Assessment of the Mwanzo Bora Nutrition Program Social …...Assessment of the Mwanzo Bora Nutrition...

Assessment of the Mwanzo Bora Nutrition Program Social and Behavior Change Communication Interventions

December 2017

Prepared by ICF and FXBT Health, consultants for Africare

Assessment of the Mwanzo Bora Nutrition Program Social and Behavior Change Communication Interventions ii

EXECUTIVE SUMMARY The Mwanzo Bora Nutrition Program is a seven-year (2011–2018) program that seeks to improve the nutritional status of children and pregnant and lactating women in Tanzania with a specific focus on reducing stunting and maternal anemia. The program is funded by the United States Agency for International Development (USAID) through Feed the Future (FtF) and the Global Health Initiatives (GHI); and implemented by a consortium of partners—Africare (the prime), Centre for Counselling, Nutrition and Health Care (COUNSENUTH), Deloitte Touche Tohmatsu Limited Tanzania (Deloitte), and The Manoff-Group (TMG). The MBNP also partners with regional and district government institutions, and civil society organizations. Partners bring complementary skills sets and relationships with communities and networks allowing for a comprehensive, integrated approach that seeks to create an enabling environment for the promotion, adoption and scaling up of key desired behaviors that impact the first 1000 days of the life of a child.

In July 2017, the consultants-ICF, and FXBT Health conducted an assessment on the MBNP interventions (which uses the Social and Behavior Change Communication (SBCC) strategy), in three regions of Dodoma, Manyara and Morogoro in Tanzania, to understand which key desired behaviors have been adopted, what factors helped individuals and households to adopt these practices, and what barriers prevented individuals and households from adopting behaviors. A qualitative field study that included semi-structured interviews, focus group discussions and key informant interviews with program beneficiaries and implementers (with emphasis on interviews with women who were pregnant or who had a child less than 2 years of age) was conducted in three MBNP zone of influence regions and two comparison regions (Arusha and Tanga) not reached by the program. To triangulate the qualitative findings and further understand behavioral changes, data from the 2010 and 2015 Tanzania Demographic and Health Surveys (TDHS) were analyzed for the MBNP catchment area and the comparison area. These results were further complemented by a literature review of MBNP reports, government and development partners’ policy, strategy, and survey reports as well as Tanzania and Regional studies for key determinants of stunting, maternal anemia, and other related key child and maternal nutrition and health indicators.

Key results from the assessment showed that the MBNP SBCC messages and activities have been far-reaching among the target population who displayed a specific and high level of knowledge regarding the importance and benefits of the key desired behaviors. In the comparison area, the knowledge of key behaviors was more generic, with lack of knowledge for some of the behaviors. Key behaviors that showed significant increases in the program area included: attending early antenatal (ANC) visit; taking iron folic acid (IFA) supplements during pregnancy; deworming; using mosquito nets; exclusive breastfeeding; and, feeding the child a variety of foods. Key behaviors that improved in both program and comparison area were: early breastfeeding; giving colostrum; and, continued breastfeeding until at least two years of age.

SBCC behaviors that were most likely to be adopted showing the highest levels of practice in the MBNP area were: increasing consumption of iron rich foods during pregnancy; sleeping under mosquito nets; initiating complementary feeding after six months; and feeding babies older than six months, semi-solids and finely chopped foods. These practices were closely followed by: ensuring newborns get colostrum; initiating breastfeeding within one hour of birth; and, continued breastfeeding for the babies up to two years and beyond.

Assessment of the Mwanzo Bora Nutrition Program Social and Behavior Change Communication Interventions iii

A divergence for the levels of practice between the MBNP area and the comparison area were registered for: attending ANC within first three months of pregnancy; taking IFA supplements and deworming tables during pregnancy; exclusively breastfeeding their infant less than six months; and, feeding their babies older than six months a variety of foods. Key behaviors that still require additional support, further addressing of barriers, and individual, household and community follow up in the MBNP area are: attending ANC within the first three months of pregnancy; adhering to malaria treatment during pregnancy; and increasing the amount of food and frequency of feeding as the baby gets older to reach three meals a day with a snack.

The high levels of practice measured within the MBNP area most likely were the result of the MBNP SBCC comprehensive and integrated approach. Core MBNP activities included: developing and strengthening national SBCC policy and strategy; testing, piloting and scaling up SBCC packages including the 1000 Days (Parent) Kit; orienting and mobilizing district government and community leaders; mobilizing, training and supporting community volunteers and peer support groups; integrating agriculture activities (including household gardens, small livestock keeping and income generation); coordinating with health facility staff for message promotion and quality delivery of services; partnering with local organizations for skills training and vital services; and promoting intra-household dialogue for partner support and joint decision making. Facilitators recorded for the key behaviors among MBNP area qualitative field study respondents showed that the knowledge gained, skills being adopted (e.g. discuss and decide together; pay it forward agricultural model; and household gardens), and the benefit of learning from peers, and being supported by peers, household members, volunteers and health workers were key in adopting and practicing behaviors. As local household and community knowledge was strengthened, less ideal cultural practices were diminished and made obsolete. This did not hold true for the comparison area where knowledge regarding benefits of practices were minimal, and where less ideal cultural practices continued to persist. The primary barriers identified in the MBNP area for the practice of key behaviors were insufficient resources, competing priorities, and lack of time to practice the behavior rather than knowledge or understanding of the practice.

The MBNP assessment substantiates significant achievements measured in the MBNP area including: increased individual and household knowledge; increased adoption of multiple key practices; and the creation of an enabling environment that lays the groundwork (and creates a model) for further scaling and sustaining key desired behaviors. Based on the key assessment findings, several recommendations are made to guide the MBNP on the way forward to continue to sustainably improve the nutrition and health of women and children in Tanzania and enable communities to reach their full potential. These recommendations build on the program’s strengths and seek to maximize and extend the reach of facilitators identified for the adoption of key behaviors. Some key recommendations are: continued engagement at multiple levels (individual, household, community, district, regional and national) for the promotion and support of key interventions during the first 1000 day period of the life of a child; continued training and support for skills and activities that help households improve household dietary diversity (household gardens, small livestock keeping, income generation opportunities); advocacy and support for access to quality health services with a consistent supply of medicines and supplements; documentation and sharing of best practices and lessons learned to guide the quality scale up of the SBCC packages (kits) and the MBNP integrated model within Tanzania and beyond; and, integration of recent state of the art developments for nutrition models, including early childhood development, adolescent nutrition, and further income generation opportunities linked to the development of food production value chains and nutrition.

Assessment of the Mwanzo Bora Nutrition Program Social and Behavior Change Communication Interventions iv

TABLE OF CONTENTS

EXECUTIVE SUMMARY ............................................................................................................................. ii

ACKNOWLEDGMENTS ............................................................................................................................. vi

ACRONYMS ............................................................................................................................................ vii

INTRODUCTION ....................................................................................................................................... 1 Overview of Stunting and Maternal Anemia in Tanzania ...................................................................... 1

Stunting ........................................................................................................................................... 1 Maternal Anemia ............................................................................................................................. 4

Overview of the Mwanzo Bora Nutrition Program ................................................................................ 5 Government’s Response to Improve Women’s and Children’s Nutritional Status ................................. 8

Rationale for the Assessment................................................................................................................. 10

ASSESSMENT OBJECTIVES AND RESEARCH QUESTIONS .......................................................................... 11

METHODOLOGY ..................................................................................................................................... 13 Selection of MBNP and Comparison Regions and Districts .................................................................. 13 Interviews with Women ..................................................................................................................... 14

Overview ....................................................................................................................................... 14 Selection of Women Respondents.................................................................................................. 15

Focus Group Discussions and Key Informant Interviews ..................................................................... 17 Overview ....................................................................................................................................... 17 Participant Selection ...................................................................................................................... 17

Analysis.............................................................................................................................................. 19 Analysis of Women’s Interviews ..................................................................................................... 19 Analysis of Focus Group Discussions and Key Informant Interviews ................................................ 19 Analyses of Tanzania Demographic and Health Surveys.................................................................. 20

Document Review .............................................................................................................................. 20 Limitations ......................................................................................................................................... 21

RESULTS AND DISCUSSION ..................................................................................................................... 23 Research Questions 1 and 2 ............................................................................................................... 23

Pregnancy (Seed Stage) .................................................................................................................. 23 Months 0–6 (Sprout Stage) ............................................................................................................ 27 Months 6–12 (Bud Stage) ............................................................................................................... 28 Months 12–24 (Flower Stage) ........................................................................................................ 32

Research Question 3 .......................................................................................................................... 35 Pregnancy (Seed Stage) .................................................................................................................. 35 Months 0–6 (Sprout Stage) ............................................................................................................ 35 Months 6–12 (Bud Stage) ............................................................................................................... 35 Months 12–24 (Flower Stage) ........................................................................................................ 36

Research Question 4 .......................................................................................................................... 36 Pregnancy (Seed Stage) .................................................................................................................. 37 Months 0–6 (Sprout Stage) ............................................................................................................ 38 Months 6–24 (Bud and Flower Stage)............................................................................................. 39

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Cross-cutting Facilitators of Maternal and Child Health and Nutritional Practices: Findings from FGDs and KIIs ................................................................................................................................. 40

Research Question 5 .......................................................................................................................... 44 Pregnancy (Seed Stage) .................................................................................................................. 44 Months 0–6 (Sprout Stage) ............................................................................................................ 45 Months 6–24 (Bud and Flower Stages) ........................................................................................... 45 Cross-cutting Barriers to Maternal and Child Health and Nutrition Practices: Findings from FGDs and KIIs ................................................................................................................................................. 46

Research Questions 6 and 7 ............................................................................................................... 48 Program and Non-program Areas (Knowledge) .............................................................................. 49 Program and Non-program Areas (Limited Knowledge) .................................................................. 49 Program Area Specifics .................................................................................................................. 49

CONCLUSIONS ....................................................................................................................................... 51

RECOMMENDATIONS ............................................................................................................................ 53

REFERENCES .......................................................................................................................................... 56

APPENDIX 1: Sample sizes used in TDHS Analyses .................................................................................. 58

APPENDIX 2: DOCUMENTS REVIEWED ................................................................................................... 59

APPENDIX 3: FACILITATORS AND BARRIERS TO PREGNANCY-RELATED BEHAVIORS REPORTED IN WOMEN’S INTERVIEWS ......................................................................................................................... 62

APPENDIX 4: FACILITATORS AND BARRIERS TO INFANT (0–6 MONTHS) NUTRITION BEHAVIORS REPORTED IN WOMEN’S INTERVIEWS .................................................................................................... 66

APPENDIX 5: FACILITATORS AND BARRIERS TO CHILD (6–24 MONTHS) NUTRITION BEHAVIORS REPORTED IN WOMEN’S INTERVIEWS ..................................................................................................................... 70

APPENDIX 6: MULTIVARIATE REGRESSION TABLES ................................................................................. 73

Assessment of the Mwanzo Bora Nutrition Program Social and Behavior Change Communication Interventions vi

ACKNOWLEDGMENTS The report was prepared by a team of researcher consultants from ICF, USA and FXBT Health, Tanzania. The team included the following individuals:

From ICF: Cristina de la Torre, Lwendo Moonzwe, Coralie N’Gbichi, Allison Schmale, Anne Siegle, and Kirsten Zalisk.

From FXBT Health: Charles Matiko, Emmanuel Matechi, Silvia Shirima, and Maryiam Johari.

Dorothy Lee, a consultant, helped with the qualitative analysis.

In addition, Mary Bonaventure (Dodoma Regional Administration and Local Government Authority Secretariat) and Paul Lucas Malunda (Africare/Mwanzo Bora Nutrition Program) served as co-principal investigators on this study.

The consulting team is grateful to Africare and the Mwanzo Bora Nutrition Program (MBNP) for supporting this assessment. In particular, we wish to thank Vedasto Rutachokozibwa and Brian Grant for their input and guidance throughout this study. We thank Susana Oguntoye, Vedasto Rutachokozibwa, and Winfrida Mollel for their careful review of the report.

Assessment of the Mwanzo Bora Nutrition Program Social and Behavior Change Communication Interventions vii

ACRONYMS ANC Antenatal care CHW Community Health Worker COUNSENUTH Centre for Counselling, Nutrition and Health Care CSO Civil society organization DNuO District Nutrition Officer DRCHC District Reproductive and Child Health Coordinator FGD Focus group discussion FtF Feed the Future GDP Gross domestic product HLSCN High-Level Steering Committee on Nutrition IFA Iron and folic acid IMAM Integrated Management of Acute Malnutrition IPTp Intermittent preventive treatment in pregnancy ITN Insecticide-treated net IYCF Infant and young children feeding IYCN Infant and young child nutrition KII Key informant interviews M&E Monitoring and evaluation MBNP Mwanzo Bora Nutrition Program MCHN Maternal and child health and nutrition MIYCAN Maternal, infant, young child and adolescent nutrition MoHCDGEC Tanzania Ministry of Health, Community Development, Gender, Elderly and

Children MoHSW Ministry of Health and Social Welfare (name subsequently changed to

MoHCDGEC) NGO Nongovernmental organization NMNAP National Multi-sectoral Nutrition Action Plan NNS National Nutrition Strategy PMO Prime Minister’s Office PSG Peer support group RMNCAH Reproductive, maternal, neonatal, child and adolescent health SBCC Social and behavior change communication SP Sulfadoxine-pyrimethamine SSI Semi-structured interview SUN Scaling Up Nutrition TDHS Tanzania Demographic and Health Survey TFNC Tanzanian Food and Nutrition Centre TMG The Manoff-Group USAID United States Agency for International Development VASD Vitamin A Supplementation and Deworming WHO World Health Organization

Assessment of the Mwanzo Bora Nutrition Program Social and Behavior Change Communication Interventions 1

INTRODUCTION Overview of Stunting and Maternal Anemia in Tanzania

The United Republic of Tanzania has a population of 54 million, making it the most populous country in East Africa while also having the lowest population density. Tanzania has a high total fertility rate of 4.8, a population growth rate of 2.7 percent, and a young population, with 44 percent under 15 years of age. Thirty-three percent of Tanzanians live in urban areas, with the remaining 67 percent in rural areas, where higher levels of poverty, food insecurity, and undernutrition can be found. The country ranks 159 out of 187 on the United Nations Human Development Index (2014).

Although the country has many progressive policies, produces enough food to feed its population, experiences a growth in gross domestic product (GDP) of 7 percent (25 percent from agriculture), and has seen improvements in several human, social, and development indicators, unacceptable levels of stunting among children less than 5 years of age and anemia among women of child-bearing age persist.

Stunting The nutritional status of Tanzanian children as measured by percentage of children stunted has improved, from 50 percent in 1991 to 42 percent in 2010 and 34 percent in 2015–16 (see Figure 1, which uses data from the Tanzania Demographic and Health Survey [TDHS]), with an estimated 2.7 million Tanzanian children under 5 years of age stunted.1 Although this steady decrease in levels is encouraging, stunting remains a key underlying factor for deaths among children under 5 years of age (World Health Organization [WHO], 2011). Stunting is associated with increased morbidity and mortality from infections, in particular pneumonia and diarrhea but also sepsis, meningitis, tuberculosis, and hepatitis, suggesting a generalized immune disorder in children with severely stunted growth (Kossmann, et al., 2000; Olofin, et al., 2013).

The interplay of poor nutrition and frequent infection leads to a vicious cycle of worsening nutritional status and increasing susceptibility to infection (Solomons, 2007). Furthermore, stunting contributes to cognitive impairment and a child’s ability to learn and become a productive adult.

1 The methods used by the TDHS to measure stunting and anemia are described in the following final reports: 2015 TDHS: https://dhsprogram.com/pubs/pdf/FR321/FR321.pdf 2010 TDHS: https://dhsprogram.com/pubs/pdf/FR243/FR243[24June2011].pdf

Stunting, or low height-for-age, is a sign of chronic undernutrition that reflects failure to receive adequate nutrition over a long period, leading to a weakened immune system, an increased susceptibility to illness, and repeated infections. Children under 5 years of age whose height-for-age Z-score is below minus two standard deviations (-2 SD) from the median of the WHO reference population are considered short for their age (stunted), or chronically undernourished. Children whose height-for-age Z-scores are below minus three standard deviations (-3 SD) are severely stunted. Undernutrition most affects children under 5 years of age and women of reproductive age (particularly pregnant and lactating women) due to their physiological needs for growth and reproduction. The 1,000-day period, from conception to 2 years, provides a key opportunity for actions that can impact good growth and begin to break the inter-generational cycle of stunting.


In Tanzania, stunting increases with a child’s age, reaching levels of 40 percent or higher among children ages 18–47 months (TDHS, 2015). One in six children ages 24–35 months is severely stunted (< -3 SD height/age). Stunting levels vary by geographical regions, with rural areas registering higher levels, in some cases twice as high, compared to urban areas (Figure 2). All three Mwanzo Bora Nutrition Program (MBNP) areas targeted by this study (Dodoma, Manyara, and Morogoro) showed a significant reduction in stunting levels from 2010 to 2015. However, one in three children under 5 years of age in each of these three regions continue to be stunted (see Figure 3).

Source: 2015 TDHS Given that stunting is a cumulative process that can begin in utero and continue until about two years after birth, attention is being given to addressing determinants of stunting during the first 1,000 days following conception. Evidence indicates that undernutrition is handed down from one generation to the next, with malnourished women or adolescent girls giving birth to babies with low birth weight. These children grow up in an environment of suboptimal feeding practices, household food insecurity, high burden of infectious diseases, poor sanitary conditions, and low access to quality care, making it almost impossible to experience catch-up growth in subsequent years, further contributing to an intergenerational cycle of stunting.

Figure 3: Prevalence of childhood stunting in 2010 and 2015 in three MBNP regions

56.046.0 44.0

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0.0

20.0

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Dodoma Manyara Morogoro

2010 TDHS 2015 TDHS

Figure 1: Trends in childhood stunting and malnutrition in Tanzania

Figure 2: Stunting in children by region, 2015


For Tanzania, specifically, studies utilizing 2010 and 2015 TDHS data identified the most consistent risk factors for stunted and severely stunted children ages 0–59 months (Abubakar, et al., 2012; Chirande, et al., 2015; Semali et al., 2015; Shiratori, 2014). These risk factors are as follows:

• Children considered very small (51 percent) or small (46 percent) by their mothers at birth, compared to those described as being average or large (33 percent)

• Children in households in the lowest wealth quintile (39.2 percent, compared to 19.2 percent in the richest quintile)

• Children in households with several children under 5 years of age • Children with mothers who had no schooling (39.2 percent, compared to 23.1 percent among

children with mothers with secondary education) • Children whose mothers were young • Children in households where the head of household is under 35 years of age • Male children2 • Households with unsafe sources of drinking water • Children living in rural residences (37.8 percent, compared to 24.7 percent in urban areas)

The 2015 TDHS data provide insight on national and region-specific trends for several key infant and child care behaviors that are associated with protecting and promoting an infant’s and child’s growth and development. Breastfeeding is widely practiced, with 98 percent of all children having been breastfed for some time during their life. Exclusive breastfeeding was measured at 59 percent, showing a steady increase over the past 20 years. More than half of the children received breastmilk until 20 months of age. Complementary feeding practices for young children, however, are of concern. Although 90 percent of children 6–8 months of age and 97 percent of children 9–11 months of age receive timely complementary food, only 9 percent of children 9–23 months of age are being given a minimum acceptable diet (includes frequency of feeding, quantity, and nutrient quality of food). Young children are not being fed often enough and do not have a diverse diet. They are primarily being given cereal-based diets with poor consumption of micronutrient-dense foods such as animal products, fruits, and vegetables. Subsequently, micronutrient deficiencies are widespread, and children are vulnerable to poor growth and illness. Important differences exist in the percentage of urban (39 percent) and rural children (21 percent) and children from the highest (49 percent) and lowest wealth quintiles (15 percent) who are being given foods from at least four food groups. Slightly more than half of the households (57 percent) can satisfy their food needs, with rural households and poor households experiencing higher levels of food insecurity.

Periodic vitamin A supplementation and deworming medication are important interventions for children in Tanzania, given existing poor household dietary diversity, repeated infections and resulting depletion of micronutrient stores, and poor sanitary conditions. Vitamin A supplementation coverage decreased, from 61 percent in 2010 to 41 percent in 2015, and children receiving deworming medication decreased, from 49 percent in 2010 to 34 percent in 2015. However, the 2014 National Nutrition Survey indicated that 71 percent of children received vitamin A supplementation in last six months, and 72 percent of children received deworming medicine in the past six months. Given that coverage rates are dependent on the reach and success of each six-month Vitamin A Supplementation and Deworming (VASD) 2 Male children are more likely to become stunted or severely stunted in Tanzania. This finding is consistent with other country findings in sub-Saharan Africa. Community behavioral practices contribute to this, including male children being offered supplemental food at earlier ages and in larger quantities, which leads to higher rates of diarrhea (Chirande et al., 2015).


campaign cycle, variations in coverage are to be expected.3 Other interventions that impact a child’s ability to prevent infection and protect growth are the use of insecticide-treated nets (ITNs), access to a clean drinking water source, use of an improved toilet facility, and handwashing practices. Sixty-six percent of households own an ITN, and 54 percent of children under 5 years of age sleep under an ITN. Forty-nine percent of rural households have access to a clean water source. Of concern is that 86 percent of rural households use an unimproved toilet facility or lack a toilet facility. An encouraging 81 percent of households had a handwashing station. However, handwashing at critical times, particularly after cleaning a baby’s bottom or before preparing food, is of concern in the MBNP program areas included in this study.

Maternal Anemia In Tanzania, concerning levels of anemia persist among women ages 15–49, and levels are highest among pregnant women. The prevalence of anemia is 57 percent among pregnant women, 46 percent among breastfeeding mothers, and 43 percent among women who are neither pregnant nor breastfeeding (2015 TDHS). Anemia levels among women in Tanzania have shown no improvement over the last five years and instead have increased. The same is true for maternal anemia in the three regions that are part of the study area (see Figure 4).

Maternal anemia is associated with poor maternal, newborn, and infant outcomes, including low birth weight, preterm birth, increased blood loss at delivery, increased risk for postpartum hemorrhage, and perinatal, neonatal, and maternal mortality (Rasmussen, 2001; Stoltzfus, et al., 2004). Although iron deficiency is considered the leading cause of anemia, other causes include deficiencies in micronutrients such as folate, vitamin B12, and vitamin A, infestations with parasites such as helminthes or malaria, chronic inflammation, and untreated genetic hemoglobin disorders (Balarajan, et al., 2011; Black, et al., 2013; Branca, et al., 2014; Scholl, 2011).

Tackling maternal anemia is particularly challenging because iron requirements increase over the course of pregnancy, making iron needs more difficult to meet even when an optimal diet is being consumed (Bothwell, 2000). Ideally, women should enter pregnancy with sufficient iron stores to meet their full requirements. Nutrient availability is important around conception and during early pregnancy for key developmental processes (Cetin, et al., 2010). Achieving and maintaining adequate 3 In Tanzania, vitamin A supplementation and deworming medicine are provided simultaneously through national campaigns referred to as VASD that are conducted twice per year. Studies show that advocacy for VASD campaigns is high, but in 2010 only 21 percent of districts allocated sufficient funds for the campaigns (Lyatuu, et al., 2016).

