (Lema & Majule, 2009). Based on daily records from a centrally located rain gauge in each of the two study sites, rainfall during the first of two wet seasons in the period of data collection was particularly poor, with 447 mm (30 rain days) received in Sanza Ward and 275 mm (21 days) in Majiri Ward. Following a community‐wide census, lists were compiled of households that met the eligibility criteria of including a child under 24 months of age, currently keeping chickens or having expressed an interest in keeping chickens and intending to reside within the area for the duration of the study. Sample size calculation for the cluster randomised controlled trial involving 20 communities (of which this study evaluates findings from eight) was based on an estimated baseline stunting rate of 35% with an aim of reducing this to 25% by the end of the project (i.e., a 10% reduction), giving 80% power to detect this difference as being significant at the two‐sided 5% level, assuming an intracluster correlation coefficient of .014. Two‐stage sampling was used to first enrol all eligible households with children under 12 months of age and then enrol additional households with children aged 12–24 months using random selection to give 240 households in Sanza Ward and 280 households in Majiri Ward. Baseline data collection was completed for 229 households in Sanza Ward in May 2014 and 274 households in Majiri Ward in November 2014, as part of the staged implementation within the larger project design, with follow‐up data collected at six monthly intervals to May 2016 (Figure 1). Overview of administrative units in the study area, with the number of enrolled households and the timing of quantitative and qualitative data collection (including the 6‐month delay between baseline data collection in the two wards) Male and female enumerators were recruited from the community and trained to administer a coded structured questionnaire to mothers of children enrolled in the study. This questionnaire was developed from the Demographic and Health Survey, applied in Tanzania most recently in 2015 (Ministry of Health, Community Development, Gender, Elderly and Children et al., 2016). Questions covered the timing of initiation of breastfeeding, prelacteal feeding, the timing and nature of complementary feeding, reasons for introduction of complementary foods before 6 months of age, and total duration of breastfeeding. Information was also collected on mothers' participation in formal education, employment and relationship status, water access, and sanitation facilities. Printed survey questions and training sessions were in Swahili, with enumerators encouraged to make use of local languages where appropriate to aid in communication. This questionnaire formed part of the baseline data collection and was applied in an abridged form at six monthly intervals until May 2016, to collate longitudinal information on child feeding practices (Figure 1). Child length or height measurements were also taken every 6 months to May 2016. Measurements were performed by trained personnel from the Ministry of Health and recorded to the nearest 1 mm using UNICEF portable baby/child length‐height measuring boards. Recumbent length was measured for children up to 24 months of age and standing height for children over 24 months. Where this protocol was not followed, in order to minimise stress to the child and maximise measurement accuracy (6.0% total measurements), a standard adjustment was applied—with standing height approximated to be 7 mm less than recumbent length (WHO, 2006). Child birthdates were verified against health clinic records where possible (80.7%), with some cases where children had not been issued with an official health record, or where records had been misplaced or damaged. Equal numbers of male and female community representatives (Community Assistants) were employed and trained to visit households on a twice monthly basis for ongoing data collection. Information was recorded on the number of chickens owned and the breastfeeding status of enrolled children within the previous 2 weeks: (a) exclusively breastfed, (b) receiving breast milk and complementary foods, or (c) nonbreastfed. Exclusive breastfeeding was defined as receiving no other food or drink (even water) except breast milk but allowing for oral rehydration solutions and drops or syrups, including vitamins, minerals, and medications (WHO, 2002). In Sanza Ward, pictorial record charts were distributed to all enrolled households at four monthly intervals, in the months of August and December in 2014 and April, August, and December in 2015, to document the consumption of poultry products over a period of four consecutive weeks. This research tool was developed for use in communities with low levels of literacy, adapted from an approach used in reproductive health research in Tanzania and Uganda (Francis et al., 2013; Francis et al., 2012) and intended to be able to be used without an understanding of written language. Simple artwork depicting a chicken, eggs, an infant, a pregnant woman, and a breastfeeding mother was presented in a table layout (Figure 2). Prior to each data collection period, the Community Assistants were trained to instruct a representative from each participating household to use a mark to record any meal containing chicken or egg consumed by the enrolled child or by a pregnant or breastfeeding woman in their household (if present). Community Assistants visited each household at the end of each week to review the pictorial charts and assist participants in recording data in any incomplete charts. Design of pictorial record chart (with English translations of Swahili text) for completion by