Around the world, nutrition plays a significant role in children’s health and well-being. UNICEF estimates that nearly half of all deaths of children under 5 are attributable to undernutrition, totaling more than 3 million children per year. Inadequate nutrition during a child’s first 1,000 days from conception to age 2 can also result in stunting, which is associated with impaired cognitive ability and academic achievement.
IMA World Health strives to improve nutrition for young children to contribute to the healthy development of their mind, body, and spirit. Beginning in 2015, IMA collaborated with the government of Tanzania to improve nutrition and reduce the prevalence of stunting among Tanzanian children younger than 2 years old through the Addressing Stunting in Tanzania Early (ASTUTE) program, which was funded by UK Aid through its Department for International Development (DFID).
ASTUTE was a five-year project implemented in five regions of the Lake Zone: Kagera, Kigoma, Mwanza, Geita and Shinyanga. Nearly 7,800 district health workers and non-health sector service providers were trained through ASTUTE, and the project reached three million mothers, caregivers and decision-makers with improved child feeding, sanitation and hygiene, and early childhood development (ECD) information.
Positive Deviance/Hearth (PDH) is a key intervention of ASTUTE. Through PDH programming, malnourished children are rehabilitated in their own homes using approaches identified by caregivers of well-nourished children (positive deviants) in their community. Such approaches facilitate behavior changes in feeding, hygiene, early childhood development, homestead gardening, and health seeking behaviors.
In PDH, children and their caregivers participate in a 12-day program with a community health worker (CHW) and other caregivers from their area where they learn how to cook with locally available, nutrient-dense foods chosen to promote weight gain. They also learn about proper sanitation and hygiene practices, such as washing before and after cooking and eating meals, washing with soap, and constructing a hands-free wash station known as a “tippy-tap.” The importance of stimulating young children to foster healthy brain development and interpersonal relationships is also emphasized during the program.
During ASTUTE’s home visits with caregivers, CHWs negotiate what behavior changes the caregiver will adopt to improve their child’s nutrition. In the home visit negotiation process, CHWs directly engage the caregivers in deciding what’s best and manageable behavior for them and their children. CHWs first ask detailed questions about the practice of recommended behaviors and challenges the caregiver faces. Then they listen to responses and identify best practices the caregiver can do to address those challenges.
Then together, the caregiver and CHW decide which practice(s) the caregiver will try. This negotiation approach ensures the CHWs are not merely going house to house giving the same sterile, one-way lecture on best nutrition practices that may be unrealistic for many caregivers to follow. When caregivers feel heard and that their specific situations are considered, they are more likely to attempt the agreed upon behavior changes and sustain the behaviors that work. Through these discussions, the CHW and caregiver identify practices the caregiver can do to address the challenges.
The following illustrates a typical ASTUTE home visit:
The CHW asks the caregiver about a behavior related to ECD, infant and young child feeding (IYCF), water, sanitation and hygiene (WASH), agriculture, or maternal nutrition that she is practicing to prevent stunting in her child.
The CHW listens carefully and identifies what she is doing well or facing as a challenge.
The CHW suggests a small, doable action related to ECD, IYCF, WASH, agriculture, or maternal nutrition to the caregiver and other household members, explaining its significance in achieving better nutrition for the child.
The CHW and the caregiver discuss how best they could successfully integrate that action into their routines before the next home visit.
In addition to the caregiver, the CHW includes other household members such as fathers, mothers-in-law, grandmothers, and older siblings in the discussion and brainstorms ways they can contribute to the success of the behavior change. This includes lessening the burden of traditional gendered roles for the mother or female caregiver like fetching firewood or cooking dinner so that they can focus on their own health and the health of the child.
In follow-up visits, the CHW determines whether or not the caregiver tried the new practice and discusses adaptations the caregiver can make to address any challenges they may have faced.
In addition to the physical care IMA helped provide these children and their families, community faith leaders were essential partners in caring for their spirits and motivating them to participate in the program interventions. IMA sensitized Christian and Muslim leaders in the program area to good nutrition and hygiene practices, and they in turn encouraged their followers to adopt the practices as they conducted their other spiritual and community engagement duties.
The ASTUTE program ended in May 2020. However, the activities listed above as well as radio programming to promote nutrition more broadly were set to continue as they had been designed to be community and government-driven efforts. Unfortunately, the emergence of COVID-19 has forced a temporary moratorium on the in-person meetings and services once associated with ASTUTE. Luckily, the radio programming continues and is being adapted to include health and safety measures to mitigate the spread of the COVID-19.
In its final months, funding under ASTUTE was also re-purposed to establish a government-led call center to mitigate the spread of rumors regarding the outbreak and help track the disease country-wide. IMA also created the ASTUTE Stunting Reduction Toolkit, which contains resources in English and Swahili that donors, implementing partners, government officials, and CHWs can adapt to further stunting reduction activities in a post-pandemic environment.
About the Author
Dr. Generose Mulokozi is a Public Health Nutritionist and Food Scientist. She has a PhD in Bioscience from Chalmers University of Technology, Sweden. Dr. Mulokozi has over 29 years of comprehensive experience in research and program implementation in Nutrition, Food Science, Public Health, laboratory analysis and other related programs. She is focused on working with the most vulnerable groups of the population such as women, adolescent girls and children focusing on areas such as micronutrient deficiencies. She is currently working as a Team Leader for the ASTUTE nutrition program, the largest nutrition program in the country operating in 5 Lake zone regions of NW Tanzania and covering over 10 million people.