Anemia is defined as a low level of hemoglobin in the blood, measured as fewer numbers of functioning red blood cells. Anemia in pregnancy (maternal anemia) is defined as a hemoglobin concentration of less than 110 g/L (less than 11 g/dL). Anemia in non-pregnant women is a hemoglobin concentration of less than 112 g/L or less than 12g/dL. (WHO standards)

28.0 27.1

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10.015.020.025.030.035.040.045.050.0

Dodoma Manyara Morogoro2010 TDHS 2015 TDHS

Figure 4: Prevalence of maternal anemia in 2010 and 2015 in three MBNP regions


maternal iron levels presents a significant challenge for rural women in Tanzania due to a host of factors, including household food insecurity, suboptimal diets, particularly poor availability and consumption of animal source protein, heavy workloads, poor sanitation, increased morbidity especially from malaria and intestinal helminthes, young age of mother at first birth (39 percent of women in the study area have their first child by age 19), low coverage of at least 90 day iron folic acid supplementation among pregnant women, multiple pregnancies, short inter-pregnancy intervals, and prolonged lactation, among others (Ramakrishnan, et al., 2012).

Pregnant women in Tanzania are particularly at risk of moderate-to-severe anemia, with the effect modified by urban versus rural residence, education, and wealth, with rural, low educated, poor women having the highest risk. Studies on key determinants for anemia among women in Tanzania (Wilunda, et al., 2013) indicate that the highest levels of anemia are associated with the following:

• Women with low education levels • Pregnant women • Households without proper sanitation facilities

During pregnancy, infections are a key cause of anemia and can be prevented by sleeping under an ITN and taking intermittent preventive treatment in pregnancy (IPTp) for malaria and deworming pills. Antenatal care (ANC) visits with a skilled provider provide a vital link to receiving key messages, counseling, and inputs for preventing and correcting anemia, including iron and folic acid (IFA) supplements. Quality ANC contributes to improved maternal and newborn outcomes. Ninety-eight percent of pregnant women in Tanzania had an ANC visit with a skilled provider, and levels of more than 90 percent have been maintained for the past two decades. Only 24 percent of pregnant women made an ANC visit during the first trimester, however, and 51 percent made the desired four ANC visits during their pregnancy. (These 2015 TDHS figures are higher than percentages from the 2010 TDHS).

The 2015 TDHS indicated that 71 percent of pregnant women received malaria prophylaxis, with 35 percent receiving the desired two doses of sulfadoxine-pyrimethamine (SP)/Fansidar during their pregnancy. Fifty-four percent of pregnant women sleep under an ITN (a decrease from 75 percent in 2010). Eighty-one percent of pregnant women received IFA tablets, up from 59 percent in 2010. Of concern is that only 21 percent of pregnant women took IFA supplements for at least 90 days during their pregnancies. Sixty-three percent of pregnant women received deworming medication. Although coverage is improving for some services, tackling maternal anemia will require purposeful efforts to address the remaining key contributors, including women’s workloads, poor dietary diversity, hygiene and sanitation, exposure to parasites (malaria and other), and closely spaced multiple pregnancies.

Overview of the Mwanzo Bora Nutrition Program

The MBNP is a seven-year (2011–2018) integrated nutrition program in Tanzania, funded by the United States Agency for International Development (USAID) through Feed the Future (FtF) and the Global Health Initiatives (GHI), and implemented by a consortium of partners—Africare (the prime), Centre for Counselling, Nutrition and Health Care (COUNSENUTH), Deloitte Touche Tohmatsu Limited Tanzania (Deloitte), and The Manoff-Group (TMG). In the regions, the program partners with regional and district government institutions and civil society organizations (CSOs). The overall goal of the program is improved nutritional status of children and pregnant and lactating women in Tanzania. This goal is to be attained through the achievement of two principle objectives: (1) strengthened capacity of government and indigenous nongovernmental organizations (NGOs) to deliver quality nutrition education and communication; and (2) strengthened delivery of community-based nutrition services and social


behavior-changing education, resulting in a model that can quickly be scaled up to reduce child stunting and maternal anemia. Achievement of the overall goal is measured against two key indicators: (1) the percentage reduction (target set at 20 percent) in the prevalence of stunting (low height for age) among children under 5 years of age, and (2) the percentage reduction (target set at 20 percent) in maternal anemia (as measured by blood hemoglobin concentration) over five years in the targeted regions. The program contributes to five intermediate results of the USAID Tanzania FtF Results Framework, as shown in Figure 5.

Figure 5: USAID Tanzania Feed the Future Results Framework

The program operates in six regions of mainland Tanzania: Dodoma, Iringa, Manyara, Mbeya, Morogoro, and Songwe, and three districts in Zanzibar: Chake, Micheweni, and Kaskazini A. These regions were selected because they had some of the highest levels of stunting in the country, with an estimated 56 percent in Dodoma, 52 percent in Iringa, 50 percent in Manyara, 46 percent in Mbeya, 44 percent in Morogoro, and 50 percent in Songwe in 2010. This exceeds the 40 percent prevalence rate above which WHO considers stunting as “very high.” In addition, almost 40 percent of women 15–49 years of age in Tanzania were anemic, with 1 percent suffering from severe anemia (hemoglobin < 70g/L for pregnant woman (2010 TDHS).

Based on evidence from global research showing that one of the best ways to address malnutrition sustainably is through intergenerational behavior change that instills positive nutritional behaviors at the household level, the MBNP focused its interventions on changing nutritional practices. The program’s social and behavioral change communication (SBCC) approach is based on the diffusion of innovations theory to encourage communities to adopt the top 17 behaviors that are recognized globally as the main keys to reducing stunting (Lancet Maternal and Child Nutrition Series, 2013). It uses specially designed SBCC kits and materials, peer support groups (PSGs), and community-trained volunteers to encourage communities to adopt and sustain key behaviors that are known to reduce stunting and anemia. The two kits are described as follows:


• The SBCC 1000 Days (Parent) Kit promotes optimal nutrition practices (behaviors) in the first 1,000 days of a child’s life from conception until 2 years of age, giving the caregiver (primarily mothers) clear and feasible steps to take during each stage of growth.

• The Dietary Diversity Kit promotes supportive behaviors such as improved household food production and consumption, hygiene, and joint household decision-making.

The SBCC materials are guided by the Tanzanian national guidelines for infant and young child nutrition (IYCN); the Lancet Maternal and Child Nutrition Series (2013); and the Tanzanian National Nutrition Social and Behavior Change Communication Strategy, 2013–18, which was developed by TFNC with MBNP support. They are designed to promote behavior change of targeted beneficiaries in the uptake of the following:

• Micronutrient supplementation, such as vitamin A, for children under 5 years of age • Maternal micronutrients, mainly IFA supplementation and malaria prevention services

(i.e., provision and uptake of long-lasting ITNs and IPTp supplied at ANC visits) • IYCN practices, particularly early, exclusive breastfeeding for the first 6 months of age and

appropriate complementary feeding and continued breastfeeding from 6 to 24 months of age • Appropriate nutrition during pregnancy and lactation • Consumption of a diverse and balanced diet adequate in quality and quantity, using locally

available and affordable foods, as well as fortified foods • Use of health and nutrition services (micronutrient supplementation, appropriate home-based

care for childhood illnesses, and deworming) • Appropriate hygiene practices at the household level, including hand-washing with soap using

“tippy taps” and safe food handling • Appropriate nutrition knowledge and practices at the household level

MBNP is building on and contributing to Tanzania’s pro-nutrition political will with support for the development of policies and strategies at the national level while supporting dissemination of the same through the development and delivery of innovative SBCC packages that are dynamic, integrated, and relevant at the local and community levels through the MBNP implementation model (see Figure 6). The program’s mid-term evaluation revealed an extensive SBCC effort that established partnerships; strengthened linkages between health facilities, volunteers, and communities; and provided training and support to create an enabling environment that included PSGs where key household nutrition and health practices are more likely to be adopted and sustained (MBNP MTE, 2015). Encouraging findings from the 2010 and 2015 TDHS indicate that childhood stunting has decreased over those five years between the surveys in the three MBNP focus regions of Dodoma, Manyara, and Morogoro; however, maternal anemia appears to have increased over that same period. Given the differing results, the project now needs an assessment that is robust and provides scientific evidence on the extent to which the SBCC interventions are achieving their goals. The Government of Tanzania is ready and taking initial steps to scaling up the SBCC approach and tools developed by MBNP. The Government launched the SBCC toolkit—the “Mkoba wa Siku 1000”—as a national tool on nutrition for the first 1,000 days and is putting in place mechanisms for rolling out the kit in the country. Lessons learned from this assessment will help inform the future use of the Siku 1000 toolkit.


Figure 6: Mwanzo Bora Nutrition Program Implementation Model

Government’s Response to Improve Women’s and Children’s Nutritional Status

Although the decrease in the percentage of children stunted is encouraging, given the irreversible impact of stunting on a child’s development and the persistence of widespread maternal anemia and its consequences, the Government of Tanzania and its partner development stakeholders have made child and maternal nutrition a national and local priority, backing it up with strong policies, updated strategies, resources, and action. The national strategic direction to address stunting and maternal anemia is stipulated in the National Road Map to Improve Reproductive, Maternal, Newborn, Child and Adolescent Health in Tanzania (2016–2020) One Plan II, which aims to reduce stunting to 22 percent by 2020 and reduce anemia in pregnancy to 37 percent by 2020 (MoHCDGEC, 2016). The plan is robust and targets the scale up of maternal, infant, young child, and adolescent nutrition (MIYCAN) interventions to the regions where the burden of stunting is highest, including the MBNP zone of influence. The plan called for progressive scale up, first targeting the regions of Dodoma, Iringa, Mbeya, Morogoro, Njombe, and Songwe in 2016/2017, and then expanding to Geita, Kagera, Kigoma, Mwanza, Ruvuma, Shinyanga, and Simiyu regions in the second year (2017/2018) before scaling to the rest of the country.

The Government of Tanzania is demonstrating its commitment to reducing food insecurity and undernutrition with a national response that seeks to create an enabling environment that leads to improved and sustained nutrition outcomes. The recently updated Tanzania National Multi-sectoral Nutrition Action Plan (NMNAP) 2016–2021 calls for a community-centered, multi-sectoral nutrition system made up of multiple sectors at multiple levels with multiple partners coordinating and tracking


interventions, resources, and results that address the immediate, underlying, and basic causes of malnutrition. The goal is to eliminate malnutrition as a problem of public health significance in Tanzania by 2030. As part of this plan, the Prime Minister’s Office (PMO) convened a multi-stakeholder platform, the High-Level Steering Committee on Nutrition (HLSCN). The HLSCN operates within and leverages existing government systems and dialogue mechanisms for developing cooperation, such as the Joint Assistance Strategy for Tanzania and the Food Security Thematic Group in the agriculture sector. A Multi-sectoral Nutrition Technical Working Group supports the HLSCN and is chaired by the Director of the Tanzanian Food and Nutrition Centre (TFNC), a government institution that guides, coordinates, and catalyzes nutrition work in the country. Representatives from different sectors, including NGOs, the private sector, academics, donors, and United Nations agencies, are part of this cooperative effort. Many challenges exist to the continued roll out of the NMNAP, such as budget shortfalls of more than 70 percent ($268 million USD still needed). However, energy is high, and priority is being given to building capacity at the local level for (1) increasing coverage of MIYCAN, (2) scaling up of Integrated Management of Acute Malnutrition (IMAM) among children under 5 years of age, and (3) prevention of anemia among women.

The government launched a multi-sectoral National Nutrition Strategy (NNS) in 2011 (Ministry of Health and Social Welfare, 2011). The goal of National Nutrition Strategy was to have “all Tanzanians attain adequate nutritional status, which is an essential requirement for a healthy and productive nation.” This was to be achieved through policies, strategies, programs, and partnerships that deliver evidence-based and cost-effective interventions to improve nutrition. The strategy included the placement of a nutrition officer in every district and nutrition focal points in each ministry. This included improving the infant and young children feeding (IYCF) practices and nutrition status by strengthening community health services and provision of integrated reproductive, maternal, neonatal, child, and adolescent Health (RMNCAH) and nutrition services. Tanzania is placing strong emphasis on decentralization to ensure that nutrition is on the agenda with those working closest to affected communities. In 2017, the number of nutrition officers working at the local level is expected to increase from 120 to 600. For 2018, the government will double its spending on nutrition, increasing it to $6 million USD. Complementing the National Nutrition Strategy, the Government of Tanzania has a National Nutrition and Social Change Behavior Strategy, June 2013–June 2018, to specifically promote key nutrition behaviors and tackle challenges related to adopting and sustaining these key behaviors. Also of continued importance is Scaling Up Nutrition (SUN), a global movement that Tanzania became a part of in 2011. The presence of SUN helps unite national leaders, civil society, bilateral and multilateral organizations, donors, businesses, and researchers in collective efforts to improve nutrition. USAID and IrishAid are the donor conveners of SUN in Tanzania.

The goal of the United Republic of Tanzania is that “Children, adolescents, women and men in Tanzania are better nourished leading to healthier and more productive lives that contribute to economic growth and sustainable development.” To achieve this, continued advancements are required toward an integrated multi-sectoral innovative response that engages the public and private sectors and civil society, addresses the challenges of climate change vulnerabilities and sustainable agriculture, and can mobilize and extend resources to reach marginalized populations. The future looks promising in Tanzania, with political commitment from the highest levels, multi-sectoral coordinating structures in place, capacity-building efforts underway, results tracking systems developed, a resource mobilization plan in place to address existing budget shortfalls, and commitments made to prioritize available resources to geographical areas with the highest stunting burden and to the local level to achieve individual, household, and community impact.


Rationale for the Assessment The MBNP has developed and implemented innovative SBCC materials and interventions in an effort to accelerate the adoption of key behaviors that can decrease childhood stunting and maternal anemia. Findings from this assessment will help determine how these SBCC approaches are influencing these behaviors and thus contributing to reductions in stunting and maternal anemia in Tanzania. The assessment will elucidate which factors facilitate and hinder behavior change and will highlight lessons learned through the implementation of the SBCC approaches that can increase the positive impact of MBNP interventions for the remaining life of the project. The assessment results will benefit nutrition stakeholders in Tanzania looking to impact nutrition behaviors and will also inform future implementation of the Government of Tanzania’s National Nutrition SBCC Strategy. The findings will contribute to concrete guidance for future programming and potential scale up of the SBCC approaches developed by MBNP.


ASSESSMENT OBJECTIVES AND RESEARCH QUESTIONS The purpose of the assessment was to help quantify and qualify the contribution of MBNP interventions toward improved health and nutritional practices among pregnant women and lactating mothers of children under 5 years of age, focusing on the first 1,000 days of the life of a child (from conception to 2 years of age). It examined which program and external factors have facilitated or impeded adoption of key nutritional behaviors. The assessment focused on the project’s SBCC interventions, which sought to impact childhood stunting and maternal anemia through the promotion of sound nutritional practices. These practices were defined according the developmental stage of the child: pregnancy (termed the seed stage), the first 6 months of life (termed the sprout stage), months 6 through 12 (bud stage) and months 12 through 24 (flower stage).

Objectives of this assessment were to:

• Identify nutritional practices most likely to be adopted by pregnant women and lactating mothers of children under 2 years of age

• Understand factors that facilitate women’s adoption of the 17 key behaviors promoted through the program’s SBCC campaign (see Figure 7, page 13)

• Determine how exposure to the program’s SBCC interventions has influenced the adoption of the key behaviors

• Identify factors that hinder the adoption of those 17 key behaviors • Examine the extent to which the behaviors and motivations diverge between women in the

MBNP area of influence and women in comparison regions • Help MBNP learn which aspects of the SBCC approach are working and better understand where

to focus efforts in the last months of the program

The consultants operationalized the assessment objectives into research questions, as shown in Table 1.

Table 1: Key research questions and data sources for the assessment

Research question Data source 1. To what extent did the proportion of women practicing

each of the desired behaviors increase in the MBNP area and in the comparison areas between 2010 and 2015?

• 2010 TDHS and 2015 TDHS

2. Was the change in the proportion of women practicing these behaviors greater in the program area compared to the comparison areas?

• Women’s semi-structured interviews • 2010 TDHS and 2015 TDHS

3. Which nutritional practices are most likely to be adopted by pregnant women and lactating mothers of children under 2 years of age?

• Women’s semi-structured interviews • TDHS 2010 and TDHS 2015

4. What factors facilitate adoption by women of the 17 key behaviors promoted through the MBNP SBCC campaign?

• Women’s semi-structured interviews • Focus group discussion (FGD) and key

informant interviews (KII) with influencers and community leaders

5. What factors hinder adoption by women of the 17 key behaviors promoted through the MBNP SBCC campaign?

• Women’s interviews • FGD and KII

6. To what extent do the behaviors and motivations diverge between women in the MBNP area of influence and women in comparison regions?

• Women’s semi-structured interviews

7. How did exposure to project’s SBCC interventions influence the adoption of the key behaviors?

• Women’s semi-structured interviews • FGD with influencers and PSG leaders


Figure 7: The 17 key behaviors promoted by MBNP

Source: MBNP


METHODOLOGY The assessment consisted of a comparative analysis covering MBNP and non-MBNP regions, using a combination of quantitative and qualitative methods. The assessment included secondary data analyses using the 2010 and 2015 TDHS. Primary data collection in both intervention and comparison areas, conducted in July 2017, included semi-structured interviews (SSIs) with 290 pregnant and lactating women and focus group discussions (FGDs) and key informant interviews (KIIs) with husbands, grandmothers, community health workers, community leaders, and MBNP program staff.

Selection of MBNP and Comparison Regions and Districts

The assessment covered three regions that have been part of MBNP since its beginning in 2011/2012: Dodoma, Manyara, and Morogoro (shown in red outline in Figure 8). Comparison regions included Arusha and Tanga; and Lindi and Ruvuma Regions were added for selected TDHS analyses (shown in green outline in Figure 8).4 The comparison regions were selected for illustrative purposes based on the following criteria:

• Similar childhood stunting levels in 2010 (per TDHS data) • Geographical proximity to the three MBNP regions5

The three MBNP regions included in the assessment are landlocked. Coastal districts in the comparison regions were excluded from the assessment because increased access to fish markets in coastal districts could affect nutritional behaviors and reduce comparability for the assessment. Districts that were predominantly urban were also excluded from all analyses to narrow the focus on nutritional practices in rural communities.

4 Originally, only Arusha and Tanga were included for comparison, and primary data collection was restricted to those regions. Lindi and Ruvuma were added later to increase sample sizes for the TDHS analyses. 5 For primary data collection, the comparison regions needed to be adjacent to the interventions areas due to budget limitations. We used multivariate logistic regression to control for characteristics that could vary across our intervention and control groups. We discuss this approach further in the Limitations section.


Figure 8: Map of the MBNP and comparison regions included in the assessment

Interviews with Women

Overview In July 2017, SSIs were administered to 290 women who were either pregnant or had a child under 2 years of age to understand factors that affect the adoption of key nutritional practices promoted by MBNP SBCC interventions. The interviews focused on understanding barriers to and facilitators for the adoption of key practices for improving maternal nutrition and health and for improving IYCF practices. Individual women were interviewed according to the module that was most relevant to their status (i.e., pregnant, has an infant ages 0–5 months, or has a child ages 6–24 months). If a woman met the criteria for two groups, the youngest child was selected. For example, if she had a child under 2 years of age and was pregnant at the same time, she was interviewed on the current pregnancy only.

The questionnaire included close-ended questions to collect data on women’s socio-demographic characteristics and to ask about their behaviors. Open-ended questions were used to obtain a richer understanding of the respondent’s beliefs and attitudes toward the behaviors. The Standard Knowledge

Map Key Red outline=Intervention regions included in the assessment for DHS analysis Red crosshatch=Intervention districts where primary data collection was conducted in 2017 Green outline=Comparison region Green crosshatch=Comparison districts where primary data collection was conducted in 2017 Black crosshatch=Districts from target regions that were excluded from the assessment


Practices and Coverage Survey questionnaire6 was adapted to measure the 17 key behaviors promoted by the 1,000 Days Kit. The assessment team adapted questions from Barrier Analysis tools7 to examine motivations, perceived advantages and disadvantages of the behaviors, and factors that made it easier or more difficult for the women to practice these behaviors.

To reduce recall bias, the assessment restricted interviews to women who were pregnant or had children under 2 years of age at the time of interview and focused on their current practices. This was particularly important because we wanted to measure specific motivations and barriers associated with practicing these behaviors, and we did not think that women would have good recall relating to behaviors that occurred months or years in the past.

Selection of Women Respondents We interviewed a total of 290 women, 145 each in the MBNP and comparison regions. We used a multi-stage sampling process to randomly select districts, wards, and villages in each region. A total of 12 villages in the MBNP region and 12 villages in the comparison regions were included. In each village, we interviewed approximately 12 women (the number ranged from 9 to 15). For this qualitative component, the selection process was intended to obtain perspectives from women in several distinct project areas and to document a range of perspectives and experiences regarding the nutritional behaviors and exposure to program interventions.

To be eligible, the women had to be at least 18 years of age and had to be pregnant (in the second or third trimester) or have a child under 2 years of age. In MBNP regions, the assessment team targeted pregnant and lactating women who had participated in at least two sessions of MBNP-sponsored PSGs. The evaluation made a deliberate effort to balance the number of women who were pregnant and mothers of children under 2 years of age, although no specific quotas were set.

In MBNP villages, pregnant and lactating women were selected from direct program beneficiaries. The assessment team collaborated with the local MBNP implementing partner to help identify and recruit respondents. The local CSO manager was requested to invite women who are members of PSGs in the village. The data collection team met those who accepted to participate either at their homes or at locations in the village where they usually meet for PSG meetings and screened them to confirm that they met the selection criteria.

In non-MBNP villages, pregnant and lactating women were randomly selected from among women seeking ANC for themselves or wellness care for children under 2 years of age at the local health facility. Selecting women directly from health facilities may mean that they had more contact with formal health services than women samples in the intervention areas. This may result in our underestimating differences between the intervention and comparison areas if contact with health facilities increases the likelihood of adopting healthy behaviors. Almost 90 percent of women in Tanzania seek services for ANC, however, so we do not expect this group to be vastly different than the women sampled in the intervention areas.

6 Knowledge Practices and Coverage surveys were developed by the Maternal and Child Survival Program and are available at http://www.mcsprogram.org/resource/knowledge-practice-coverage-tool/?submit=Search&_sf_s=KPC. 7 Making them specific to the behaviors under analysis


Interviews were conducted with all eligible pregnant and lactating women exiting these services, aiming to reach a total of 12 women. Facility staff helped introduce the data collection team to the women attending the clinic. Tables 2 and 3 show the number and distribution and demographic characteristics of the women interviewed in the MBNP region and the comparison regions. Among the women interviewed, the women in the intervention tended to be slightly older, with higher parity, more land ownership, and slightly less education on average, compared to the women in the comparison regions. The differences did not seem large enough to seriously bias findings, although we cannot rule out this possibility.