a representative of each household, to indicate the consumption of poultry products by children enrolled in the study, and a pregnant or breastfeeding woman within the same household The qualitative phase of data collection was conducted in October 2016. Thirty‐nine in‐depth interviews were carried out with a subset of mothers of children enrolled in the longitudinal study. Stratified purposive sampling was used to identify four to six women in each of the eight villages. Eligibility criteria were that women were available on the intended day of interview and willing to engage in discussions for approximately 1 hr. With the aim of achieving diverse representation of households, selection of mothers for interviews was also guided by children's HAZ (both more than two standard deviations below and above the median), marked changes in HAZ over successive measurements (both improving and failing growth patterns), timing of introduction of complementary foods (prior to 6 months, at 6 months and beyond 6 months), chicken ownership and flock size in the previous 24 months (households with no chickens, intermittent and consistent ownership of chickens, and small and larger flocks), and language group (targeting both Gogo and Sukuma households), as determined by prior analysis of questionnaire and anthropometric data. The majority of interviews were conducted at women's homes, with a smaller number held in a central location in the village at the time that women and their children attended the local health facility. Distances to be travelled to reach women at their home were not a consideration in selection of interviewees. Discussions were conducted predominantly in Swahili with occasional use of the language of the more common group, Kigogo, and were led by an English speaker familiar with the study setting, using a semistructured guide with open‐ended questions and facilitated by a translator. For each interview, a Community Assistant was also present to lead introductions and provide additional translation assistance where required. Audio recordings and written notes, predominantly in English, were taken. Questions were based around three main themes: infant and young child feeding, household diets, and poultry keeping. A selection of topics was covered with each interviewee, keeping discussions within the approximate time frame of 1 hr. Analysis of quantitative data was performed using Genstat software (VSN International, version 18). Descriptive analysis was used to characterise IYCF practices, by ward and in the overall study population, including the timing of initiation of breastfeeding, use of prelacteal fluids, timing and nature of complementary feeding, reasons for introduction of complementary foods prior to 6 months of age, and total duration of breastfeeding. Filter questions within the six monthly questionnaire were designed to restrict data collection on the timing of weaning to events within the prior 6 months but led to missing data when mothers erroneously thought this information had been provided during the previous application of the questionnaire. In these cases and those where mothers were not available to complete the six monthly questionnaire (132 children), children's breastfeeding status was drawn from fortnightly records collected by the Community Assistants. Demographic characteristics, livestock ownership, and children's height‐for‐age were compared (a) between the two wards and (b) between the interviewed households and others within the study population. Intergroup comparisons were performed using t tests and chi‐square tests for continuous and bivariate categorical variables, respectively. Differences were considered significant at p < .05. Descriptive summaries were also compiled using data from pictorial records of chicken and egg consumption to determine the proportion of children and breastfeeding or pregnant women consuming chicken or eggs and mean number of meals containing these food items, over each of the five 4‐week data collection periods. Evaluating children's consumption of chicken and eggs separately, univariable analyses using generalised linear mixed models were initially performed to test associations with child gender, child age, and maternal consumption of chicken or eggs. Geographic and temporal variation was accounted for through the inclusion of ward, village and subvillage locations, and data collection period as random effects. Multivariable models were constructed using variables of suggestive significance (p < .1) based on univariable models and backward elimination used to manually remove variables not significant at the 5% level to reach the final models. Retrospective coding of written interview notes by the primary investigator was used to detect common themes surrounding three broad topics: infant and young child feeding, household diets, and poultry keeping. Thematic analysis was conducted manually, to identify points of consensus and difference among interviewees. Quotations are given in English, derived from translations provided in the context of interviews and later review of audio recordings. Interviewees have been de‐identified, and responses are identified by women's age and household location. Study design, protocols, and research instruments were approved by the National Institute for Medical Research ethics committee (NIMR/HQ/R.8a/Vol.IX/1690) in Tanzania and the University of Sydney Human Research Ethics Committee (2014/209). All participants provided informed consent prior to participating in the study, with assurance of confidentiality, anonymity, voluntary participation, and no adverse effects in case of refusal.
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