Table 2: Total number of women interviewed in 2017 in the MBNP and comparison areas by respondent type

Type of respondent Number of women in MBNP area

Number of women in comparison areas

Pregnant women 50 59 Mothers of children 0–5 months of age

35 30

Mothers of children 6–23 months of age

60 55

Table 3: Characteristics of women interviewed in MBNP and comparison areas by respondent type

Type of respondent MBNP area Number and percent

Comparison area Number and percent

Pregnant women Mean age 30.75 26.61 Education

None Primary

Secondary or higher

6 12.00% 33 66.00% 11 22.00%

6 10.17% 38 64.41% 15 25.42%

Married or cohabitating Single

45 90.00% 5 10.00%

56 94.92% 3 5.08%

Mean number of children 2.12 1.52 Number of acres of land owned

None Fewer than two acres

Two or more acres

7 14.00% 15 30.00% 28 56.00%

17 29.31% 10 17.24% 31 53.44%

Own animals 34 68.00% 24 40.68% Mothers of children 0–6 months of age Mean age 27.68 26.86 Education

None Primary

Secondary or higher

3 8.57% 25 71.43% 7 20.00%

5 16.67% 18 60.00% 7 23.33%


32 91.43% 3 8.57%

27 90.00% 3 10.00%



Two or more acres

5 14.29% 7 20.00% 23 65.22%

7 23.33% 7 23.33% 16 53.33%

Own animals 21 60.00% 22 73.33%


Type of respondent MBNP area Number and percent

Comparison area Number and percent

Mother of children 6–24 months of age Mean age 30.51 29.05 Education

None Primary

Secondary or higher

2 3.28% 48 78.69% 11 18.03%

15 27.78% 21 38.89% 18 33.33%


57 95.00% 3 5.00%

44 81.48% 10 18.52%



Two or more acres

6 10.17% 24 40.68% 29 48.15%

9 16.98% 17 32.08% 27 50.94

Own animals 53 88.33% 37 67.27%

Focus Group Discussions and Key Informant Interviews

Overview FGDs and KIIs were administered to further investigate and understand barriers to and facilitators for the adoption (or non-adoption) of key behaviors from the perspective of different actors.

FGDs and KIIs were conducted with fathers of children under 5 years of age, grandmothers, community leaders, community health workers (CHWs) or PSG leaders, healthcare workers, district leadership, and program staff, as described in this section. FGDs and KIIs used interview guides that explored a set of predefined topics but allowed for flexibility to ask about issues in more depth and to explore unanticipated lines of inquiry.

Participant Selection A purposive sampling approach was used for the FGD and KII in the same villages as those selected for the women’s interviews. Respondents were identified with support from Regional and District Nutrition Officers (DNuOs) and local CSOs based on guidance and criteria sent by the data collection team ahead of time. Selection criteria for the FGD participants and key informants were as follows:

Fathers: Men who live in the selected villages and who have children under 5 years of age. In the regions where the MBNP operates, we sought men who had participated at least once in a PSG meeting organized through the MBNP, although this was not always achieved.

Grandmothers: Women who live in the villages visited and who have a grandchild under 5 years of age who also lives in the same village.

Community leaders: Designated community leaders (including Village Executive Officers and other local government leaders) who reside in the villages or wards visited.

Community volunteers and PSG leaders: Volunteers officially affiliated with a health or nutrition project or program who help provide services to the community. They must work in the wards where the fieldwork is undertaken. In MBNP villages, these were CHWs who have been working under an MBNP-supported CSO.


Agriculture extension workers: Agriculture extension workers officially affiliated with an agriculture or nutrition project and who work in the wards where the fieldwork was undertaken.

Community-based organizations: Organizations implementing projects in the wards visited that are related to nutrition, maternal and child health, agriculture, or income generation.

Health facility staff: The facility closest to or in the villages visited was selected for inclusion. Any staff member at the facility who provides nutrition, ANC, or child wellness services was eligible to be interviewed. Staff were selected based on their availability.

District-level staff: District coordinators for nutrition or reproductive and child health were eligible and were selected based on their availability.

MBNP staff: Staff who have worked in program implementation or monitoring and evaluation (M&E) for two or more years were eligible and were selected based on their availability.

National-level staff: Staff from ministries or national-level agencies who have worked with MBNP for two or more years were eligible and were selected based on their availability.

Table 4: Number of FGDs conducted with each respondent category

Respondents # FGDs in MBNP area

# FGDs in comparison areas

Total # FGDs

Fathers of children under 5 years of age 3 4 7 Grandmothers of children under 5 years of age (influencers)

6 3 9

Community volunteers or PSG leaders 6 5 11 Agriculture extension officers 3 3 6 Community leaders 3 3 6 TOTAL 21 18 39

FGDs included three to six participants per group and provided a format to share opinions and experiences on the selected topics. KIIs were conducted with one individual at a time, seeking out their knowledge, experience, and opinions on the selected topics.

Table 5: Number of KIIs conducted with each respondent category

Respondents # KIIs in MBNP area

# KIIs in comparison areas

# KIIs at the national level

Total # KIIs

CSO 3 4 7 District leadership 9 4 13 Agriculture extension officers 3 1 4 Health facility staff 10 11 21 MBNP staff

4 4

National nutrition representatives from the President’s Office Regional Administration and Local Government (PORALG) and TFNC

2 2

TOTAL 25 20 51

Demographic data were not collected from FGD and KII participants in part to protect their identities. ICF collaborated with FXBT Health to jointly train data collection teams that consisted of interviewers, supervisors, and note takers. All data collection tools were translated to Kiswahili and pre-tested in Dar


es Salaam. Fieldwork took place simultaneously in the five regions over a two-week period in July 2017. Interviews were done in teams of two, generally consisting of one female interviewer and one male interviewer, or two female interviewers in each team. Interviewers would alternate interviewing and taking notes. The research team trained to mitigate for a potential interviewer effect. Teams were instructed to take cues from the respondent and to change the interviewer if the respondent appeared uncomfortable.

The interviews and FGDs were conducted in Kiswahili, with one interviewer and one note taker present at each discussion. Informed consent was obtained from all participants. Ethical approval was received from ICF’s Internal Review Board and from Tanzania’s National Institute for Medical Research.

FXBT Health coordinated and supervised data entry tasks. Notes from all interviews and FGDs were translated from Kiswahili to English and entered electronically in Microsoft Word. Quantitative data for the women’s questionnaires were entered in SPSS and later converted to STATA for analysis. Qualitative responses were typed and translated to English. Subsequently, these data were coded and entered into the same database.

Analysis

The assessment used a number of data sources. The assessment used the qualitative data from women and members of the community to understand motivation and facilitators for and barriers to behavior change. Data from the TDHS were analyzed to examine trends over time in behaviors and support the findings from the qualitative methods.

Analysis of Women’s Interviews The assessment team constructed indicators for each of the key behaviors and compared the frequency of women practicing them across the MBNP and comparison areas. Descriptive statistics were used to examine and compare the characteristics of the respondents in each of the MBNP and comparison areas and to examine how women’s perceptions and attitudes of the key behaviors varied across the MBNP and comparison areas, as well as how they varied across women’s characteristics.

Open-ended responses in the women’s interviews were coded as follows. A group of 25 questionnaires were reviewed, and possible response categories for each question were listed in a codebook. The team then reviewed the codes and made adjustments to combine codes or clarify specific ones. Two coders then coded the same questionnaires using ATLAS.ti and compared coding to ensure a common understanding of how and when to apply the codes. Following this exercise, the final coding categories were determined, and the coders worked independently to code responses and discuss them when questions arose. Multiple codes could be assigned to a response. After coding, the coded data were entered in the existing database, allowing us to quantify these responses. We used STATA for analysis.

Analysis of Focus Group Discussions and Key Informant Interviews All notes were uploaded in the qualitative analysis software ATLAS.ti for coding and analysis. The research team developed a codebook using emergent themes identified through the data collection and review process, deductive codes that corresponded to the assessment questions, and inductive codes that captured capturing additional emergent themes. The final codebook contained 56 codes grouped into the following categories: behavioral determinants (11), maternal and child health and nutrition (7), maternal health and nutrition (15), child health and nutrition (9), and overarching codes (14).


With the codebook established, the research team coded the same sample of three sets of interview notes. The coded notes were then reviewed for coding consistency, and the team clarified any discrepancies and arrived at a common understanding. After coding consistency and reliability were established, the research team read the notes and coded each statement or exchange. The team met regularly to discuss questions and points of clarification. After all the data were coded, they were analyzed to understand the facilitators for and barriers to maternal and child health and nutrition (MCHN) behaviors (both general and key) and to answer the research questions.

Analyses of Tanzania Demographic and Health Surveys The 2010 and 2015 TDHS data were analyzed to assess changes in women’s nutritional behaviors over time. The 2010 TDHS was conducted from December 2009 to May 2010. The 2015 TDHS was conducted from August 2015 to March 2016.

The regions and districts for analysis were selected as described above, excluding coastal and predominantly urban districts. We used descriptive statistics to highlight the socio-demographic characteristics of respondents in the different surveys and comparison groups.

Using STATA, we calculated and summarized the descriptive statistics for the key behaviors for both MBNP and comparison areas in 2010 and 2015. We used chi-square tests to determine whether statistical changes were noted (1) over time for the program area and non-program areas separately, and (2) between the project and non-project areas in 2010 and in 2015. The sample sizes are shown in Appendix 1.

We used a pooled dataset of the 2010 and 2015 TDHS to fit regression models that included variables for time and project area to examine how much of the change in the average nutrition behavior indicators is explained by each of these factors, while controlling for known confounders.8 We also fit a model that included an interaction term for time and project area to test whether the effect of time on the behavior of interest was statistically different in the program area compared to the non-program area when controlling for known confounders. Control variables were entered into the models if they were thought theoretically to affect the outcomes, regardless of their significance. We did not fit regression models for behaviors that had little variation in outcome (i.e., the majority had adopted the behavior or the majority was not practicing the behavior).

Document Review

The document review included these documents: available national and subnational nutrition and health reports; relevant Tanzania policy documents (e.g., National Nutrition SBCC Strategy, National Nutrition Strategy, NMNAP, National Strategy for Gender Development); and MBNP program reports, assessments, progress reports, and program M&E documents. This review was conducted with the objectives of (1) understanding the context in which the program operates, (2) understanding how the program has been implemented and what interventions and policies have been used to improve practices and services in the program areas, (3) identifying broader contextual factors that may have affected nutrition and nutritional practices during the previous five years, and (4) filling information gaps and triangulating findings with those of the other assessment methods.

8 The confounders controlled for in these analyses are listed in the regression tables in Appendix 6


Also reviewed were Tanzania national and subnational studies that examined levels, causes, and determinants of stunting among children under 5 years of age and maternal anemia. These included studies that measure the behaviors promoted by MBNP. Examples of types of documents that were included in the review are the National Nutrition Survey, the World Food Programme Comprehensive Food Security and Vulnerability Analysis, the United Nations Children’s Fund report on Women and Children in Tanzania, published studies relevant to Tanzania, and related district and regional monitoring and performance reports.

The document review started before the qualitative field research was conducted so that relevant study factors could be further refined and integrated into interviewer guides and interviewer orientation and training. Africare and its counterparts submitted relevant program documents. Additional online searches were initiated to complement these documents and provide further information on the Tanzania implementing environment and proposed study factors. During the analysis of the assessment findings and development of conclusions, additional regional, national, and local relevant studies and reports were identified and used to further enlighten the interpretation of findings and ensure the relevancy of the recommendations in the Tanzania context. A total of 40 documents were reviewed. The list of documents that were reviewed is provided in Appendix 2.

Limitations

This assessment is not an evaluation and does not seek to measure the specific impact of MBNP on nutritional practices. Rather, it seeks to obtain a greater understanding of the pathways through which improved behaviors can come about and how SBCC interventions can influence them. To this end, the assessment aims to understand whether there are differences in the MBNP area and comparison areas regarding the uptake of behaviors and in the factors motivating women to start practicing these behaviors. Although the study can help identify key differences, it cannot attribute these differences solely to the program itself.

MBNP operates in a complex environment where multiple projects and initiatives are working to improve nutrition and health outcomes among women of reproductive age and children under 5 years of age. We included two non-MBNP regions for comparison, but we recognize that no regions of Tanzania were completely devoid of health and nutrition interventions during the time period covered by the assessment. Therefore, interpretation of results was done with caution. We elected to choose comparison sites based similar levels of stunting at baseline and proximity to intervention sites. Many other factors may affect the comparability of our intervention and comparison samples, and it is likely that we have not adequately controlled for all confounders in our analysis. We did, nevertheless, conduct multivariate regression analysis using DHS data to get more robust findings.

The women’s interviews conducted through this assessment were not intended to be representative, nor are they comparable to the TDHS because the sampling approaches are different. Financial restrictions limited the number of respondents we could interview. Therefore, instead of focusing on point estimates (which were available through the TDHS), the assessment focused on qualitative information that would permit us to understand barriers and motivations that facilitate behavior change.

The assessment helped identify key factors of success and barriers to the adoption of improved nutritional behaviors. However, it was not possible to explain the multiple ways in which culture, gender, household economics, markets, and climate interact to influence individual behavior.


The eligibility criteria omitted women who participated in the program in past years but did not have children under 2 years of age or were not pregnant (in the second or third trimester) at the time of data collection. Therefore, the assessment may have missed some past successes of the MBNP. On the other hand, because SBCC interventions require time to change behavioral attitudes and norms, focusing on current behaviors may still account for the long-term effects of the program.

A note about comparing findings from the TDHS with the women’s interviews done for this assessment

The sample drawn for the women’s interviews as part of this assessment in 2017 was not meant to be representative, nor was the sample size sufficient to obtain reliable point estimates. The purpose was to obtain information on factors that facilitated behavior adoption. In addition, the sample design was different: TDHS used household surveys and the assessment sampled from program beneficiaries (in the MBNP area) and women seeking services at health facilities (in comparison areas). Measurement of the behavioral indicators diverged. The TDHS asked retrospective questions about practices in last pregnancy or when child was young, whereas the assessment asked about current practices only. The questions and time period covered are therefore not the same.

Nevertheless, we note that results for the comparison area are generally similar to what is reported in the 2015 TDHS. Results for the MBNP are sometimes higher in the sample than the data reported in the 2015 TDHS. This discrepancy may be because the assessment data allowed for 2 more years of program implementation, and the program effects have accrued. Program beneficiaries were specifically targeted in the MBNP sample, which may also explain why the results are higher than among a random household sample in this area, again indicating a positive program effect among direct beneficiaries.


RESULTS AND DISCUSSION This section provides a discussion of the results for each of the seven research questions asked by the MBNP assessment. All data sources, including the SSIs with women in 2017,9 FGDs, KIIs, TDHS data and analysis, and document review, are brought together and used to triangulate findings and gain a comprehensive understanding of the results for each research question. The discussion following each research question is organized by stage of development (i.e., Pregnancy, Sprout, Bud, and Flower) and the corresponding key promoted behaviors in each stage. Please note that for research questions 4 and 5, the Sprout and Flower stages are combined due the sharing of several key practices across the two stages and the commonality of facilitators and barriers mentioned for the practices in these stages. In addition, research questions 6 and 7 are combined because they are interrelated and are discussed with an overview of the MBNP effort and assessment findings rather than according to specific stages.

Research Questions 1 and 2

• To what extent did the proportion of women practicing each of the desired behaviors increase in the MBNP area and in the comparison areas between 2010 and 2015?

• Was the change in the proportion of women practicing these behaviors greater in the program area compared to the comparison area?

Pregnancy (Seed Stage) The Pregnancy (Seed Stage) includes five key promoted behaviors: early ANC visit; daily intake of IFA supplement throughout pregnancy; increased consumption of iron-rich foods; sleeping under long-lasting ITNs; and adhering to malaria treatment and deworming tablets as prescribed. All behaviors represent key critical actions to protect and promote the development of the fetus as well as the guard and improve the nutritional status of the pregnant woman. These adopted behaviors result in better birth outcomes for mother and newborn and make an important early contribution toward the reduction of stunting among children.

Encouragingly, for all Pregnancy (Seed Stage) behaviors, program beneficiaries in the MBNP area revealed a good level of knowledge regarding the desired behaviors and their importance. In the MBNP area, increases in practice of key desired behaviors were measured consistently over time for the following10:

• Early ANC visit • Daily intake of IFA supplement during pregnancy • Adhering to malaria treatment during pregnancy (two or more intermittent doses of

sulfadoxine-pyrimethamine (SP) /Fansidar)

9 The number of women interviewed is small (approximately 50 in each area, i.e., the MBNP area and comparison areas), and therefore the sample was not designed to obtain valid point estimates, so data on the proportion of women practicing the various behaviors need to be interpreted with caution. Nevertheless, we present the findings to demonstrate the relative importance of the behaviors practiced by women. 10 This finding is based on 2010 and 2015 TDHS data.


According to 2017 SSIs with women, high levels of coverage were measured in the MBNP area for the following:

• Taking deworming tablets during pregnancy (76 percent) • Consumption of iron-rich food sources during pregnancy, including animal sources of protein

(98 percent) • Sleeping under a mosquito net (98 percent)11

For the comparison area, increases from the 2010 TDHS to the 2015 TDHS in key promoted behaviors were measured for early ANC and iron and folic acid supplementation during pregnancy. According to the 2017 SSIs with women, the only indicator in which higher practice coverage was recorded in the comparison areas was adherence to malaria treatment during pregnancy, measured at 47.5 percent, compared to 36 percent in the MBNP area. In the TDHS, this indicator had a significantly higher increase in the MBNP area, from 28 percent in 2010 to 41 percent in 2015; in the comparison areas, coverage decreased slightly during the same timeframe, from 36 percent in 2010 to 34 percent in 2015.

ANC attendance in the first trimester, taking iron supplements every day of the previous three days, and taking deworming were reported far more frequently among women in the MBNP area than women in the comparison areas. The levels reported by the MBNP program beneficiaries during the 2017 SSIs with women were much higher than those in the MBNP area in the 2015 TDHS. It is possible that such discrepancies arise because our interviews specifically targeted women known to have participated in program interventions, whereas the TDHS sampled randomly from all households regardless of participation. For the comparison areas, the levels measured were similar to those reported in the 2015 TDHS.

Table 6: Key pregnancy practices reported in 2017 SSIs with women

Key behaviors MBNP area Comparison areas Percentage N Percentage N

Attended ANC within first three months of pregnancy 64.0% 50 25.4% 59

Took iron and folic acid supplements every day the three days before the survey

76.0% 50 17.0% 59

Adhered to malaria treatment: took two or more doses of SP during the current pregnancy

36.0% 50 47.5% 59

Took deworming tablets at least once during this pregnancy

76.0% 50 54.2% 59

Consumed any iron-rich food in the previous three days12

98.0% 50 98.3% 59

Consumed meat, fish, or eggs in the previous three days 98.0% 50 94.9% 59 Slept under a mosquito net the night before the interview

96.0% 50 91.5% 59

11 The practice level recorded by the SSIs with women differed significantly from that of the TDHS measurements, which showed a decrease in coverage from 2010 (65.1 percent) to 2015 (29.4 percent). The variation in findings could be attributed to how the indicator was measured, time of year when survey was conducted, or when last net distribution occurred, among others. Mass distribution campaigns were conducted prior to the 2010 TDHS but were not repeated until after the 2015 TDHS was conducted (TDHS 2015).

12 Iron-rich foods include dark green or leafy vegetables, dried fruit, nuts or seeds, meat, organ meat, fish or shellfish, eggs and dairy products (milk, cheese or yogurt).


Table 7: Key pregnancy practices reported in the 2010 and 2015 TDHS, MBNP and comparison areas

Attended ANC early Indicator: Percentage of women who received ANC during the first trimester of pregnancy (last birth only) Numerator: Number of women who received ANC during the first trimester of pregnancy (last birth only) Denominator: Number of women who had a birth in the five years preceding the survey 2010 TDHS 2015 TDHS

p-value % (95% CI) WN* % (95% CI) WN

MBNP area 18.5 (15.0 - 22.6) 712 27.1 (23.1 - 31.5) 917 0.0049

Comparison area 17.8 (14.1 - 22.3) 635 27.4 (23.0 - 32.3) 661 0.0010

p-value 0.8123 0.9165

Took iron and folic acid supplements daily throughout pregnancy Indicator: Percentage of women who took iron tablets or syrup for at least 90 days during their pregnancy (last birth only) Numerator: Number of women who took iron tablets or syrup for at least 90 days during their pregnancy (last birth only) Denominator: Number of women who had a birth in the five years preceding the survey

2010 TDHS 2015 TDHS p-value

% (95% CI) WN % (95% CI) WN

MBNP area 5.3 (3.2 - 8.5) 712 23.1 (19.1 - 27.8) 917 0.0000

Comparison area 2.7 (1.5 - 5.0) 635 21.4 (18.2 - 25.1) 661 0.0000

p-value 0.0898 0.5380 Adhere to malaria treatment as prescribed Indicator: Percentage of women who received two or more doses of SP/Fansidar during their pregnancy (last birth only) Numerator: Number of women who received two or more doses of SP/Fansidar during their pregnancy (last birth only) Denominator: Number of women who had a birth in the five years preceding the survey

2010 TDHS 2015 TDHS p-value

% (95% CI) WN % (95% CI) WN MBNP area 28.3 (23.3 - 33.9) 712 40.6 (35.5 - 45.8) 917 0.0022 Comparison area 36.0 (30.2 - 42.2) 635 34.7 (30.0 - 39.8) 661 0.7554 p-value 0.0623 0.1094 Adhered to deworming tablets as prescribed Indicator: Percentage of women who took deworming tablets during their pregnancy (last birth only) Numerator: Number of women who took deworming tablets during their pregnancy (last birth only) Denominator: Number of women who had a birth in the five years preceding the survey 2010 TDHS 2015 TDHS

p-value % (95% CI) WN % (95% CI) WN

MBNP area N/A (0.0 - 0.0) 0 69.5 (64.5 - 74.0) 917 N/A

Comparison area N/A (0.0 - 0.0) 0 63.5 (58.0 - 68.6) 661 N/A

p-value N/A 0.0974 N/A = not available; 2010 TDHS did not contain relevant questions for numerator


Slept under a long-lasting ITN when pregnant Indicator: Percentage of pregnant women who slept under an ITN the night preceding the survey Numerator: Number of pregnant women who slept under an ITN the night preceding the survey Denominator: Number of pregnant women 2010 TDHS 2015 TDHS


MBNP area 65.1 (51.0 - 76.9) 95 29.4 (21.3 - 39.1) 135 0.0001

Comparison area 43.6 (30.4 - 57.7) 103 30.1 (22.5 - 38.9) 88 0.1023

p-value 0.0333 0.9171

Slept under long-lasting ITNs Indicator: Percentage of women who gave birth in the five years preceding the survey who slept under an ITN the night preceding the survey Numerator: Number of women who gave birth in the five years preceding the survey who slept under an ITN the night preceding the survey Denominator: Number of women who had a birth in the five years preceding the survey 2010 TDHS 2015 TDHS


MBNP area 61.4 (51.8 - 70.1) 712 31.3 (24.7 - 38.8) 917 0.0000

Comparison area 55.5 (47.0 - 63.7) 635 40.3 (33.6 - 47.5) 661 0.0144

p-value 0.3546 0.0776

*WN: weighted number of respondents.

Based on findings from the 2017 SSIs with women, ANC attendance in the first trimester, taking iron supplements every day of the previous three days, and taking deworming were reported at significantly higher levels among women in the MBNP area than women in the comparison areas. FGDs and KIIs completed in the MBNP area also revealed a higher and more detailed level of knowledge and understanding of these practices. For the comparison area, levels measured in the 2017 SSIs with women were similar to those reported in the 2015 TDHS. For the MBNP area, however, the levels measured in the 2017 SSIs with women were much higher than those reported in the 2015 TDHS. It is possible that such discrepancies arise from the fact that our interviews specifically targeted women known to have participated in program interventions, whereas the TDHS sampled randomly from all households regardless of participation. Also noteworthy is that in the 2010 and 2015 TDHS, indicators for early ANC visit and taking two or more doses of SP/Fansidar during pregnancy show larger percentage points gains over time in the MBNP area than in the comparison area. Results of interest for the key indicators are as follows:

• ANC within first three months, results from 2017 SSIs with women: 64 percent for the MBNP area, 25 percent for the comparison areas

• Iron supplement every day during the previous three days, results from the 2017 SSIs with women: 76 percent for the MBNP area, 17 percent for the comparison areas

• Deworming medicine during pregnancy, results from 2017 SSIs with women: 76 percent for the MBNP area, 54 percent for the comparison areas

• Taking two or more doses of SP/Fansidar during pregnancy, results from the 2010 and 2015 TDHS: increase of 12 percent in the MBNP area, decrease of 1 percent in the comparison areas


According to the 2017 SSIs with women, consuming iron-rich foods (98 percent in the MBNP area, 98 percent in the comparison areas) and an animal source of protein (98 percent in the MBNP area, 95 percent in the comparison areas) in the previous three days was encouragingly high in both the MBNP area and in the comparison areas. Other results from the 2017 SSIs with women indicate high levels of sleeping under a mosquito net in both the MBNP area (96 percent) and the comparison areas (92 percent). As mentioned earlier, the 2010 and 2015 TDHS data showed a decrease in this practice, with a 36 percent decrease in the MBNP area and a 14 percent decrease in the comparison areas. The 2015 decrease is most likely related to mosquito net supply, because nets had not been recently distributed near the time of the survey. The surveys were also completed during different months of the year, potentially impacting reported use of nets. Also, in some of the comparison areas, a continuous school-based net distribution was in operation during that time period.

Months 0–6 (Sprout Stage) The Sprout Stage focuses on three key promoted behaviors: initiate early breastfeeding within 1 hour of birth, give the baby colostrum (i.e., first milk), and breastfeed exclusively (breastmilk only for first 6 months, no water). These practices provide vital protection for the newborn and infant, leading to improved neonatal and infant survival and decreased neonatal and infant mortality.

Table 8: Key practices for mothers of children 0–6 months of age reported in 2017 SSIs with women


Infant is exclusively breastfed 76.5% 34 50.0% 30 Initiate breastfeeding within first hour after birth 80.0% 34 86.7% 30 Give baby colostrum 91.4% 34 90.0% 30

Data from the 2010 and 2015 TDHS indicate that the MBNP area showed significant increases for early and exclusive breastfeeding. The practice of exclusive breastfeeding increased by 21.5 percent, and early breastfeeding increased by 10.4 percent. The TDHS did not include questions regarding giving infants colostrum, so increases in this indicator could not examined. However, according to the 2017 SSIs with women in the MBNP area, all three key behaviors achieved high rates of reported practices, as follows (see Table 8):

• Giving the baby colostrum (91.4 percent) • Initiating breastfeeding within 1 hour of birth (80 percent) • Exclusively breastfeeding infant (75 percent)

Data from the 2010 and 2015 TDHS indicate that early initiation of breastfeeding (within 1 hour of birth) increased significantly in both the MBNP and comparison areas (see Table 9). Approximately two in three women practiced this behavior in 2015, with no significant differences observed between the MBNP and the comparison areas in 2010 or 2015. However, the increase between 2010 TDHS and the 2015 TDHS was larger in the MBNP area, and by 2015, the proportion of exclusively breastfeeding women was significantly higher in the MBNP area (51 percent) than in the comparison areas (39 percent).


Table 9: Key practices for mothers of children 0–6 months of age from the 2010 and 2015 TDHS, MBNP and comparison areas

Exclusively breastfeed (not even water) during the first 6 months Indicator: Percentage of women who exclusively breastfed their last-born child during the first 6 months Numerator: Number of women who exclusively breastfed their last-born child during the first 6 months Denominator: Number of women who have a living child 6–59 months of age 2010 TDHS 2015 TDHS

p-value % (95% CI) WN % (95% CI) WN MBNP area 29.9 (24.9 - 35.5) 583 51.4 (45.6 - 57.0) 767 0.0000 Comparison area 24.8 (20.1 - 30.2) 530 39.4 (32.9 - 46.2) 549 0.0004 p-value 0.1678 0.0084 Initiate breastfeeding within 1 hour of birth Indicator: Percentage of women who started breastfeeding their last-born child within 1 hour of birth Numerator: Number of women who started breastfeeding their last-born child within 1 hour of birth Denominator: Number of women who had a birth in the 5 years preceding the survey 2010 TDHS 2015 TDHS p-value % (95% CI) WN % (95% CI) WN MBNP area 59.9 (52.7 - 66.6) 712 70.3 (65.7 - 74.4) 917 0.0130 Comparison area 54.2 (44.7 - 63.5) 635 66.6 (61.7 - 71.3) 661 0.0311 p-value 0.3440 0.2701

For the Sprout Stage, the most significant difference between the MBNP area and the comparison areas for practicing behaviors was found in exclusive breastfeeding within the first 6 months. Between the 2010 and 2015 TDHS, the MBNP area experienced a 21.5 percent increase, and the comparison areas had a 14.6 percent increase. The 2017 SSIs among women showed that 76.5 percent of women in the MBNP area reported exclusively breastfeeding their infant, compared to 50 percent of women in the comparison areas. Data from the 2010 and 2015 TDHS show that initiating breastfeeding within the first hour of birth increased in both the MBNP area (increase of 10.4 percent) and the comparison areas (increase of 12.4 percent). Levels of exclusive breastfeeding reported by women during the 2017 SSIs were higher in the MBNP area (76.5 percent) than in the comparison areas (50 percent). As measured by the 2017 SSIs with women, giving the baby colostrum was practiced equally high in both areas (91.4 percent in the MBNP area and 90% in the comparison area) (see Table 8).

Months 6–12 (Bud Stage) The Bud Stage promotes five key practices: initiate complementary feeding after 6 months, feed babies older than 6 months of age semi-solids and finely chopped foods, feed babies older than 6 months of age a variety of foods, increase the amount of food and frequency as the baby gets older to reach three meals with a snack every day, and continue breastfeeding for babies. These behaviors are often the most difficult to practice because households face the challenges of food insecurity, time and fuel required to prepare food, poor hygiene practices, moving from passive feeding to actively feeding a child, and others. However, timely, appropriate complementary feeding that is adequate in quality and quantity and prepared in a hygienic manner are core ingredients for optimizing a child’s growth and thereby preventing illness and stunting.


Table 10: Key practices for mothers of children 6–24 months of age reported in 2017 SSIs with women


Continue breastfeeding the child 87.9% 58 90.6% 53 Child given foods other than breastmilk 98.3% 58 100.0% 53 Child ate foods from all three of the food groups (fruit, animal, and vegetables) in the day before the survey

82.8% 58 30.2% 53

Data from the 2010 and 2015 TDHS show that all five key practices for the Bud Stage increased in the MBNP area. The practice of initiating complementary feeding increased significantly, continued breastfeeding remained at 100 percent, and the practices for the remaining behaviors in this stage increased minimally. The practice of continued breastfeeding until the end of the first year of life was recorded at 100 percent for the MBNP area in both the 2010 and the 2015 TDHS. In the 2017 SSIs with women in the MBNP area, high levels of practice were measured for complementary feeding (98.3 percent) of children 6–24 months of age (Bud and Flower stages combined) and for feeding their child foods from at least three food groups each day (82.8 percent).

Table 11: Key practice s for mothers of children 6–12 months of age from the 2010 and 2015 TDHS, MBNP and comparison areas

Initiate complementary feeding after 6 months Indicator: Percentage of women who initiated complementary feeding when their last-born child was 6–8 months of age Numerator: Number of women who initiated complementary feeding when their last-born child was 6–8 months of age Denominator: Number of women who have a child 9–59 months of age who lives with her 2010 TDHS 2015 TDHS p-value % (95% CI) WN % (95% CI) WN MBNP area 28.5 (23.9 - 33.7) 519 51.9 (45.8 - 58.0) 696 0.0000 Comparison area 23.4 (18.6 - 29.0) 487 38.9 (32.4 - 45.9) 485 0.0003 p-value 0.1642 0.0061 Feed babies older than 6 months of age semi-solids (thick porridge/mashed foods) and finely chopped foods Indicator: Percentage of women who fed their last-born child solid, semi-solid, or soft foods the day before the survey Numerator: Number of women who fed their child solid, semi-solid, or soft foods the day before the survey Denominator: Number of women whose last-born child is 6–11 months of age and lives with her 2010 TDHS 2015 TDHS p-value % (95% CI) WN % (95% CI) WN MBNP area 94.8 (86.6 - 98.1) 98 95.2 (88.3 - 98.1) 123 0.9101 Comparison area 99.1 (93.2 - 99.9) 74 95.7 (84.1 - 99.0) 68 0.1871 p-value 0.0904 0.8794


Feed babies older than 6 months of age a variety of foods, including foods of animal origin, fruits, and vegetables Indicator: Percentage of women who fed their last-born child foods of animal origin, fruits, and vegetables the day before the survey Numerator: Number of women who fed their last-born child foods of animal origin, fruits, and vegetables the day before the survey Denominator: Number of women whose last-born child is 6–11 months of age and lives with her 2010 TDHS 2015 TDHS

p-value % (95% CI) WN % (95% CI) WN MBNP area 2.1 (0.4 - 10.3) 98 4.8 (1.8 - 11.9) 123 0.3968 Comparison area 9.1 (3.2 - 23.1) 74 8.7 (4.0 - 18.0) 68 0.9570 p-value 0.1025 0.3152 Increase the amount of food and frequency as the babies get older to reach three meals with a snack every day Indicator: Percentage of women who fed their last-born child solid, semi-solid, or soft foods at least three times the day before the survey Numerator: Number of women who fed their last-born child solid, semi-solid, or soft foods at least three times the day before the survey Denominator: Number of women whose last-born child is 6–11 months of age and lives with her 2010 TDHS 2015 TDHS

p-value % (95% CI) WN % (95% CI) WN MBNP area 29.5 (17.8 - 44.7) 98 29.7 (20.2 - 41.3) 123 0.9804 Comparison area 40.2 (24.2 - 58.6) 74 16.7 (9.7 - 27.1) 68 0.0165 p-value 0.3446 0.0670 Continue breastfeeding for the baby Indicator: Percentage of women who continue to breastfeed their last-born child Numerator: Number of women who continue to breastfeed their last-born child Denominator: Number of women whose last-born child is 6–11 months of age and lives with her 2010 TDHS 2015 TDHS p-value % (95% CI) WN % (95% CI) WN MBNP area 100 (0.0 - 0.0) 98 100 (0.0 - 0.0) 123 N/A Comparison area 100 (0.0 - 0.0) 74 95.8 (85.2 - 98.9) 68 0.1223 p-value N/A 0.0482

Although women in both areas reported high levels of initiating complementary feeding when the child is older than six months during the 2017 SSIs with women, the TDHS 2010 and 2015 levels were lower but did show significant percentage point increases across the 5-year time period. Data from the 2010 TDHS show that less than a third of women with children under 5 years of age reported initiating complimentary feeding of their youngest child between the ages of 6 and 8 months (see Table 11). The proportion doing so increased significantly in both the MBNP and comparison areas between 2010 and 2015, with a more substantial increase in the MBNP area. Data from the 2015 TDHS show that the proportion starting complementary feeding between 6 and 8 months of age was significantly higher in the MBNP area (52 percent) than in the comparison area (39 percent).

Among women with children 6–12 months of age at the time of 2015 TDHS, more than 95 percent were feeding their children soft, semi-solid, or solid foods in both survey years and across both the MBNP area and comparison areas (see Table 11). However, data from the 2015 TDHS show that less than 10 percent of women were feeding their children 6–12 months of age foods from all of three food


groups (fruits, animal,13 and vegetables) the day before the survey across both the MBNP and comparison areas (see Table 11).

In both TDHS survey rounds, in the MBNP area, 30 percent of mothers of children 6–12 months of age fed their children soft, semi-soft, or solid foods at least three times a day. In the comparison area, this indicator experienced a significant decrease between 2010 and 2015. During the 2017 SSIs with women, 82.8 percent of women in the MBNP area reported giving their child food from at least three food groups the day before, compared to 30.2 percent of women in the comparison areas.

Increasing the amount of food and frequency as baby gets older to reach three meals a day with a snack remained almost the same in the MBNP area between the 2010 and 2015 TDHS surveys, with an increase from 29.5 percent in 2010 to 29.7 percent in 2015. The comparison area experienced a significant decrease in this practice, from 40.2 percent in 2010 to 16.7 percent in 2015.

In both the 2010 and 2015 TDHS, continued breastfeeding for children 6–12 months of age was reported by 100 percent of women in the MBNP area. The comparison areas experienced a small decrease in the proportion of women who continued breastfeeding for children 6–12 months of age. Women in both the MBNP and comparison areas reported high levels of continued breastfeeding practice.

Data from the 2010 and 2015 TDHS indicate that the following practices in the Bud State experienced better achievements in the MBNP area than in the comparison areas:

• Initiating complementary feeding at 6 months: 23.4 percent increase in the MBNP area, 15.5 percent increase in the comparison areas

• Feeding babies older than 6 months a variety of foods: 2.7 percent increase in the MBNP area, 0.4 percent increase in the comparison areas

• Increasing the amount of food and frequency as the baby gets older: 0.2 percent increase in the MBNP area, 23.5 percent decrease in the comparison areas

In the 2017 SSIs with women, the MBNP area reported a significantly higher percentage of women feeding their child older than 6 months of age a variety of foods, including foods of animal origin, fruits, and vegetables, measured at 82.8 percent, compared to 30.2 percent in the comparison areas. The MBNP’s focus on using PSGs to promote home gardening and small livestock keeping and to combine this with infant and young child feeding education and joint household decision-making was most likely a strong contributor to the variations in the reported practice measured between the two areas. As noted earlier, the TDHS measured low levels for this indicator in both areas. The differences in findings may be due to how the indicator was measured as well as how survey respondents were selected. The time of year for when data are collected may also have an impact on seasonal availability of fruits and vegetables.

As mentioned previously, based on 2010 and 2015 TDHS data, both the MBNP area and the comparison areas saw an increase in initiating complementary feeding after 6 months of age. This increase was higher for the MBNP area (23.4 percent increase) than for the comparison area (15.5 percent increase). During the 2017 SSIs with women, both areas reported a high level of initiating complementary feeding (98.3 percent in the MBNP area and 100 percent in the comparison areas).

13 Includes milk, yogurt, cheese, eggs, and meat


Continued breastfeeding was high and remained high in both the MBNP and comparison areas. This practice was measured at 100 percent in the MBNP area in the 2010 and 2015 TDHS. The comparison area recorded a slight decrease between 2010 and 2015 TDHS, from 100 percent in 2010 to 95.8 in 2015. Feeding babies older than 6 months semi-solid and finely chopped foods was also widely practiced and maintained in both MBNP (95.2 percent in the 2015 TDHS) and comparison areas (95.7 percent in the 2015 TDHS).

Increasing the amount of food and frequency as baby gets older to reach three meals a day with a snack remained the same from the 2010 TDHS to the 2015 TDHS in the MBNP area (29.5 percent) but experienced a 23.5 percent decrease in the comparison area (16.7 percent) in the 2015 TDHS (see Table 11).

Months 12–24 (Flower Stage) The Flower Stage reinforces several key promoted behaviors from the Bud Stage. The focus of behaviors is to improve the quality, quantity, and frequency of the child’s feeding, complemented by continued breastfeeding. During the first 2 years of life, a child is in its most rapid stage of growth. This unique period presents an opportunity to maximize growth and is the most critical period to prevent stunting. Improving the minimum acceptable diet indicator for children in developing countries is challenging and requires a sustained effort. Integrated activities, such as the MBNP’s home gardens, small livestock keeping, and income generation, provide practical help to improve the quantity and quality of a household’s diet.

In the Flower Stage, women in the MBNP area had a high percentage for practicing the following:

• Feeding the child solid foods (mashed or chopped when necessary) (100 percent in the 2015 TDHS)

• Feeding the child a variety of foods (at least three food groups the day before the survey) (82.8 percent in the 2017 SSIs with women)

• Continuing to breastfeed the child up to 2 years of age and beyond (79.9 percent in the 2015 TDHS)

According to the TDHS, feeding of solid, semi-solid, or soft foods to children 12–24 months of age was exceptional because it was practiced by 99 percent of women in 2010 and by 100 percent of women in 2015 (see Table 12) in both the MBNP and comparison areas. In the MBNP area, 82.8 percent of women reported that their child ate foods from the three food groups the day before the survey, compared to 30.2 percent in the comparison areas. By mid-term, the MBNP had well exceeded its targets to promote community and household production of staple and quality food such as fruits, green and yellow vegetables, and animal proteins through the adoption of household gardening and fish and small livestock keeping such as poultry and rabbits (MBNP, MTE 2015). Demonstration garden plots proved to be an effective method for skills transfer of household gardening. MBNP also leveraged the local USAID funded Pamoja Tuwalee Project, implemented by Africare, to train PSG members in income-generating activities.

Data from the 2010 and 2015 TDHS show that levels for feeding children foods from all three food groups (fruits, animal,14 and vegetables) in the day before the survey increased in both the MBNP area (from 5.3 percent in 2010 to 12 percent in 2015) and comparison areas (from 11.3 percent in 2010 to

14 Includes milk, yogurt, cheese, eggs, and meat


22 percent in 2015) (see Table 12). In the comparison areas, the proportion feeding all three food types was double that in the MBNP area in both TDHS years. The variation in the practice levels for the two data sources for this indicator may be related to the 2017 SSIs with women purposively reaching MBNP beneficiaries, while the 2015 TDHS randomly selected from all households in the districts.

Among women who had children 12–24 months of age, the proportion feeding these children food at least three times per day remained constant in the MBNP area between 2010 and 2015 at around 40 percent (see Table 12). In the comparison areas, however, that proportion decreased significantly, from 50 percent to 32 percent over the same period. At MBNP mid-term evaluation, the minimal acceptable diet (measures quality and frequency of feedings) for children 6–24 months of age was recorded at 51 percent, well above the 20 percent recorded in 2010 TDHS at the national level. The proportion of mothers feeding their children 12–24 months of age at least four meals per day was very low, below 7 percent in both areas in 2015 (see Table 12). Although no significant change was seen over time in the MBNP area, the comparison areas showed a significant decrease, from 15 percent in 2010 to 5 percent in 2015.

The proportion of women who continue to breastfeed their children 12–24 months of age was around 80 percent in both areas as measured by the 2015 TDHS (see Table 12). Although no significant change was seen over time in the MBNP area, there was a significant decrease in the comparison areas, from 90 percent in 2010 to 80 percent in 2015.

Table 12: Key practices for mothers of children 12–24 months of age, from the 2010 and 2015 TDHS, MBNP and comparison areas

Feed babies solid foods (family foods), mashed or chopped if necessary Indicator: Percentage of women who fed their last-born child solid, semi-solid, or soft foods the day before the survey Numerator: Number of women who fed their last-born child solid, semi-solid, or soft foods the day before the survey Denominator: Number of women whose last-born child is 12–23 months of age and lives with her 2010 TDHS 2015 TDHS

p-value % (95% CI) WN % (95% CI) WN MBNP area 99.6 (97.1 - 99.9) 184 100 (0.0 - 0.0) 240 0.2659 Comparison area 98.9 (92.8 - 99.8) 142 100 (0.0 - 0.0) 170 0.2619 p-value 0.4583 N/A Feed babies a variety of foods, including foods of animal origin, fruits, and vegetables Indicator: Percentage of women who fed their last-born child foods of animal origin, fruits, and vegetables the day before the survey Numerator: Number of women who fed their last-born child foods of animal origin, fruits, and vegetables the day before the survey Denominator: Number of women whose last-born child is 12–23 months of age and lives with her 2010 TDHS 2015 TDHS

p-value % (95% CI) WN % (95% CI) WN MBNP area 5.3 (2.3 - 12.0) 184 12.1 (7.4 - 19.1) 240 0.0739 Comparison area 11.3 (6.6 - 18.9) 142 22.4 (15.1 - 32.0) 170 0.0284 p-value 0.1217 0.0420


Increase the amount of food and frequency as the babies get older to reach three meals every day Indicator: Percentage of women who fed their last-born child solid, semi-solid, or soft foods at least three times the day before the survey Numerator: Number of women who fed their last-born child solid, semi-solid, or soft foods at least three times the day before the survey Denominator: Number of women whose last-born child is 12–23 months of age and lives with her 2010 TDHS 2015 TDHS

p-value % (95% CI) WN % (95% CI) WN MBNP area 40.0 (29.4 - 51.5) 184 38.9 (29.5 - 49.3) 240 0.8870 Comparison area 49.3 (35.9 - 62.8) 142 32.2 (24.8 - 40.6) 170 0.0470 p-value 0.3005 0.2942 Increase the amount of food and frequency as the babies get older to reach three meals and one snack every day Indicator: Percentage of women who fed their last-born child solid, semi-solid, or soft foods at least four times the day before the survey Numerator: Number of women who fed their last-born child solid, semi-solid, or soft foods at least four times the day before the survey Denominator: Number of women whose last-born child is 12–23 months of age and lives with her 2010 TDHS 2015 TDHS p-value % (95% CI) WN % (95% CI) WN MBNP area 9.3 (5.1 - 16.6) 184 6.8 (3.6 - 12.6) 240 0.4770 Comparison area 14.6 (9.5 - 21.7) 142 5 (2.5 - 10.1) 170 0.0068 p-value 0.2182 0.5362 Continue breastfeeding for the baby up to 2 years and beyond Indicator: Percentage of women who continue to breastfeed their last-born child Numerator: Number of women who continue to breastfeed their last-born child Denominator: Number of women whose last-born child is 12–23 months of age and lives with her 2010 TDHS 2015 TDHS

p-value % (95% CI) WN % (95% CI) WN MBNP area 82.1 (73.8 - 88.1) 184 78.3 (71.2 - 84.1) 240 0.4594 Comparison area 90.5 (83.6 - 94.7) 142 79.9 (71.5 - 86.3) 170 0.0382 p-value 0.0644 0.7518

For practices in the Flower Stage, the MBNP area measured a higher level of women who reported feeding their child a variety of foods in the 2017 SSIs with women, and both the MBNP and comparison areas doubled their percentages for this practice from the 2010 to the 2015 TDHS. Both the MBNP area and comparison areas maintained high rates of continued breastfeeding until 2 years of age (in both the 2017 SSIs with women and the TDHS), although the comparison areas had a larger drop in percentage points across the 2010 to 2015 TDHS. The 2017 SSIs with women showed that increasing the amount of food and frequency as the child gets older to reach three meals and two snacks every day was reported much more frequently by women in the MBNP area. The 2010 to 2015 TDHS levels for this practice were maintained in the MBNP area, but they decreased in the comparison area during that time period. Data on key practices for the Flower Stage are as follows:

• Feeding child (12–24 months of age) a variety of foods, including foods of animal origin, fruits, and vegetables: 2017 SSI with women: 82.8 percent in the MBNP area, 30.2 percent in the comparison areas; 2010 to 2015 TDHS: MBNP increased from 5.3 percent in 2010 to 12.1 percent in 2015, comparison areas increased from 11.3 percent in 2010 to 22.4 percent in 2015


• Continued breastfeeding until 2 years of age and beyond: 2010 and 2015 TDHS: 100 percent for the MBNP area for both years; a 9.5 percent decrease in the comparison areas, from 100 percent in 2010 to 90.6 percent in 2015

• Increasing amount of food and frequency as child gets older: 2010 and 2015 TDHS: MBNP areas maintained this percentage with 40 percent in 2010 and 38.9 percent in 2015; comparison areas experienced a decrease from 49.3 percent in 2010 to 32.2 percent in 2015

Research Question 3

• Which nutritional practices are most likely to be adopted by pregnant women and lactating mothers of children under 2 years of age?

Pregnancy (Seed Stage) Based on the practices reported for the MBNP area in the 2017 SSIs with women, the practices that are most likely to be adopted by pregnant women during the Seed Stage are as follows:

• Consuming iron-rich foods and foods of animal origin, fruits, and vegetables (98 percent) • Sleeping under a mosquito net (96 percent)

These two practices are followed by:

• Taking iron and folic acid supplements during pregnancy (76 percent) • Taking deworming medicine during pregnancy (76 percent) • Attending an ANC visit within the first 3 months of pregnancy (64 percent)

Finally, the practice of adhering to malaria treatment (taking two or more doses of SP/Fansidar) during pregnancy was practiced by only a third of the women (36 percent).

Months 0–6 (Sprout Stage) For the Sprout Stage, according to the 2017 SSIs with women in the MBNP area and based on increases recorded between the 2010 and 2015 TDHS, the practices most likely to be adopted by lactating mothers of children under 2 years of age are as follows:

• Ensuring that babies get colostrum (first milk) (91.4 percent in the 2017 SSI MBNP area) • Initiating breastfeeding within 1 hour of birth (80 percent in the 2017 SSI MBNP area) • Exclusively breastfeeding only, not even water during the first 6 months (76.5 percent in the

2017 SSI MBNP)

All three of the practices in this stage were found to be practiced at high levels in the MBNP area. When a pregnant woman is prepared for birth through ANC visits and delivers with a skilled attendant, she has a much greater chance of adopting these practices. Continued support from peers and volunteers in the community and from members in the household helps encourage the mother to exclusively breastfeed.

Months 6–12 (Bud Stage) For the Bud Stage, the practices that are most likely to be adopted are as follows:

• Initiating complementary feeding after 6 months (2017 SSI: 98.3 percent in the MBNP area, 100 percent in the comparison areas)


• Feeding children older than 6 months of age semi-solid, chopped, and solid foods (2015TDHS: 95.2 percent in the MBNP area, 95.7 percent in the comparison areas)

• Continued breastfeeding for the babies (2010 and 2015 TDHS: 100 percent in 2010 and 2015 for the MBNP area, 100 percent in 2010 and 95.8 percent in 2015 for the comparison areas)

Also, likely to be adopted is the practice of feeding babies older than 6 months of age a variety of foods, including foods of animal origin, fruits, and vegetables (82.8 percent in the 2017 SSI MBNP area). This was most likely adopted at high levels in the MBNP area because of the behavior change promotion efforts, combined with practical agriculture linkage support such as home gardening, small livestock keeping, and income generation. The orientation and support for couples to discuss and decide together most likely offered vital intra-household support needed to improve dietary diversity. At the same time, however, the 2017 SSIs with women recorded low levels (30.2 percent) in the comparison areas on this same practice.

The practice in this stage that was most challenging to adopt was increasing the amount of food and frequency as the babies get older to reach three meals and two snacks every day. This practice takes time and fuel to prepare the food and time and patience to actively feed a child as he or she adapts to new tastes and textures. Less than a third of women reported doing this practice (2015 TDHS: 29.7 percent for the MBNP area, 16.7 percent for the comparison areas).

Months 12–24 (Flower Stage) For the Flower Stage, the practices that are most likely to be adopted are as follows:

• Feeding babies solid food (family foods), mashed or chopped if necessary (2015 TDHS: 100 percent in both MBNP and comparison areas)

• Continued breastfeeding for babies up to two years of age and beyond (2015 TDHS for children 12–24 months of age: 79.3 percent in the MBNP area, 79.9 percent in the comparison areas; 2015 TDHS for children 6–12 months of age: 100 in both MBNP and comparison areas)

As mentioned in the Sprout Stage, a practice that shows potential for being adopted if practical support is given (such as promotion of household gardens, small livestock keeping, and income-generating activities) is feeding babies a variety of foods, including foods of animal origin, fruits, and vegetables. With supportive interventions, according to the 2017 SSIs with women, 83 percent in the MBNP area reported this practice, compared to 30 percent in the comparison areas.

As with the Sprout Stage, the practice in the Flower Stage that require additional promotion and support is increasing the amount of food and frequency as the baby gets older to reach three meals and two snacks every day. In the 2015 TDHS, less than a third of the women in the MBNP area (29.5 percent) and only 16.7 percent in the comparison areas reported this practice.

Research Question 4

• What factors facilitate adoption by women of the 17 key behaviors promoted through the MBNP SBCC campaign?

To assess the factors that facilitate the adoption by women of the 17 key behaviors promoted, the 2017 field work as described earlier included SSIs with pregnant women and women with a child less than 2 years of age. The women were asked the advantages of practicing a specific behavior and what made it easier for them do so. FGDs and KIIs were also conducted to investigate and explore facilitators for the


adoption of key behaviors from the perspective of different actors. Participants included fathers of children under 5 years of age, grandmothers, community leaders, community health workers, PSG leaders, agriculture extension officers, healthcare workers, district leadership, and program staff. This section explores the findings from the SSIs with women, identifying facilitators by stage of development (Seed, Sprout, Bud, and Flower—note that the Bud and Flower Stages are combined in the discussion because the two stages share many of the same practices) and for specific practices in each stage. This is followed by a broader discussion of factors, including structural, community, household, and individual-level factors, as discussed in the FGDs and KIIs. In addition, Table 13 lists the facilitators mentioned for each behavior and by MBNP or comparison area.

Pregnancy (Seed Stage) For the desired practices in the Seed Stage, common themes mentioned by women interviewed were knowledge of the benefits of the practice for mother’s and babies’ health; proximity to health facility, with closer distance making it easier to get to an ANC visit and to obtain IFA supply; convenience of direct observation at the clinic for taking deworming medication and SP/Fansidar onsite at the time of the ANC visit; and free distribution of mosquito nets. Many of these facilitators are well documented in studies that look at facilitators for these practices, particularly having access to quality affordable healthcare facilities with adequate supplies (IFA supplements, ITNs, SP/Fansidar, and deworming medication, among others), complemented by education and counseling. Following is a summary of facilitators mentioned for each specific practice:

Attending ANC in first trimester: Women noted that having received prior information about the importance of early ANC was an important facilitator to seeking care. They also mentioned that needing proper medical attention for specific symptoms or illnesses motivated them to seek ANC early on. A few women noted that having a discussion with their partner about seeking ANC helped. Finally, proximity to the health clinic made it easier for women to seek ANC care. Results from the multivariate regression using TDHS data indicate that being in wealthier quintiles and living in a rural setting increased the odds of attending ANC in first trimester (see Appendix 6).

Taking iron and folic acid tablets: Many women indicated that knowing that iron tablets improved women’s and babies’ health made it easier for them to take the tablets. Another cited factor that facilitated taking IFA supplements was being advised to do so at the clinic. Results from the multivariate regression using TDHS data indicate that having a wanted pregnancy and having gone to three or more ANC visits significantly increased the odds of taking folic acid during pregnancy (see Appendix 6).

Taking deworming tablet: Women mentioned that being given the deworming tablet at the clinic and taking it there made this action easy. Receiving advice from nurses and knowing that taking the tablet is beneficial for their own and their babies’ health also helped make it easier to carry through with the practice. A few women mentioned that the tablets were easy to take.

Adhering to malaria preventative treatment: As with deworming medicine, women mentioned that having the tablets provided and taken at the health facility made it easier for them to do this practice. Living close to a facility was also a facilitator. Women also mentioned that knowing that the tablets help protect the mother and baby from malaria was also a facilitator. Studies completed in Tanzania on compliance with this practice found the availability of drug during an ANC visit, followed by women’s knowledge regarding the dangers of placental malaria, to be the strongest factors facilitating compliance. (Mdetele, et al., 2017). Results from multivariate regression using TDHS data indicate that being married, being in the upper wealth quintiles, and having three or more ANC visits were significantly correlated with taking at least two doses of IPTp.


Sleeping under a mosquito net: Women noted that knowing that nets help to protect from disease helped them sleep under them. Others mentioned the motivation that nets help them sleep better because there is less nuisance from mosquitoes buzzing. The presence of larger quantities of mosquitoes facilitated net use, especially during the rainy season. Other facilitators mentioned were owning a net and getting nets free of charge. Results from multivariate regression using TDHS data indicate that being in the upper wealth quintiles and living in urban areas significantly increased the odds of sleeping under a mosquito net during pregnancy.

Eating iron-rich foods: Availability of and access to iron-rich foods and having the resources to buy them were the most commonly mentioned factors that facilitated their consumption. Women also noted that it helped to like the taste of these foods and understand the benefits of eating them.

Months 0–6 (Sprout Stage) All three practices in the Sprout Stage showed improvement. Some common facilitators mentioned by the women for doing these practices were knowing the health advantages for the mother and baby; a complication-free delivery that allowed the mother to focus on early breastfeeding, including giving the colostrum; receiving instruction and education from healthcare providers about the practices; and drinking adequate water and eating nutritious foods to stimulate breastmilk production. Many of these facilitators are well known and are part of strategic program designs, including birth planning and delivering with trained staff in a skilled facility. For exclusive breastfeeding, women are more likely to be successful when they are supported, have adequate hydration and nutrition, and get adequate rest. The MBNP SBCC Parent Kit referred to this as “rest, share, and eat.” Partner and intra-household support, also promoted by MBNP, were valued facilitators. For the specific behaviors in this stage, women mentioned the following facilitators:

Initiate breastfeeding within an hour of birth: Women were aware of the advantages of initiating breastfeeding within an hour of birth, and they had an understanding of the health benefits to the child, which helped facilitate this behavior. We asked women what made it easy for them to breastfeed within an hour after birth to identify other possible facilitators for this behavior (see Appendix 4 for a comprehensive list of facilitators cited). The most common response was that if the mother was not sick or had no complications after birth (mentioned by 29 percent in the MBNP area and 22 percent in the comparison areas). Other responses about facilitators for breastfeeding within an hour of birth included that the mother understood the importance of this practice and that she received advice from the health facility to breastfeed within an hour after birth.

Colostrum: Fewer mothers were aware of the benefits of feeding their child the colostrum, or first, yellowish milk, after birth; however, those who did know mentioned the nutrients and vitamins in colostrum that help the child grow and protect the child’s health. They stated that receiving education or training on the importance of the colostrum facilitated this behavior (mentioned by 35 percent in the MBNP area and 9 percent in the comparison areas), along with the knowledge that breastmilk has nutrients and advantages for the child. Although 35 percent had specific knowledge about the benefits of colostrum, 90 percent reported actually giving colostrum. Delivering with a skilled assistant or trained health worker can help facilitate this practice.

Exclusive breastfeeding for the first 6 months: Overall, women were aware of the health benefits of breastfeeding their child for the first 6 months of life, which helped motivate them to perform this behavior. Many women responded that having adequate food and water for breastmilk production facilitated exclusive breastfeeding for six months (mentioned by 44 percent of women in the MBNP area and 25 percent of women in the comparison areas). Women also stated the importance of having a


variety of foods and receiving education about exclusive breastfeeding to enable this behavior. Results from the multivariate regression using TDHS data indicate that women with secondary or higher education, those who delivered in a health facility, and those in the third and fourth wealth quintile were more likely to exclusively breastfeed their babies for the first 6 months.

Months 6–24 (Bud and Flower Stage) For the Bud and Flower Stages, facilitators play a critical role in improving the minimum acceptable diet for children 6–24 months of age. A mother’s health and time, the household’s food security, and a caregiver’s knowledge about how often, how much, and what a child should eat are all important factors. MBNP was able to exceed its targets for promoting home gardens and small livestock keeping and also formed partnerships to help households with income-generating opportunities. These activities were combined with key messages regarding infant and child feeding practices, with the goal of improved consumption of a diverse diet at the household level. For continued breastfeeding, staying well hydrated, having a good diet, and being able to stay with the child help facilitates the practice.

The common facilitators mentioned by women that help them feed their child a variety of foods, help them increase the number of times they feed their child each day, and help them continue to breastfed until 2 years of age and beyond included knowing the benefits of the behavior, having adequate resources to grow or purchase food, having adequate time to prepare food and feed the child, and keeping the mother healthy and disease free. Following are the facilitators mentioned for specific behaviors:

Feeding the child a variety of foods: The majority of women were aware that dietary diversity contributed to a baby’s health after 6 months and could identify facilitators to help diversify a child’s diet. The majority of women stated that having enough money to buy the different foods (mentioned by 66 percent of women in the MBNP area and 41 percent of women in the comparison areas) was a facilitator for adding a variety of foods to a child’s diet (see Appendix 5 for a more comprehensive list of all facilitators cited). Other common facilitators included availability of or access to foods, receiving education about giving a child a diverse diet, keeping small animals, and cultivating a vegetable garden. Results from the multivariate regression analysis using TDHS data indicate that factors that increased the odds that a woman fed her child a variety of foods included being married, living in a smaller household, belonging to wealthier quintiles, and living in urban settings.

Meal frequency: Many mothers could state the health advantages for increasing the number of times a child ate per day. Women stated that having money to buy food (mentioned by 49 percent of women in the MBNP area and 30 percent of women in the comparison areas) enabled them to give their child several meals and snacks per day. Women also stated the availability of and access to food and the mother having enough time to prepare food for the child as facilitators enabling them to give their child several meals and snacks per day. Multivariate regression using TDHS data shows that children were more likely to eat three or more meals if their mothers were not employed and if they had attended a postnatal checkup within 2 months of birth.

Continued breastfeeding: The majority of women were aware of the benefits of continued breastfeeding for the child’s health and were able to list facilitators for this specific behavior. Women stated that being able to spend the day with the baby made it easy to continue breastfeeding after 6 months (mentioned by 48 percent of women in the MBNP area and 26 percent of women in the comparison areas). Other common facilitators included having a good health status or not having a disease that would cause the mother to stop breastfeeding and receiving information to continue breastfeeding after 6 months.


Cross-cutting Facilitators of Maternal and Child Health and Nutritional Practices: Findings from FGDs and KIIs Participants discussed structural, community, household, and individual-level factors that promoted or facilitated behaviors and practices to improve MCHN. All participants discussed knowledge and education as primary facilitators, and they stated that education should be provided at all levels: individual (including healthcare workers), household, and community (including ward and district-level staff). Nutritional programs, including the MBNP, were mentioned as playing an important role in the provision of education, and participants specifically mentioned nutrition programs implemented in their community as helpful. Partner and household support for practices was also identified as a key facilitator, as well as access to health facilities. The following are more specifics regarding facilitators at the various levels:

Structural-level factors: These included changes in adherence to traditional and cultural norms. Participants noted a shift in individuals not adhering to cultural practices that restrict the types of foods that can be consumed. For example, a grandmother stated:

“Long time ago we used to restrict women on milk and beans so that the baby doesn’t grow too big but now we give them everything.” As part of combating negative impacts of traditional practices, a healthcare worker stated, “If we educate traditional birth attendants on nutrition education for mother and child, it would make it a lot easier for mothers to listen because traditional birth attendants have a voice and are listened to more by many mothers.”

Participants also noted that having infrastructure to make it easier to get to the clinic, having the clinics near the homes, or having outreach services in locations where there are no facilities would improve MCHN. Program and national-level staff noted that nutrition is now a government priority. Increased awareness at the district level and collaboration across partners and key stakeholders has contributed to the improvements in MCHN.

Household-level factors: Financial and emotional support from husbands were identified as household-level facilitators for practicing behaviors. This was a salient theme discussed by all participants as critical to improving MCHN practices. A precursor to providing the appropriate type of support was knowledge and education. For example, some influencers stated that is it important for partners to understand the importance of a diverse diet and how it impacts health outcomes for both women and children so they can provide women with appropriate support. Other key informants also noted the importance of male support and involvement; for example, a district reproductive and child health coordinator (DRCHC) said:

“According to the system in our community, the father is the one to decide, when the mother gets training on what to eat it will be difficult to decide herself, therefore sometimes they (mothers) ask us to write for a note or ask for her husband to also attend the trainings.”

Making decisions jointly as a couple or cooperation between parents was also discussed as a facilitator of improved MCHN. Specific to children’s health and nutrition, participants discussed several facilitators, such as the importance of vaccinations, creating an environment where children can grow well, ensuring that mothers have adequate nutrition, encouraging breastfeeding, ensuring that women remain healthy, and practicing family planning. The MBNP SBCC kits included messages on partner dialogue and joint decision-making. The Parent Kit specifically had messages on “discuss and decide together.”


Community-level factors: Participants mentioned that encouragement and support should be provided by multiple groups, including influencers, other family members, the community, and healthcare workers. Specific to healthcare workers, participants stated that it is important for them to support women and encourage them to perform the key behaviors. In addition, participants stated that women having to take medication and supplements at clinics in the presence of the healthcare worker in addition to ensuring the availability of the medication were facilitators of improved MCHN. Participants also stated that healthcare workers need to be trained and that in some instances the number of healthcare workers should be increased. Program and national-level staff acknowledged that although the government is making efforts to train and recruit more healthcare workers, there is still a shortfall. At the community level, participants discussed building the capacity of local leaders. A DRCHC noted the importance of engaging influential leaders, including religious leaders in providing nutritional education because they are trusted members of the community.

Resources were another salient facilitator mentioned. Specifically, participants discussed the importance of financial and agricultural (land, gardens, animals, and livestock) resources. Education is one aspect of increasing resources, and participants emphasized the importance of educating community members and households on how to improve resources through lessons on how to keep small animals and grow vegetable gardens. Agricultural extension officers discussed seeing an increase in the number of households with various types of gardens, such as tin gardens, sack gardens, and tower gardens. They also noted seeing an increase in the number of households preserving food as a way to deal with food shortages, including seasonality and wastage. National and program-level staff noted that the increase in preservation in food is facilitated by council by-laws that are promoting this practice. A healthcare worker also noted that community gardens are a helpful resource for those who do not have a place to farm. Participants also discussed having a business and saving or budgeting for food as a way to increase the resources needed to improve MCHN. In the context of limited financial resources, the provision of free services or having a loan program were also described as facilitators. The MBNP SBCC Parent Kit promoted “raise and grow” and “earn and buy” as a means to improve resources available to the household.

Individual-level factors: Women’s attitudes and perceptions were mentioned as a facilitator to the behavior. Key informants stated that women should prepare, plan for, and make personal efforts to improve their health.

Table 13 presents facilitators mentioned by participants that were specific to the key behaviors. It is important to note that qualitative interviewer guides did not specifically ask about each of the key behaviors, but rather general practices around MCHN. Thus, many of the responses about the key behaviors were a result of the discussion or through spontaneous responses by the participants highlighting their familiarity with the practices being promoted through the MBNP.


Table 13: Facilitators of key behaviors

P=participants in the MBNP area, C=participants in comparison areas

Key behavior Facilitator Seed Stage

Early ANC Encouragement and support from CHWs and partners (P, C) Provision of free services (C) Giving advice on importance of ANC (P) Wanting to avoid negative consequences of not attending early ANC (P) Reminding mothers to go to ANC early (P) Women having positive attitude/perception about early ANC attendance (P) Provision of education and advice on early ANC attendance (P)

Using mosquito net

Encouragement and reminders to sleep under net by husbands (P, C) Education and promotion of using a net (P) Women responding well to messages promoting use of mosquito nets (P)

SP Availability of SP (P, C) Promoting SP as a practice women should do (P, C) Provision of SP for free (P) Mothers and fathers having an understanding of the importance of taking SP (P) Women having a positive attitude/perception about taking SP (P) Taking SP at the clinic (P) Community leaders raising awareness of importance and encouraging SP use (P) Women being tested for malaria at facilities (P)

Deworming Availability of deworming tablets (P, C) Women receiving encouragement to take deworming tablets (P, C) Provision of deworming tablets for free (P, C) Women taking the deworming tablets at the clinic (P) Women being reminded to take deworming tablets (P) Women responding well to the message to take deworming tablets (P) Women having an understanding of the importance of taking deworming tablets (P) Provision of education to communities and healthcare workers by MBNP (P)

Mother should get rest

Partner support and assistance (P, C) Community members help pregnant women with their chores (P)

Dietary diversity (woman)

Fathers’ knowledge of the importance and purchasing diverse foods (P, C) Healthcare workers promoting and encouraging women to eat diverse foods (C, P) Having income to purchase diverse foods (C) Family having livestock (C) Education provided by MBNP emphasizing the importance of women eating diverse foods (P) Understanding of importance of diverse diet (P) Countering traditional/cultural expectations that are in contradiction (P) Availability of foods (P) Women responding well to the messages (P) Community members and leaders encouraging women to eat diverse foods (P)

Consumption of iron-rich foods

Having income to buy iron-rich foods (P, C) Male partners’ knowledge of importance of iron-rich foods (P, C) Educating women on the importance of iron-rich foods (P, C) Healthcare workers encouraging women to consume iron-rich foods (P, C) Knowledge of what would happen if mother gets anemia (P, C) Provision of iron-rich foods by male partners/influencers (C, P) Support by community members (C) Encouragement of mothers to have home gardens growing iron-rich foods (P)


Key behavior Facilitator Mother keeping small animals and livestock (P) Knowledge by influences that women’s diet should not be restricted due to tradition/culture (P) Availability of iron-rich goods (P)

Iron and folic acid supplements

Knowledge that taking them prevents anemia and is a key practice (P, C) Availability and provision of tablets (P, C) Encouragement to take tablets and partner support (P, C) Provision of education by CHWs (P, C) Education provided by MBNP (P) Mothers asking for the supplements (P) Women being motivated and having a positive attitude about taking supplements (P) Provision of advice to take tablets at night as a way to prevent nausea (P)

Sprout Stage Early initiation of breastfeeding

Healthcare workers and CHWs providing education on early initiation of breastfeeding (C)

Colostrum Healthcare workers encouraging mothers to give babies the first milk (P, C) Change in the traditional belief that first milk is dirty (P) Practicing behaviors to help milk come out (P) Knowledge of importance of taking first milk (P) Support from health facilities (P)

Exclusive breastfeeding

Influencers encouraging women to exclusively breastfeed (P, C) Women knowing the importance of exclusively breastfeeding (P, C) Providing education, advice, and awareness of the importance of exclusive breastfeeding (P, C) Partner support (P, C) Women hearing success stories of other women who exclusively breastfed (P) Breastfeeding framed as an “easy” practice that mothers do not have to pay for (P)

Bud and Flower Stages Dietary diversity (child)

Available income to buy different types of foods (C) Mothers receive advice and education on how to diversify child’s diet after 6 months (P, C) Knowledge on the importance of dietary diversity (i.e., helps prevent malnutrition and poor health) (P, C) Availability of different kinds of foods or having a vegetable garden (P, C) Keeping small animals (P)

Meal frequency (child)

Having income to buy diverse foods (C) Having a vegetable garden (P, C) Provision of education on the importance of feeding multiple times per day (P, C) Knowledge of the importance of meal frequency (P, C) Encouraging mothers to increase meal frequency (P) Success stories from other mothers (P)

Other promoted behaviors Sanitation Knowledge of the importance of proper sanitation (P)

Promotion of hygienic practices (P) Promotion of the use of tippy taps (P) Education provided by the MBNP (P)

Animal rearing Knowledge that having small animals can improve overall MCHN (P) Council having a budget to help women get poultry (P) Encouragement and provision of education on advantages of keeping small animals (P) Households making joint decisions (P)

Joint decisions Wanting mother and child to be healthy (P, C) Education on the importance of making joint decisions (P, C)


Key behavior Facilitator Cooperation between partners (P, C) Knowing the importance of involving mothers (C) Education provided by MBNP (P) Encouraging fathers to go with mothers to ANC clinics (P)

Partner support Fathers’ awareness of and education on the importance of their support (P, C) Fathers and household earning an income (P, C) Fathers going to clinics with women (P, C) Discussing the importance of the child’s health (C) Fathers’ knowledge about key behaviors (P) Grandmothers educating the fathers to provide support to pregnant women (P) Seeing that male supports leads to better household nutrition (P) Encouraging male involvement (P)

Research Question 5

• What factors hinder the adoption by women of the 17 key behaviors promoted through the MBNP SBCC campaign?

Barriers to the practice of key behaviors were explored through the 2017 SSIs with women and through FGDs and KIIs with the various community and program stakeholders. Table 14 lists the barriers identified organized by the specific behavior and further labeled by source (i.e., by MBNP or comparison areas). This section includes a discussion of barriers according to each stage of growth as identified by pregnant women and women with children less than 2 years of age. This is followed by the cross cutting barriers to the adoption of key practices as identified by respondents participating in the FGDs and KIIs.

Pregnancy (Seed Stage) Attending ANC in first trimester: None of the women in either area cited any disadvantages of attending ANC in the first trimester, and more than half mentioned that nothing made it difficult to do so. A number of women noted that being required to attend with a male partner15 made it more difficult to attend ANC early in the pregnancy. Distance to the health facility and not having child care were also mentioned as barriers. Having symptoms, being unwell, or feeling “lazy” were frequently mentioned as barriers to early ANC attendance. Finally, women mentioned that they were not always sure early on whether they were pregnant, and the uncertainty could cause them to delay going for ANC.

Taking iron tablets: More than two-thirds of respondents thought that there were no difficulties associated with taking iron tablets. The main barriers mentioned were experiencing side effects and supplements not always being available at the clinic.

Taking deworming tablets: Again, the majority of women did not think there were important difficulties to taking deworming tablets. Several women cited not being given the tablets at a clinic as an important barrier. Side effects were only mentioned by a couple of women.

Adhering to malaria preventative treatment in pregnancy: The only potential barrier for SP/Fansidar cited by women was not having attended ANC. The practice for adhering to malaria treatment during pregnancy was among the lowest recorded. Intermittent preventative therapy has been in practice in Tanzania since 2000, but levels of compliance are far too low. Compliance studies completed for

15 This is often required in Tanzania to encourage partner testing for HIV.


Tanzania found that the most significant barrier was unavailability of drugs at ANC visit, followed by clinics not practicing Direct Observation Therapy, women’s lack of knowledge regarding recommended dosage during pregnancy, and fear of side effects. (Mdetele, et al., 2017)

Eating iron-rich foods: Lack of finances and low availability of iron-rich food sources were the most commonly cited barrier to the consumption of iron-rich foods. Other barriers included having difficulty preparing food, not liking these types of foods, and experiencing side effects of pregnancy (nausea).

Months 0–6 (Sprout Stage) Initiate breastfeeding within an hour of birth: Although most women stated that there were no disadvantages to initiating breastfeeding within an hour of birth, they did provide potential barriers that may make it difficult for women. Most of these responses were related to post-delivery symptoms or complications, such as exhaustion, continued bleeding, stomach pains, complications during delivery, or other unspecified health problems. This was similar to reasons women gave when asked why they were not able to breastfeed within an hour of birth. These responses included experiencing post-delivery complications, exhaustion, and prolonged bleeding after delivery. Results from the multivariate regression using TDHS data show that being employed and the child being the mother’s first born significantly decreased the odds that a woman breastfed her child early.

Colostrum: Many women stated there was no disadvantage to giving the child the first milk or colostrum after birth, but some were aware of potential difficulties of this practice. These women mentioned complications during or after delivery or the mother not feeling well as the main barriers for women giving the colostrum to their newborn.

Exclusive breastfeeding for the first 6 months: The majority of women did not think that there were disadvantages to exclusive breastfeeding for the first 6 months of life. When probed for potential difficulties to exclusive breastfeeding, however, women stated not getting enough to eat for adequate breastmilk production, having any illnesses, not having adequate time to breastfeed, and the milk not coming in.

Months 6–24 (Bud and Flower Stages) Feeding the child different types of food: For this behavior, most women stated no disadvantages to feeding the child different types of food. When asked about barriers, however, most women responded that barriers were not having enough money to buy food (mentioned by 54 percent of respondents in the MBNP area and 50 percent of respondents in the comparison areas). Women also stated the lack of availability of or access to foods as a barrier, but this was not as common.

Meal frequency: Few women stated disadvantages to feeding their child several times a day; however, those who did state disadvantages mainly talked about abdominal discomfort for the child, but this did not come up as a major barrier to feeding children several times a day. Most women responded that not having enough money was a barrier to increased meal frequency for their child (mentioned by 33 percent of respondents in the MBNP area and 24 percent of respondents in the comparison areas). Other barriers that women stated included not having the food available and not having time with the child. Multivariate regression using THDS data indicates that children were less likely to eat frequent meals if their mothers were employed.

Continued breastfeeding: Most women reported that they continued breastfeeding past 6 months; however, those who were not able to continue stated that maternal health problems were the main reason for discontinuing breastfeeding after 6 months. The majority of women also stated no


disadvantages to continued breastfeeding, and when asked about potential reasons for not continuing, most women replied that there were none. Some women did provide reasons why they may not be able to continue breastfeeding, however, and the most common responses were unintended pregnancy and the mother having diseases or getting sick. Other reasons were the mothers being too busy with domestic activities or farming and that it could be difficult for mothers with tuberculosis or HIV.

Cross-cutting Barriers to Maternal and Child Health and Nutrition Practices: Findings from FGDs and KIIs The primary structural constraints or barriers mentioned by participants were limited resources. Participants stated that some of the primary barriers to achieving adequate MCHN were limited finances; transport; land for cultivation; skilled personnel; commodities, medications, and supplements; and information. Program and district-level staff also discussed resources as the main challenge in the scale up of MCHN services and noted that the lack of a specific budget for nutrition-related services was a challenge. Education was another structural constraint discussed, and participants stated that the lack of education for both women and influencers as well as limited awareness or understanding of promoted MCHN-related behaviors were barriers to adequate health and nutrition. A program/district staff member noted, “The capacity of the community to understand continues to be challenging … for example, some children in the community are given foods without regarding their age ... in [one community] for example, fruits such as avocados are for selling instead of giving some to children.” Environmental and climate constraints, specifically weather patterns or diseases that affect animals and crops, also impacted agricultural productivity, which was related to MCHN. Specifically, agricultural extension officers noted that some areas get limited rainfall, which leads to water shortages that make it difficult to grow vegetables.

Household-level factors: At the household and community levels, lack of support from male partners was the most commonly cited barrier to positive MCHN outcomes, specifically in cases in which men were not informed of or educated about the importance of key MCHN practices. Participants also stated that in cases in which the expectant father is not involved or away, women face challenges in accessing MCHN services. In addition, some men viewed certain practices, such as breastfeeding, as the sole responsibility of the woman and thus provided limited support.

Community-level factors: Participants also discussed limited or minimal support from other household members and communities as a barrier to positive MCHN nutrition outcomes. Traditional and cultural practices were also reported as barriers; for example, influencers noted that Maasai women are not allowed to eat fattening food, and key informants also noted that Maasai men eat better than women. Healthcare workers reported patriarchy and participation in traditional practices (e.g., home delivery) as factors that pose general health challenges. Program and district-level staff noted the slow adoption of changes to cultural practices as a barrier. Societal expectations related to gender norms can hinder partner support and joint decision-making, which also serve as barriers to positive MCHN outcomes. In addition, household and societal pressures and competing priorities also make it difficult for women to focus on MCHN practices. Participants stated that women are sometimes too busy to eat or that they sell food rather than keep it for themselves and their children.

Individual-level factors: Individual factors, such as personal preference and ignoring messages or education provided, were also cited. Key informants at the district level stated that there are also women who have had multiple successful pregnancies and therefore think that they do not need to practice these newly promoted behaviors.


Table 14: Summary of barriers specific to the key behaviors

P=participants in the MBNP area, C=participants in comparison areas

Key behavior Barriers Seed Stage

Early ANC Limited partner support, partners are busy or uncooperative (P, C) Mothers do not understand the importance (C) Limited resources (money for transport) (C) Have not yet been reached by MBNP (P)

Using mosquito net Difficulty in getting accustomed to using a net (C) Not wanting to use nets, even though they are available (P)

SP Side effects (nausea) (C) Stockouts (P)

Mother should get rest Responsibility of women to do household chores and duties with assistance (P, C) Customary practices of working in farms, even in late stages of pregnancy (P) Limited partner support and knowledge about the importance of rest (P)

Avoidance False or inaccurate information (P) Dietary diversity (woman)

Eating one type of food is common practice (P) Certain foods not available during the dry season (P)

Consumption of iron-rich foods

Low or limited income (P, C) Green vegetables not available during the dry season (C) Limited access to meat (no butcher in village) (C) High cost of purchasing meat (P) Personal choice to not consume vegetables, even when available (P) Customary and traditional practices such as not consuming meat or eggs during pregnancy (P)

Iron and folic acid supplements

Women have difficulties in taking the supplements and complain of their bad smell or adverse reactions such as nausea and itchiness (P, C) Stockouts (P, C) Perception that taking supplements would make them barren (C)

Sprout Stage Colostrum Grandmothers thinking that breastmilk will be delayed and therefore give the baby

water (P) Grandmothers think that colostrum is not good (P)

Excusive breastfeeding Traditional practice of feeding babies porridge and milk (P, C) Inadequate diet of mother limits milk supply (P, C) Mothers are busy and unavailable to breastfeed (P, C) Grandmothers give baby cow milk when woman does not produce enough milk (C) Limited knowledge of and support from partners (C) Inaccurate beliefs such as thinking that babies are not satisfied with breastmilk P) Limited understanding about the advantages of excusive breastfeeding (P) Mother gave birth via cesarean and does not produce milk readily (P)

Bud and Flower Stages Dietary diversity (child) Failure of caretakers to provide different types of foods (P)

Mothers are busy and see diversifying diet as an interference (P) Limited income (P)

Meal frequency (child) Mother is busy to increase frequency of meals (P) Other promoted behaviors

Sanitation Lack of clean and safe water (P) Animal rearing L or limited training (P)

Preference or laziness by households (P) Poultry diseases are a deterrent to keeping chickens (P)


Key behavior Barriers Joint decisions Limited cooperation between men and women (C)

Culturally, husbands are the decision-makers (C) Grandmothers are decision-makers and provide advice to mothers (C) MCHN decisions are thought of as woman’s responsibility (P)

Partner support Harmful behaviors by male partners (e.g., alcoholism, drug abuse) (P, C) Limited income (C, P) Lack of education (P, C) Competing priorities, such as being busy or having another family (P, C) Fear of going to clinic for HIV testing or to get HIV results (P) Patriarchal cultural and traditional norms and customs (P) Lack of male cooperation (P)

Research Questions 6 and 7

• To what extent do the behaviors and motivations diverge between women in the MBNP area of influence and women in comparison regions?

• How did exposure to the project’s SBCC interventions influence the adoption of the key behaviors?

Women in the MBNP area demonstrated a more detailed and sophisticated understanding of the benefits of practicing the 17 key behaviors (Appendices 3-5). When asked about the advantages of specific behaviors, they were able to spontaneously cite specific consequences (such as the baby benefitting physically and mentally from breastfeeding), compared to women in the comparison areas, who gave vaguer responses such as “it helps the baby.” When asked about advantages of early ANC attendance, women in the MBNP area spontaneously mentioned specific diseases and conditions that were important to get screened for and were more likely to mention benefits, such as getting advice and guidance on how to care for the baby after birth. Women in the comparison areas were more likely to respond that they did not know of any advantages of specific behaviors. This was true for all the behaviors we examined.

In addition, when asked about facilitators for practicing the behaviors, women from the MBNP area readily mentioned behaviors and activities promoted by the program. For example, the MBNP SBCC Parent Kit key messages of discuss and decide together, raise and grow, and earn and buy were reflected in the discussion on facilitators. Women mentioned how helpful it was when they had the support of their partners to practice the behavior. The fact that their partners knew the importance of the behavior and its benefits was an advantage for gaining their support to adopt the behavior. The women also mentioned that having household gardens, raising small livestock, and doing small income-generation activities helps their household practice the message of eating a wide variety of foods and feeding the child more times each day. The elimination of several harmful cultural taboos in the MBNP area was also an added benefit resulting from the improved knowledge gained from SBCC promotion activities and combined with the efforts to engage community leaders for raised awareness and support for interventions that promote improved health for women and children within the 1,000-day period.

The supportive systems developed and encouraged by the MBNP, including partner support, PSGs, community volunteer networks, mobilized and engaged community leaders, collaboration with skilled agricultural officers, MBNP-oriented district health facility staff, and partnerships with local organizations, all worked together to create an enabling environment where women and households gain knowledge of key desired behaviors and their benefits and receive support to adopt those


behaviors. The differences in the percentage of women practicing the behaviors as measured by the 2017 SSIs with women and further supported by findings of the FGDs and KIIs show the benefits that the MBNP was able to bring about. Following is a brief discussion on the divergence between program and non-program areas regarding knowledge of and support for MCHN activities and their impact on the adoption of behaviors.

Program and Non-Program Areas (Knowledge) Among FGD and KII respondents, behaviors that participants in both program and non-program areas were knowledgeable about included sleeping under a mosquito net, ensuring that a mother gets rest and reduces workload during pregnancy, dietary diversity for the mother, consumption of iron-rich foods, taking iron and folic acid supplements, children’s meal frequency, and partner support. Specifically, joint decision-making was noted as a key facilitator in the program area. A CHW in the program area noted that wife and husband now make decisions together, whereas in the past the husband had the final say, and this change is a result of the education they got from MBNP that encouraged couples to discuss and decide together and to both learn about MCHN key desired behaviors and their benefits.

Program and Non-Program Areas (Limited Knowledge) Limited understanding of knowing the importance of doing key behaviors was more common in non-program areas. Behaviors with limited knowledge in both program and non-program areas were initiating breastfeeding and giving the baby colostrum. Influencers did not specifically mention the importance of giving babies the first milk, and only a few key informants specifically mentioned this key behavior. Nonetheless, the program area registered a much higher level (more than two times higher) than the comparison areas for this practice as measured by the 2017 SSIs with women. This high percentage was most likely the result of having and seeking access to trained, skilled support during delivery.

Program Area Specifics Findings indicate that key informants in program areas were making more efforts to get community members involved in improving MCHN. Key informants in the program areas discussed the limited or lack of involvement by village heads and community leaders as a barrier to maternal and child health in general, highlighting the importance of gaining the support of community leaders for MCHN activities. The MBNP made significant efforts to gain the support of district staff and community leaders. Although a limited or lack of education was not reported by influencers as a barrier to maternal health-related outcomes in program areas, some healthcare workers and other key informants in program areas described lack of education as a barrier to recommended MCHN practices. Other key informants in program areas also stated the challenge of community members not wanting to implement what they are being taught.

Although key informants in program and non-program areas were aware of the importance of early ANC attendance, specifics about why it was important were mentioned only by influencers in the program area. Influencers in the program area were also able to state the reasons why early attendance is important (e.g., prevention of anemia) and also emphasized the importance of the participation of husbands. Knowledge about SP was also more prevalent among influencers and key informants in the program area. Influencers discussed prevention of malaria as a key practice, and key informants stated that it was their role to educate women on using SP. They mentioned that women are now taking SP as being a program success. Deworming was also only discussed by influencers in the program area and by more key informants in the program area who stated that they received training to encourage women


to take deworming tablets. Diversifying the diet of children and starting complementary feeding at 6 months is another key behavior discussed only by influencers in the program area, although key informants in both areas noted its importance. Other behaviors such as proper hygiene, animal rearing, and joint decision-making were discussed only by influencers in the program area.

Community leaders in the program area also noted the difference in those who were part of the intervention with regard to MCHN. One of them noted that there are differences between those who received MBNP education and those who did not; those who got the education were joyful and happy, but those who did not tended to be weak. Program and national staff noted important contributions that the program has made in training CHWs and PSG leaders. They described the user-friendly nature of the SBCC Kits as a great success, as reflected in their high demand. For example a DRCHC from the program area said:

“There was a woman I met …she was drying green leafy vegetables, fruits, and nutrition potatoes, then she packed them to sell; she would grind nutrition potatoes and get nutrition potatoes flour; then I asked her where did she get these lessons from and she replied I get the lessons from Mwanzo Bora.”


CONCLUSIONS The messages and activities promoted by the MBNP SBCC packages, including the Siku 1000 Days (Parent) Kit, were apparent in the survey responses of women and throughout the FGDs and KIIs conducted with women, community volunteers, agriculture officers, PSG members, healthcare workers and district staff in the MBNP area. The MBNP SBCC approach, which included orienting community leaders, mobilizing and training community volunteers and PSGs, integrating agriculture activities, coordinating with health facility staff, partnering with local organizations, and promoting intra-household dialogue for partner support and joint decision-making, contributed to an enabling environment in which practices could be adopted, supported, and sustained. The key findings from the MBNP assessment are as follows:

• Messages have reached women and their households in the MBNP area, revealing more specific and detailed knowledge and understanding of the importance and benefits of the key behaviors promoted, compared to knowledge of key behaviors found among households in the comparison areas. The understanding and practice of joint household decision-making and doing activities to improve household dietary diversity (including household gardening and small livestock keeping) was also significantly more prevalent in the MBNP area.

• Multiple key behaviors promoted by MBNP showed significant increases in the program area as measured by the women’s survey, including early ANC visit, IFA supplements during pregnancy for at least 90 days, deworming, ITN use, exclusive breastfeeding, and feeding the child a variety of foods. These behaviors did not improve significantly in the comparison areas. Early breastfeeding, giving colostrum, and continued breastfeeding improved in both the MBNP and comparison areas.

• Key behaviors most likely to be adopted included increasing consumption of iron rich foods during pregnancy, sleeping under long-lasting ITNs, initiating complementary feeding after 6 months, and feeding babies older than 6 months semi-solids and finely chopped foods.16 In addition, high levels of practice were measured in ensuring that newborns get colostrum, initiating breastfeeding within an hour of birth, and continued breastfeeding for the babies up to 2 years and beyond.17

• Facilitators identified across several key behaviors in the MBNP area included perceived benefits of practicing the behavior, avoidance of negative consequences if the behavior is not practiced, and encouragement of success stories shared by peers practicing the behavior. Additional factors identified in MBNP area were access to health education; changes in traditional taboos; partners discussing and deciding together; and having household gardens, keeping small livestock, and income-generation activities. In both the MBNP and comparison areas, the provision of free services that are easy to access, adequate resources, and emotional and financial partner support were identified as motivating factors.

• Barriers identified for practicing key behaviors in the MBNP area included insufficient resources, competing priorities, and lack of time to practice the behavior. Adequate knowledge and household support were not mentioned as barriers in the MBNP area. In both the MBNP and

16The 2017 SSIs with women recorded 98 percent or higher practice levels for these three behaviors in the MBNP area. 17 The 2017 SSIs with women recorded between 80 and 90 percent practice levels for these three behaviors in the MBNP area.


comparison areas, barriers related to avoiding undesirable consequences (e.g., nausea with IFA supplementation) were identified. Traditional practices persist but were mentioned more frequently in comparison areas, as was lack of partner support.

• A divergence in the practice of behaviors was seen between the MBNP and comparison areas for the following behaviors (with women in the MBNP area reporting a significantly higher percentage of practice18): attending ANC within first 3 months of pregnancy, taking iron and folic acid supplements and deworming tables during pregnancy, exclusively breastfeeding their infant less than 6 months of age, and feeding their babies older than 6 months of age a variety of foods. Motivations for practicing behaviors were more specific and comprehensive in the MBNP area than in the comparison areas. In the MBNP area, community volunteers, health facility workers, and PSGs are valued sources of health information, helping women understand the benefits and the “how to” of practicing the desired behaviors.

• In the MBNP area, local district government and community leaders’ understanding of, support for, and coordination of improved child and maternal nutrition helped to elevate the receptivity and promotion of activities. In addition, partnerships with agriculture officers, health facility workers, and local NGOs for the provision of quality education, services, and training provided pathways and support for the adoption of the key desired behaviors.

18Based on findings from the 2017 SSIs with women.


RECOMMENDATIONS The MBNP assessment shows that significant achievements have been made, including increased individual and household knowledge, increased adoption of multiple key practices, and the creation of an enabling environment that lays the groundwork and creates a model for further scaling and sustaining key desired behaviors. The following recommendations are based on the key findings of the assessment and are aimed at providing guidance for the way forward on the path to sustainably improve the nutritional status of women and children and for the reduction of stunting and maternal anemia in the MBNP area and beyond.

• Continue to create an enabling environment that can sustain the adoption of key practices and provision of key services. Continue to use multiple avenues, including continued and increased engagement with district government staff, district nutrition officers, district development partners, community leaders, and local civil society organizations for strengthened coordination and reach of services and interventions that contribute to the ability of individuals, households, and communities to adopt and sustain key nutrition and health practices. Continue to raise awareness of and support for nutrition interventions during the 1,000-day period. Give attention to areas where re-districting has happened or where there has been high turnover of government staff.

• Continue to strengthen and expand the reach of community volunteers and PSGs. Peer-to-peer learning models like the one applied in the MBNP model are invaluable for promoting practices and providing readily available real-time encouragement and support. These networks can continuously target and seek to reach the most vulnerable households (i.e., those who are least likely to adopt the practices or be a part of a PSG without encouragement). Vulnerable households might include mothers who are currently not using available services or women who are pregnant for the first time. Find innovative mechanisms to encourage and motivate the most vulnerable households to join PSGs for peer-to-peer learning. Find solutions and messaging that meets their unique circumstances.

• Prioritize key behaviors and related supportive practices (e.g., decide and discuss together) based on current adoption of key practices, readiness for change among the target population, local context (e.g., malaria season, high diarrhea incidence, food insecurity), and identified needs and opportunities. See recommendations for specific behaviors below. Support local stakeholders to advocate for prioritization and good use of available resources, both public and private.

• Consider new nutrition evidence and developments in thinking, and seek to include aspects of early childhood development, stimulation, adolescent nutrition, and income generation in future programming to better enable beneficiary populations to participate effectively in the nutrition value chain.

• Build on program successes through documenting and sharing best practices from the MBNP SBCC model. Share within the Tanzania environment and beyond to support the quality scale-up of the integrated model. The MBNP applied an integrated comprehensive model that worked at multiple levels, from policy efforts to community implementation, and included simple but strategically packaged messages, integrated activities, and supportive peer networks.


More specifically, given the MBNP assessment findings, program efforts should prioritize increased adoption of and mobilize household and community support for the following key behaviors across the 1,000-day period:

Pregnancy/Seed Stage (conception to birth):

• Continue promoting the practice of attending ANC early, as soon as the woman knows or suspects she is pregnant, and making at least four ANC visits during the pregnancy. Seeking out an early, quality ANC visit within the first trimester is key to providing an entryway to multiple interventions that support good fetal development, improve maternal nutrition and health, and lay the groundwork for good birth planning and improved newborn and maternal health outcomes. An early, quality ANC visit is important to ensuring that the additional ANC visits are completed. With quality ANC visits, key interventions are introduced: IFA supplements and education; anemia detection; access to ITNs and education on the importance of sleeping under an ITN; intermittent preventive treatment/IPTp with direct observation of SP/Fansidar; direct observation of taking deworming medication; HIV screening; early detection of pregnancy complications; birth planning for a safe, clean delivery with a skilled assistant; and health message communication, including eating a diverse diet and getting adequate rest during pregnancy. Health facility workers, community leaders, community volunteers, and PSGs can continue to encourage women and gain the support of household members to help women seek early ANC if any suspicion of pregnancy exists. MBNP can work with district and health facility staff and the community to advocate for women by removing barriers to seeking an early ANC visit, including barriers at all levels (intra-household, community, health facility, and district). Special attention should be given to supporting women who are pregnant for the first time and mothers who are not currently participating in PSGs.

Sprout Stage (0–6 months):

• Continue promoting the initiation of breastfeeding within the first hour after birth and give the first yellow milk (colostrum) to protect the baby from illness. Continue promoting individual, household, and community knowledge and support for breastfeeding within the first hour after birth and providing the infant the first yellow milk or colostrum. Early initiation of breastfeeding has multiple benefits for mother and newborn. Women appreciated learning about the benefits of this behavior during ANC visits, so continued education before birth is encouraged, and a well-informed mother is more likely to carry out this practice. For targeting, women most at risk of not adopting this practice are women who make a low number of ANC visits, women who deliver without a skilled attendant, and women who experience labor complications. Women cited delivery complications as a major barrier to early breastfeeding. The program can train and equip health facility staff and volunteers on how to counsel and support women for early breastfeeding under these circumstances.

Bud Stage (6–12 months) and Flower Stage (12–24 months):

• Continue promoting practice of increasing the amount of food and frequency as the babies get older to reach three meals and two snacks every day and ensuring that a variety of foods is offered. Where feasible, expand the reach of the integrated activities, including home gardening, small livestock keeping, and income generation.


Frequency of meals for children needs to be addressed more noticeably. A minimal acceptable diet for children, adequate in nutrients and quantity, to complement continued breastfeeding until 2 years of age, is of key importance for the protection of good growth and strong immunity. Feeding a child three meals and two snacks a day will require time and support from all household members. PSGs and community volunteers can help support the understanding and uptake of this practice. The MBNP promotion of household gardens, small animal husbandry (pay it forward model), and support given for income-generating activities were notable and made a significant difference for households to be able to consume more diverse diets as well as to have more food inputs available. Integrated activities that tackle household food insecurity and address seasonal challenges are critical for the sustainable adoption of this practice and should be expanded where feasible. Sharing best practices around these activities can also help promote models for quality scale-up within and beyond program areas.


REFERENCES Abubakar, et al. (2012). Prevalence and risk factors for poor nutritional status. International Journal of Environmental Research and Public Health, 9, 3506-3518.

Balarajan, Y., Ramakrishnan, U., Özaltin, E., Shankar, A.H., & Subramanian, S.V. (2011). Anaemia in low-income and middle-income countries. The Lancet, 378, 2123–35. doi: 10.1016/S0140-6736(10)62304-5 PMID: 21813172

Black, R.E., Victora, C.G., Walker, S.P., Bhutta, Z.A., Christian, P., de Onis, M., Ezzati, M., Grantham-McGregor, S., Katz, J., & Martorell, R. (2013). Maternal and child undernutrition and overweight in low-income and middle-income countries. The Lancet, 382, 427–51.

Bothwell, T.H. (2000). Iron requirements in pregnancy and strategies to meet them. American Journal of Clinical Nutrition, 72, 257S–64S. PMID: 10871591

Branca, F., Mahy, L., & Mustafa, T.S. (2014). The lack of progress in reducing anaemia among women: The inconvenient truth. Bull World Health Organ, 92, 231.

Cetin, I., Berti, C., & Calabrese, S. (2010). Role of micronutrients in the periconceptional period. Human Reproduction Update, 16(1):80–95. doi: 10.1093/humupd/dmp025 PMID: 19567449

Chirande, L., et al. (2015). Determinants of stunting and severe stunting among under-fives in Tanzania: Evidence from the 2010 cross-sectional household survey. Retrieved from https://bmcpediatr.biomedcentral.com: https://bmcpediatr.biomedcentral.com/articles/10.1186/s12887-015-0482-9

Kossmann, J., Nestel, P., Herrera, M.G., ElAmin, A., & Fawzi, W. (2000). Undernutrition in relation to childhood infections: A prospective study in the Sudan. European Journal of Clinical Nutrition 54, 463–472.

Lyatuu, M.B., Mkumbwa, T., Stevenson, R., Isidro, M., Modaha, F., Katcher, H., & Dhillon, C.N. (2016). Planning and budgeting for nutrition programs in Tanzania: Lessons learned from the national vitamin A supplementation program. International Journal of Health Policy and Management, 5(10), 583–588. http://doi.org/10.15171/ijhpm.2016.46

Mdetele B. Ayubu and Winifrida B. Kidima, “Monitoring Compliance and Acceptability of Intermittent Preventive Treatment of Malaria Using Sulfadoxine Pyrimethamine after Ten Years of Implementation in Tanzania,” Malaria Research and Treatment, vol. 2017, Article ID 9761289, 5 pages, 2017. doi:10.1155/2017/9761289

MoHCDGEC, MoH, NBS, OCGS, and ICF. (2016). Tanzania Demographic and Health Survey and Malaria Indicator Survey (TDHS-MIS) 2015-16. Dar es Salaam, Tanzania, and Rockville, Maryland, USA: MoHCDGEC, MoH, NBS, OCGS, and ICF.

MoHSW, MoH, NBS, OCGS, and ICF. (2010). Tanzania Demographic and Health Survey. Dar es Salaam, Tanzania, and Rockville, Maryland, USA: MoHSW, MoH, NBS, OCGS, and ICF.

MoHSW. (2011). National Nutrition Strategy 2012-2016. Dar es Salaam, Tanzania: MoHSW.


MoHSW. Tanzania National Nutrition Survey. (2014). Tanzania Food and Nutrition Centre /Ministry of Health and Social Welfare.

Mwanzo Bora Nutrition Program (MBNP), 2015. Mid-Term Evaluation Report for the Program Implementation in Morogoro, Dodoma, and Manyara Regions. Dar es Salaam: Tanzania. Process Consultants and Facilitators.

Olofin, I., McDonald, C.M., Ezzati, M., Flaxman, S., Black, R.E., Fawzi, W., et al. (2013) Associations of suboptimal growth with all cause and cause-specific mortality in children under five years: A pooled analysis of ten prospective studies. PLoS One, 8, e64636.

Ramakrishnan, U., Grant, F., Goldenberg, T., Zongrone, A., & Martorell, R. (2012). Effect of women’s nutrition before and during early pregnancy on maternal and infant outcomes: A systematic review. Paediatric and Perinatal Epidemiology, 26(S1), 285–301. doi: 10.1111/j.1365-3016.2012.01281.x PMID: 22742616

Rasmussen, K. (2001). Is there a causal relationship between iron deficiency or iron-deficiency anemia and weight at birth, length of gestation and perinatal mortality? J Nutr, 131, 590S–601S; discussion 601S-603S.

Scholl, T.O. (2011). Maternal iron status: Relation to fetal growth, length of gestation, and iron endowment of the neonate. Nutrition Reviews, 69, S23–S9. doi: 10.1111/j.1753-4887.2011.00429.x PMID: 22043878

Semali, A., et al. (2015). Prevalence and determinants of stunting in under-five children in central Tanzania: Remaining threats to achieving Millennium Development Goal 4. Retrieved from https://www.ncbi.nlm.nih.gov: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4654796/

Shiratori, S. (2014). Determinants of child malnutrition in Tanzania: A quantile regression. JICA Research Institute.

Solomons, N.W. (2007) Malnutrition and infection: An update. British Journal of Nutrition, 98 (Suppl 1), 5–10.

Stoltzfus, R.J., Mullany, L., & Black, R.E. (2004). Chapter 3. Iron-deficiency anemia. In: Ezzati, M., Lopez, A.D., Rodgers, A., Murray, C.J.L. (Eds.). Comparative quantification of health risks: Global and regional burden of disease attributable to selected major risk factors. Geneva: World Health Organization, p. 163–209.

Sudfeld, C.R., McCoy, D.C., Danaei, G., Fink, G., Ezzati, M., Andrews, K.G., et al. (2015). Linear growth and child development in low- and middle-income countries: A meta-analysis. Pediatrics, 135 (5).

Wilunda, C., Massawe, S., & Jackson, C. (2013). Determinants of moderate-to-severe anaemia among women of reproductive age in Tanzania: Analysis of data from the 2010 Tanzania Demographic Health Survey. Trop Med Int Health, 18 (12), 1488-97.

World Health Organization. (2011). World health statistics. Geneva, WHO.


APPENDIX 1: Sample sizes used in TDHS Analyses

2010 TDHS 2015 TDHS MBNP area Comparison

area MBNP area Comparison

area Women with a birth in the past 5 years

586 554 645 619

Women whose last-born child is 6-23 months old

227 186 271 220


APPENDIX 2: DOCUMENTS REVIEWED List of Documents included in Literature Review

1. Anaemia in low-income and middle-income countries. Balarajan Y. et al. The Lancet. 2011; 378:2123–35. doi: 10.1016/S0140-6736(10)62304-5 PMID: 21813172

2. Children and Women in Tanzania, Volume 1, Mainland. 2010. UNICEF

3. Comparative quantification of health risks: Global and regional burden of disease attributable to selected major risk factors. Stoltzfus RJ et al. Geneva: World Health Organization; 2004. Ch. 3 p. 163–209

4. Comprehensive Food Security & Vulnerability Analysis (CFSVA), Tanzania, 2012. (2013) World Food Program

5. Determinants of Child Malnutrition in Tanzania: a Quantile Regression. JICA Research Institute. Shiratori S. (2014)

6. Determinants of moderate-to-severe anaemia among women of reproductive age in Tanzania: analysis of data from the 2010 Tanzania demographic and health survey. Tropical Medicine and International Health doi:10.1111/tmi.12199 volume 18 no 12 pp 1488–1497 December 2013. Wilunda C., Massawe S. and Jackson C.

7. Determinants of stunting and severe stunting among under-fives in Tanzania: evidence from the 2010 cross-sectional household survey. Chirande, L et al. October 2015. BMC Pediatrics201515:165 DOI: 10.1186/s12887-015-0482-9

8. Effect of women’s nutrition before and during early pregnancy on maternal and infant outcomes: A systematic review. Paediatric and Perinatal Epidemiology. Ramakrishnan U. et al. 2012; 26(S1):285–301. doi: 10.1111/j.1365-3016.2012.01281.x PMID: 22742616

9. Iron requirements in pregnancy and strategies to meet them. American Journal of Clinical Nutrition. Bothwell, TH. 2000; 72:257S–64S. PMID: 10871591

10. Is there a causal relationship between iron deficiency or iron-deficiency anemia and weight at birth, length of gestation and perinatal mortality? Rasmussen K. J Nutr 2001;131:590S–601S; discussion 601S-603S.

11. Kavishe, F. P. 2016. Report on the 2016 and Third Tanzania Joint Multisectoral Nutrition Review. TFNC report number 22040.

12. Landscape Analysis of Countries Ready to Accelerate Action in Nutrition: Tanzania Assessment for Scaling up Nutrition. 2012. Tanzania Food and Nutrition Center.

13. Linear growth and child development in low- and middle-income countries: a meta-analysis. Sudfeld CR et al. (2015) PEDIATRICS 135 (5).

14. Malnutrition and infection: an update. Solomons N.W. (2007) British Journal of Nutrition 98 (Suppl 1), 5–10.

15. Maternal and child undernutrition and overweight in low-income and middle-income countries. Black RE et al. Lancet 2013;382:427–51.

16. Maternal and child undernutrition: global and regional exposures and health consequences. Black RE, et al. Lancet 2008,371(9608):243-260


17. Maternal iron status: relation to fetal growth, length of gestation, and iron endowment of the neonate. Nutrition Reviews. Scholl TO; 69:S23–S9. doi: 10.1111/j.1753-4887.2011.00429.x PMID: 22043878

18. Mwanzo Bora Nutrition Program Mid-Term Evaluation Report for the Program Implementation in Morogoro, Dodoma, and Manyara Regions. June 2015. Process Consultants and Facilitators.

19. National Road Map Strategic Plan to Accelerate Reduction of Maternal, Newborn and Child Deaths in Tanzania 2008 – 2015. April 2008. The United Republic of Tanzania Ministry of Health and Social Welfare.

20. Nutrition Country Paper – The United Republic of Tanzania (draft). February 2003. CAADP Agriculture Nutrition Capacity Development Workshops.

21. Prevalence and Determinants of Stunting in under-Five Children in Central Tanzania: Remaining Threats to Achieving Millennium Development Goal 4. Semali, Innocent Antony et al. BMC Public Health 15 (2015): 1153. PMC. Web. 25 May 2017.

22. Prevalence and determinants of stunting in under-five children in central Tanzania: remaining threats to achieving Millennium Development Goal 4. Semali I et al. (2015) Retrieved from https://www.ncbi.nlm.nih.gov: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4654796/

23. Prevalence and Risk Factors for Poor Nutritional Status. International Journal of Environmental Research and Public Health. Abubakar A et al. (2012) 9: 3506-3518.

24. Report on the 2016 and Third Tanzania Joint Multisectoral Nutrition Review. 2016. Kavishe F. TFNC report number 2240, Dar es Salaam, Tanzania, November 2016.

25. Role of micronutrients in the peri-conceptional period. Human Reproduction Update. Cetin, I et al. 2010; 16(1):80–95. doi: 10.1093/humupd/dmp025 PMID: 19567449

26. Tanzania Demographic and Health Survey and Malaria Indicatory Survey 2015-2016. Dar es Salaam, Tanzania and Rockville, MD USA. MoHCDGEC, MoH, NBS, OCGS and ICF.

27. Tanzania Global Health Initiative Strategy 2010-2015. September 2011. USG.

28. Tanzania National Anemia Profile. USAID/SPRING.

29. Tanzania National Nutrition Survey (NNS). December, 2014. Tanzania Food and Nutrition Centre /Ministry of Health and Social Welfare.

30. Tanzania: Nutrition Profile. June 2014. USAID.

31. The lack of progress in reducing anaemia among women: the inconvenient truth. Branca F et al. Bull World Health Organ 2014;92:231

32. The National Road Map Strategic Plan to Improve Reproductive, Maternal, Newborn, Child & Adolescent Health in Tanzania. One Plan II (2016 - 2020). 2015. Ministry of Health and Social Welfare.

33. The Tanzania National Multisectoral Nutrition Action Plan (NMNAP) for the period July 2016 – June 2021: STRATEGIC PLAN: From Evidence to Policy to Action. July 2016. United Republic of Tanzania, Prime Minister’s Office.

34. The United Republic of Tanzania National Nutrition and Social Change Behavior Strategy, June 2013 – June 2018.


35. The United Republic of Tanzania National Nutrition Strategy, July 2011/2012 to June 2015/2016. Ministry of Health and Social Welfare.

36. The United Republic of Tanzania National Strategy for Gender Development. Ministry of Community Development, Gender and Children.

37. Topline Insights: Assessment of the Mwanzo Bora SBCC Kit (Powerpoint Presentation). January 2015. BBC Media Action.

38. Towards Eliminating Malnutrition in Tanzania: Vision 2025. Kavishe F. (2014)

39. World Food Program (WFP) Strategic Review 2016: Framework for Food and Nutrition Security in Tanzania. Nov. 2016. United Republic of Tanzania: Prime Minister’s Office

40. Kavishe, F.P. (2016) Report on the 2016 and Third Tanzania Joint Multisectoral Nutrition Review. TFNC report number 2240, Dar es Salaam, Tanzania.


APPENDIX 3: FACILITATORS AND BARRIERS TO PREGNANCY-RELATED BEHAVIORS REPORTED IN WOMEN’S INTERVIEWS What makes it easy for you to attend antenatal care visits in the first three months of pregnancy?

Responses Comparison N=59

Comparison %

Intervention N=50

Intervention %

3 Received prior info on advantages of ANC 4 6.78 10 20.00 2 Wanting proper medical attention for the

pregnancy 3 5.08 10 20.00

7 Wanting advice/information 12 20.34 8 16.00 8 I don’t know 12 20.34 8 16.00 9 Other 5 8.47 6 12.00 1 Experiencing symptoms or not being well

during pregnancy 8 13.56 5 10.00

6 Proximity to a clinic/health facility 9 15.25 5 10.00 5 Discussed w/ partner 2 3.39 4 8.00 4 Get tested 0 0.00 2 4.00 10 N/A 5 8.47 9 0.00

What makes it difficult for you to attend antenatal care visits in the first three months of pregnancy?


Comparison %

Intervention N=50

Intervention %

1 Nothing makes it difficult 34 57.63 22 44.00 11 Other 6 10.17 7 14.00 5 Must have partner to go to clinic 7 11.86 5 10.00 6 Does not understand importance of ANC 2 3.39 4 8.00 3 Health facility too far 4 6.78 4 8.00 10 I don’t know 3 5.08 3 6.00 9 Was not sure of pregnancy 1 1.69 3 6.00 2 Symptoms/sickness 2 3.39 2 4.00 4 Laziness 0 0.00 2 4.00 7 Stated that other women, not

themselves, may not know the importance of ANC

0 0.00 2 4.00

8 No care for other children 1 1.69 0 0.00

What makes it easy for you to take iron tablets or syrup during this pregnancy?


Comparison %

Intervention N=50

Intervention %

1 For good health 16 27.12 13 26.00 9 I don’t know 9 15.25 7 14.00 10 Other 4 6.78 4 8.00 5 Increase blood level of iron for mother

and child 0 0.00 3 6.00

4 Advised to take them from clinic 2 3.39 2 4.00 2 Prevent anemia 2 3.39 2 4.00 6 Relieves symptoms 10 16.95 1 2.00 7 Always take them/habit to take them 2 3.39 1 2.00


3 Know/understand they are important to take

2 3.39 0 0.00

8 N/A- did not take them 2 3.39 0 0.00

What makes it difficult for you to take iron tablets or syrup during this pregnancy?


Comparison %

Intervention N=50

Intervention %

1 Nothing 34 57.63 32 64.00 2 Side effects 7 11.86 8 16.00 8 I don’t know 5 8.47 4 8.00 3 Not available at clinic 2 3.39 3 6.00 9 Other 4 6.78 2 4.00 7 N/A- not given tablets 7 11.86 0 0.00

What makes it easy for you to take any deworming tablets during this pregnancy?


Comparison %

Intervention N=50

Intervention %

Given at the facility 7 11.86 11 22.00 Advantages of being treated for worms 5 8.47 11 22.00 I don’t know 10 16.95 5 10.00 Other 8 13.56 5 10.00 They are easy to take 1 1.69 5 10.00 Prevent illness 5 8.47 4 8.00 N/A-not given tablets 11 18.64 3 6.00 Nothing 3 5.08 2 4.00 Pregnancy motivates mother to take them 0 0.00 2 4.00 Using them regularly anyway 1 1.69 2 4.00 Advice from nurses 5 8.47 1 2.00 When appetite diminishes 4 6.78 1 2.00

What makes it difficult for you to take any deworming tablets during this pregnancy?


Comparison %

Intervention N=50

Intervention %

Nothing 40 67.80 38 76.00 N/A- not given tablets 12 20.34 4 8.00 Other 1 1.69 3 6.00 I don’t know 3 5.08 2 4.00 Side effects 1 1.69 1 2.00 Tablets not available at clinic 2 3.39 1 2.00 Have not attended clinic 1 1.69 0 0.00


What makes it easy for you to take (SP) during this pregnancy?


Comparison %

Intervention N=50

Intervention %

Easy access to tablets (i.e., nurses give tablets at facility)

15 25.42 17 34.00

Knowledge that they protect mother from malaria

5 8.47 11 22.00

I don’t know 4 6.78 7 14.00 Knowledge of benefits/importance to prevent sickness- unspecified

9 15.25 6 12.00

Knowledge that they protect the fetus from malaria

6 10.17 5 10.00

Other 6 10.17 4 8.00 Very easy to take 5 8.47 2 4.00 Can get the tablets from the facility 0 0.00 2 4.00 Nothing 3 5.08 1 2.00 N/A- have not used tablets 8 13.56 1 2.00 Health facility is nearby 2 63.39 0 0.00

What makes it difficult for you to take (SP) during this pregnancy?


Comparison %

Intervention N=50

Intervention %

1 Nothing 11 81.36 40 80.00 5 Other 3 5.08 5 10.00 2 Depends on the person’s feeling 0 0.00 2 4.00 4 I don’t know 4 6.78 1 2.00 3 N/A- have not attended the clinic 3 6.78 0 0.00

What makes it easy for you to sleep under a net during this pregnancy?


Comparison %

Intervention N=50

Intervention %

Other 8 13.56 12 24.00 Protection from mosquitos and other insects 10 16.95 9 18.00 Help to sleep well 5 8.47 9 18.00 I am used to it – normal 18 30.51 8 16.00 Knowledge of importance to sleep under the net

7 11.86 6 12.00

High number of mosquitos-mosquitos are nuisance

3 5.08 3 6.00

Having a net 5 8.47 3 6.00 Knowledge that they protect the fetus from malaria

3 5.08 2 4.00

Nothing 1 1.69 1 2.00 I don’t know 1 1.69 1 2.00 Getting the net for free 2 3.39 0 0.00


What makes it difficult for you to sleep under a net during this pregnancy?


Comparison %

Intervention N=50

Intervention %

Nothing 53 89.83 42 84.00

Laziness 1 1.69 3 6.00 I don’t know 1 1.69 2 4.00 Other 4 6.78 2 4.00

What makes it easy for you to eat meals with iron rich foods during this pregnancy?


Comparison %

Intervention N=50

Intervention %

Available/ access 17 28.81 31 62.00 Enough money to buy it 17 28.81 13 26.00 I don’t know 12 20.34 4 8.00 Other 2 3.39 4 8.00 I like them 8 13.56 3 6.00 Understanding/education that it is important to eat

7 11.86 3 6.00

Knowledge that it makes you healthy 2 3.39 2 4.00 My body needs them 2 3.39 1 2.00 Has vitamins 0 0.00 1 2.00 To get energy for the mother and baby 0 0.00 1 2.00 Because I’m pregnant 1 1.69 1 2.00

What makes it difficult for you to eat or prepare meals with iron rich foods during this pregnancy?


Comparison %

Intervention N=50

Intervention %

Nothing 27 45.76 23 46.00 Money/finances 22 37.29 19 38.00 Availability 6 10.17 4 8.00 Side effects of pregnancy 1 1.69 4 8.00 General challenges in food preparation 1 1.69 2 4.00 If I don’t like the food 3 5.08 1 2.00 Acceptance 0 0.00 1 2.00 I don’t know 3 5.08 1 2.00 Other 0 0.00 1 2.00


APPENDIX 4: FACILITATORS AND BARRIERS TO INFANT (0–6 MONTHS) NUTRITION BEHAVIORS REPORTED IN WOMEN’S INTERVIEWS FACILITATORS

What makes it easy for you to start breastfeeding within an hour of birth?


Comparison %

Intervention N=34

Intervention %

If the mother is not sick or has no complications after birth

7 21.88 10 29.41

Advised to breastfeed/advice from health center

3 9.38 6 17.65

Mother understands importance of breastfeeding immediately after delivery

1 3.13 5 14.71

I don’t know 4 12.50 4 11.76 So the mother knows if the baby is able to latch

0 0 4 11.76

Mother decides to breastfeed 2 6.25 3 8.82 The milk is available 0 0 3 8.82 Mother is able to spend time with child to breastfeed

1 3.13 2 5.88

Nothing 3 9.38 1 2.94 Health of the baby 0 0 1 2.94 Mother is always with child 0 0 1 2.94 Mother knows the child will get nutrients 0 0 1 2.94 Mother getting good nutrition while pregnant/after delivery

Other 4 12.50 0 0 Mother found it normal to do so 2 6.25 0 0 Child does not cry/Mother does not want the child to cry

2 6.25 0 0

Why did you wait to start breastfeeding?


Comparison %

Intervention N=11

Intervention %

Experiencing post-delivery symptoms/complications

3 50.00 4 36.36

Other 1 16.67 2 18.18 Had prolonged bleeding after delivery 0 0 2 18.18 Exhaustion/needed to rest 0 0 1 9.09 Child was crying too much 0 0 1 9.09 Difficulties getting child to latch to breast 0 0 1 9.09


What makes it difficult for you to start breastfeeding within an hour of birth?


Comparison %

Intervention N=34

Intervention %

Nothing 16 50.00 12 35.29 Health problems-unspecified 3 9.38 6 17.65 Exhaustion/bleeding/sick after labor 1 3.13 6 17.65 Complications during delivery 3 9.38 5 14.71 Milk did not come in 2 6.25 3 8.82 Dizziness/fainting 2 6.25 2 5.88 Anemia 1 3.13 2 5.88 Stomachache/pains 2 6.25 1 2.94 Did not receive good nutrition 2 6.25 1 2.94 I don’t know 1 3.13 1 2.94 Other 1 3.13 1 2.94 Headache 0 0 1 2.94 Pain/sensations on the nipple when the baby sucks

0 0 1 2.94

What made it easy for you to give the baby the first liquid (colostrum) that came from your breasts?


Comparison %

Intervention N=34

Intervention %

Receiving education/training/advice 3 9.38 12 35.29 Knowledge that breastmilk has nutrients for the baby/advantages

1 3.13 5 14.71

No complications during delivery 2 6.25 4 11.76 I don’t know 4 12.50 3 8.82 Other 3 9.38 2 5.88 Breastmilk available 2 6.25 2 5.88 The mother was always close to the child/mother was given child

1 3.13 2 5.88

Nothing 10 31.25 1 2.94 The baby wanted to breastfeed 1 3.13 1 2.94 The mother had good nutrition while pregnant

0 0 1 2.94

So the child learns to latch/breastfeed 0 0 1 2.94 Suitable space and plenty of time 0 0 1 2.94 The baby was crying/to keep the baby from crying

3 9.38 0 0

The mother is healthy and not sick 2 6.25 0 0


What made it difficult for you to give the baby the first liquid (colostrum) that came from your breasts?


Comparison %

Intervention N=34

Intervention %

Nothing 22 68.75 22 64.71 Not feeling well/mother is sick 0 0 4 11.76 Complications during/after delivery 2 6.25 2 5.88 Other 1 3.13 1 2.94 Fatigue 1 3.13 1 2.94 If the baby cries a lot 0 0 1 2.94 Inadequate breastmilk 0 0 1 2.94 Did not receive education/instructions/advice 0 0 1 2.94 No peer support group available 0 0 1 2.94 Painful to breastfeed 0 0 1 2.94 Poor nutrition 0 0 1 2.94 I don’t know 3 9.38 0 0 Stomach pains 1 3.13 0 0

What makes it easy for you to only give the baby breastmilk for the first six months of life?


Comparison %

Intervention N=34

Intervention %

Mother needs to eat and drink adequate food and water

8 25.00 15 44.12

Mother eats a variety of foods 0 0 5 14.71 Mother receives advice/education to do so 4 12.50 4 11.76 The mother has enough breastmilk 3 9.38 4 11.76 Baby is healthy 1 3.13 2 5.88 Mother is with the baby all the time 0 0 2 5.88 When the baby is calm and not crying 0 0 2 5.88 I don’t know 4 12.50 1 2.94 Other 3 9.38 1 2.94 Not giving the baby any other food 1 3.13 1 2.94 The baby is satisfied 0 0 1 2.94 Nothing 8 25.00 0 0 No complications during/after delivery 1 3.13 0 0

What makes it difficult for you to only give the baby breastmilk for the first six months of life?


Comparison %

Intervention N=34

Intervention %

Nothing 15 46.88 17 50.00 If the mother has any illnesses 3 9.38 3 8.82 If the mother does not eat enough for adequate breastmilk

3 9.38 2 5.88

I don’t know 3 9.38 2 5.88 Not having enough money 1 3.13 2 5.88 When the baby cries a lot 0 0 2 5.88 Not having enough time to breastfeed 2 6.25 1 2.94 Breastmilk doesn’t come in 2 6.25 1 2.94



Comparison %

Intervention N=34

Intervention %

If the mother gets pregnant again 1 3.13 1 2.94 Baby does not get full from the breastmilk 1 3.13 1 2.94 Other 0 0 1 2.94 The baby will be unhealthy otherwise 1 3.13 0 0


APPENDIX 5: FACILITATORS AND BARRIERS TO CHILD (6–24 MONTHS) NUTRITION BEHAVIORS REPORTED IN WOMEN’S INTERVIEWS FACILITATORS

What makes it easy for you to breastfeed your child at this age?


Comparison %

Intervention N=55

Intervention %

The mother spends the day with the baby 14 32.56 29 52.73 Good health status/not having disease that would cause mother to stop

6 13.95 10 18.18

Received information to continue breastfeeding/mother knows importance

3 6.98 8 14.54

Mother has adequate time to rest 3 6.98 5 9.09 It protects the baby from illnesses 0 0 4 9.30 Having adequate breastmilk 0 0 4 9.30 Other 4 9.30 3 5.45 Mother has adequate time to breastfeed 0 0 2 3.64 Nothing 0 0 2 3.64 The child is calm/well behaved 2 4.65 1 1.82 Family planning 3 6.98 1 1.82 Mother having good nutrition and eating enough food

1 2.33 1 1.82

Mother likes to breastfeed 0 0 1 1.82 I don’t know 9 20.93 0 0

Why did you stop breastfeeding?


Comparison %

Intervention N=11

Intervention %

Other 5 83.33 3 27.27 Mother had health problems 0 0 3 27.27 Child not willing to take other foods 0 0 1 9.09

What makes it difficult for you to breastfeed your child at this age?


Comparison %

Intervention N=61

Intervention %

Nothing 28 51.85 25 40.98 Mother having diseases/getting sick 2 3.70 10 16.39 Not eating enough food/not eating well 2 3.70 7 11.48 Mother is busy or has house activities/work/farming to do

5 9.26 5 8.20

It can be difficult for mothers with TB or HIV

0 0 5 8.20

Unintended pregnancy 6 11.11 4 6.56 I don’t know 1 1.85 2 3.28 Other 1 1.85 2 3.28 Not producing enough breastmilk 3 5.56 1 1.64 No money 1 1.85 1 1.64



Comparison %

Intervention N=61

Intervention %

Child may bite the mother 0 0 1 1.64 Death 0 0 1 1.64 If they child does not want to eat food 0 0 1 1.64 Traveling 2 3.70 0 0

What makes it easy for you to feed your child different types of food?


Comparison %

Intervention N=61

Intervention %

Having money to buy the foods 22 40.74 40 65.57 Mother farms/grows vegetables 3 5.56 19 31.15 Mother keeps animals 0 0 11 18.03 The education they received about feeding children

2 3.70 10 16.39

Availability of the foods/Access 11 20.37 9 14.75 Father helps the mother 2 3.70 4 6.56 I don’t know 4 7.41 3 4.92 Mother has time 2 3.70 2 3.28 Other 6 11.11 1 1.64 So the baby does not become fussy because they are hungry

5 9.26 1 1.64

The foods have vitamins and nutrients 2 3.70 1 1.64 Nothing 5 9.26 0 0 Because the mother decides what to feed the child

2 3.70 0 0

What makes it difficult for you to feed your child different types of food?


Comparison %

Intervention N=61

Intervention %

Not having money to buy the food 27 50.00 33 54.10 Nothing 22 40.74 16 26.23 When the food is not available 7 12.96 9 14.75 If the mother is sick 0 0 2 3.28 Lazy/carelessness 0 0 2 3.28 Not having enough time 0 0 2 3.28 Other 2 3.70 1 1.64 Not having the education on how to feed children

0 0 1 1.64

Not attending clinic or meetings to discuss feeding children

0 0 1 1.64

I don’t know 1 1.85 0 0


What makes it easy for you to give your child food several times a day?


Comparison %

Intervention N=61

Intervention %

Having money 16 29.63 30 49.18 Availability/Access to food 7 12.96 16 26.23 Mother farms vegetables 0 0 9 14.75 Mother has enough time 5 9.26 7 11.48 Received education on feeding children (Mwanzo Bora)

0 0 5 8.20

Father/mother in law help to feed child 1 1.85 4 6.56 Mother keeps animals 0 0 4 6.56 Other 2 3.70 3 4.92 The child is hungry/this satisfies the child 10 18.52 2 3.28 I don’t know 4 7.41 2 3.28 The mother wants the child to have good health

2 3.70 1 1.64

It is the mother’s decision when to feed the baby

2 3.70 1 1.64

Mother prepares the food for the baby 3 5.56 1 1.64 Nothing 10 18.52 0 0 Having specific times to feed the child 2 3.70 0 0 Mother is with the child the whole day 2 3.70 0 0

What makes it difficult for you to give your child food several times a day?


Comparison %

Intervention N=61

Intervention %

Nothing 30 36.07 30 55.56 Not enough money 13 24.07 20 32.79 If the mother is not around the baby/Does not have time with baby

5 9.26 9 14.75

If the food is not available 6 11.11 6 9.84 Other 3 5.56 6 9.84 Not receiving information on feed the child several times

0 0 1 1.64


APPENDIX 6: MULTIVARIATE REGRESSION TABLES

OR SE p-value OR SE p-value OR SE p-value OR SE p-valueSurvey

2010 DHS - - - - - - - - - - - -2015 DHS 1.686 0.197 0.000 1.745 0.287 0.001 1.662 0.196 0.000 1.751 3.450 0.001

Intervention areaNo - - - - - - - - - - - -Yes 1.008 0.124 0.950 1.046 0.198 0.812 1.662 0.196 0.000 1.146 0.770 0.443

0.940 0.231 0.801 0.910 -0.390 0.694Mother's education

No formal education - - - - - -Primary education 1.134 0.174 0.416 1.136 0.830 0.408Secondary or higher education 1.171 0.250 0.461 1.173 0.750 0.456

Marital StatusNot currently married - - - - - -Married 0.918 0.109 0.473 0.918 -0.720 0.474

Mother's age at deliveryLess than 20 - - - - - -20-34 1.255 0.246 0.250 1.252 1.140 0.25535 or older 1.259 0.301 0.336 1.258 0.960 0.338

Parity1 - - - - - -2-4 1.166 0.219 0.415 1.169 0.830 0.4065 or more 0.890 0.203 0.612 0.892 -0.500 0.618

WealthQuintile 1 (poorest) - - - - - -Quintile 2 1.503 0.237 0.011 1.502 2.570 0.011Quintile 3 1.296 0.224 0.134 1.296 1.500 0.136Quintile 4 1.854 0.344 0.001 1.859 3.360 0.001Quintile 5 (least poor) 2.208 0.508 0.001 2.206 3.410 0.001

Wanted most recent pregnancyNo - - - - - -Yes 0.998 0.117 0.986 0.998 -0.020 0.985

Place of residenceUrban - - - - - -Rural 1.400 0.235 0.047 1.400 1.990 0.048

Weighted N 2,925 2,925 2,922 2,922

Attend antenatal care early (during first trimester)Model with interaction and all

covariates

Interaction between survey year and intervention

Model with just survey and intervention

Model with survey, intervention and interaction

Model without interaction plus all covariates



2010 DHS - - - - - - - - - - - -2015 DHS 6.750 1.420 0.000 9.681 3.109 0.000 6.010 1.232 0.000 8.774 2.851 0.000


0.560 0.233 0.166 0.542 0.222 0.137Mother's education


Marital StatusNot currently married - - - - - -Married 0.897 0.151 0.517 0.898 0.151 0.523


Parity1 - - - - - -2-4 0.781 0.170 0.259 0.786 0.171 0.2705 or more 0.731 0.197 0.247 0.732 0.197 0.248


Wanted most recent pregnancyNo - - - - - -Yes 1.567 0.254 0.006 1.567 0.253 0.006

Antenatal care visits0-2 - - - - - -3 or more 4.977 1.730 0.000 5.003 1.740 0.000


Weighted N 2,925 2,925 2,910 2,910

Take iron and folic acid supplements daily throughout pregnancy (for at least 90 days)Model with interaction and all

covariates







2010 DHS - - - - - - - - - - - -2015 DHS 1.315 0.168 0.034 0.947 0.164 0.754 1.262 0.156 0.062 0.904 0.167 0.585






Parity1 - - - - - -2-4 0.819 0.127 0.200 0.807 0.124 0.1635 or more 0.742 0.145 0.128 0.736 0.144 0.119


Wanted most recent pregnancyNo - - - - - -Yes 1.091 0.134 0.482 1.094 0.134 0.465



Weighted N 2,925 2,925 2,910 2,910

Adhere to malaria treatment as prescribed (at least 2 doses of SP)Model with interaction and all

covariates







2010 DHS - - - - - - - - - - - -2015 DHS 0.338 0.088 0.000 0.557 0.197 0.100 0.275 0.074 0.000 0.489 0.172 0.043



No formal education - - - - - -Any formal education 1.209 0.368 0.533 1.298 0.407 0.407


Mother's ageLess than 30 - - - - - -30 or older 0.889 0.223 0.640 0.826 0.210 0.452

Household size1-5 de jure members - - - - - -6 or more de jure members 0.591 0.184 0.094 0.594 0.190 0.106

WealthQuintiles 1 & 2 (poorest-poorer) - - - - - -Quintiles 3, 4, & 5 (middle-least poor) 1.999 0.507 0.007 2.053 0.538 0.007


Weighted N 422 422 422 422

Sleep under treated long lasting insecticidal nets in current pregnancy Model with interaction and all

covariates







2010 DHS - - - - - - - - - - - -2015 DHS 0.384 0.072 0.000 0.543 0.133 0.014 0.348 0.063 0.000 0.520 0.120 0.005






Household size1-4 de jure members - - - - - -5-6 de jure members 0.881 0.110 0.310 0.870 0.108 0.2647 or more dejure members 0.638 0.076 0.000 0.624 0.074 0.000




Weighted N 2,925 2,925 2,910 2,910

Sleep under treated long lasting insecticidal net in last pregnancy in past 5 years Model with interaction and all

covariates







2010 DHS - - - - - - - - - - - -2015 DHS 2.242 0.294 0.000 1.968 0.367 0.000 1.931 0.312 0.000 1.729 0.396 0.018





Currently employedNo - - - - - -Yes 0.823 0.114 0.160 0.833 0.117 0.196


Birth interval between youngest child and previous childLess than 2 years - - - - - -2 years or more 1.062 0.174 0.713 1.059 0.173 0.725No sibling 0.937 0.215 0.776 0.941 0.217 0.792

Delivered in a health facilityNo - - - - - -Yes 1.343 0.189 0.037 1.340 0.189 0.040

Initiated breastfeeding within 1 hour of deliveryNo - - - - - -Yes 1.137 0.146 0.318 1.138 0.146 0.314


Youngest child received postnatal check within 2 monthsNo - - - - - -Yes 1.196 0.167 0.202 1.196 0.168 0.204

Child sexMale - - - - - -Female 0.840 0.088 0.099 1.196 0.168 0.204



Weighted N 2,429 2,429 2,064 2,064

Exclusively breastfeed only (not even water) during the first six monthsModel with interaction and all

covariates







2010 DHS - - - - - - - - - - - -2015 DHS 1.630 0.234 0.001 1.630 0.234 0.001 1.831 0.309 0.000 1.969 0.569 0.020





Currently employedNo - - - - - -Yes 0.546 0.095 0.001 0.539 0.093 0.000



Delivered in a health facilityNo - - - - - -Yes 1.086 0.150 0.550 1.087 0.150 0.546






Weighted N 2,925 2,925 2,486 2,486

Initiate of breastfeeding within 1 hour of birthModel with interaction and all

covariates







2010 DHS - - - - - - - - - - - -2015 DHS 0.972 0.502 0.956 0.661 0.363 0.452

Intervention areaNo - - - - - - - - - - - -Yes 0.661 0.363 0.452 0.667 0.527 0.609

0.983 1.078 0.987Weighted N 364 364 266 266

*Could not fit a model with coviariates. There were too few respondents who answered negatively to the outcome.

Initiate complementary feeding after 6 months (currently feeding 6-11 month olds soft, solid, or semi-solid foods)Model with interaction and all

covariates*




Model without interaction plus all covariates*



2010 DHS - - - - - - - - - - - -2015 DHS 2.421 0.327 0.000 2.083 0.410 0.000 2.295 0.375 0.000 2.124 0.507 0.002





Currently working or worked in past yearNo - - - - - -Yes 1.190 0.235 0.380 0.761 0.112 0.064



Currently breastfeedingNo - - - - - -Yes 1.016 0.109 0.883 1.015 0.109 0.893




Household size1-4 de jure members - - - - - -5-6 de jure members 1.111 0.160 0.465 1.111 0.160 0.4657 or more de jure members 0.826 0.146 0.283 0.828 0.147 0.287



Weighted N 2,188 2,188 1,866 1,866

Initiate complementary feeding after 6 months (introduced foods other than breastmilk between 6 and 8 months)Model with interaction and all

covariates







2010 DHS - - - - - - - - - - - -2015 DHS 1.123 0.638 0.839 0.846 0.872 0.872

Intervention areaNo - - - - - - - - - - - -Yes 0.612 0.366 0.412 0.494 0.438 0.428

1.501 1.857 0.743Weighted N 1,100 1,100 810 810

Feed babies older than 6 months semi solids (thick porridge/mashed foods) and finely chopped foods

*Almost 100% of respondents reproted this behavior. There was not enough variation in the outcome to fit a multivariate model.

Model with interaction and all covariates*




Model without interaction plus all covariates*



2010 DHS - - - - - - - - - - - -2015 DHS 2.107 0.537 0.004 1.923 0.607 0.040 2.875 0.957 0.002 2.481 1.012 0.027






Mother's age at deliveryLess than 30 - - - - - -30 or older 1.218 0.381 0.528 1.210 0.376 0.540





Child has been sick in past 2 weeksNo - - - - - -Yes 2.003 0.520 0.008 2.013 0.519 0.007

Child age (continuous)1.096 0.031 0.002 1.096 0.032 0.002

Household size1-5 de jure members - - - - - -6 or more de jure members 0.587 0.152 0.042 0.588 0.152 0.042

WealthQuintiles 1 & 2 (poorest-poorer) - - - - - -Quintiles 3, 4 & 5 (middle-least poor) 3.690 1.331 0.000 3.673 1.335 0.000


Weighted N 1,100 1,100 940 940

Feed babies older than 6 months a variety of foods, including foods of animal origin, fruits, and vegetablesModel with interaction and all

covariates






Increase the amount of food and frequency as the babies get older to reach 3 meals with 1 or 2 snacks everyday, depending on age


2010 DHS - - - - - - - - - - - -2015 DHS 0.708 0.147 0.099 0.448 0.143 0.013 0.603 0.136 0.026 0.439 0.160 0.025












Child has been sick in past 2 weeksNo - - - - - -Yes 1.039 0.207 0.847 1.042 0.207 0.838

Child age (continuous)1.041 0.021 0.043 1.041 0.021 0.042

Household size1-4 de jure members - - - - - -5-6 de jure members 0.830 0.173 0.372 0.849 0.176 0.4337 or more de jure members 0.846 0.178 0.428 0.857 0.181 0.468

WealthQuintiles 1 & 2 (poorest-poorer) - - - - - -Quintiles 3, 4 & 5 (middle-least poor) 1.265 0.261 0.257 1.253 0.255 0.271


Weighted N 1,100 1,100 940 940

Model with interaction and all covariates





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