Although the world has observed positive progress in improvement of child and maternal health and nutrition indicators, levels of undernutrition, particularly stunting, continue to be high with approximately 149 million children under-five were stunted in 2018 . African continent is by far the hardest hit by stunting with 30 countries out of 41 ranked worldwide with highest number of people experiencing more than one form of malnutrition (childhood stunting, anaemia in women of reproductive age and overweight among women) . The consequences of stunting are profound including increased susceptibility to infections, mortality, reduced cognitive development, diminished educational attainment, less economic productivity in the later stage of life and lower birth weight of offspring . There is also a close link between deprivation of food in early life and increased chances of adulthood chronic diseases . The collective consequences of stunting cost up to 12% of the country Gross Domestic Product of developing countries .
Nearly 45% of all under-five deaths were attributed to malnutrition which translates to approximately 3.1 million deaths per year globally. Sub-optimal infant feeding alone contributes to 800,000 deaths per year and the prevalence of deaths was much higher in South Asia and sub-Saharan Africa than in other parts of the world . Tanzania has made huge progress in reducing stunting in under-five children, from 43% in 1991 to 34% in 2015 . However, disparities exists between regions with six regions (Ruvuma, Iringa, Rukwa, Kigoma, Njombe and Songwe) out of 26 having over 40% of stunted children . This is unacceptably high by the WHO standards . Several studies have linked poor nutritional status among pregnant women and women of reproductive age with adverse birth and nutritional outcomes among newborns and children [8, 9]. Evidence in Tanzania suggests that the prevalence of underweight (BMI < 18.5) among women of reproductive age has remained low and unchanged over the past 20 years. However, overweight and obesity (BMI > 18.5) has increased substantially. The 2015/2016 Demographic and Health Survey indicates, one in ten women aged 15–49 years were either underweight or obese and 18% were overweight . Further, 45% of women of reproductive age and 57% of pregnant women were anemic .
Several studies focusing on implementation of integrated nutrition-specific interventions to reduce stunting yielded inconsistence findings [10,11,12,13]. In a controlled intervention study on complementary food supplements and dietary counseling on anemia and stunting, no impact on stunting among children 6–23 months was observed in China . Another evaluation conducted in Ethiopia among children aged 6–36 months observed no improvement in stunting when an integrated approach (water, sanitation and hygiene (WASH), health and nutrition education) was implemented in a food-insecure population with very high stunting prevalence . Haselow (2016) presented two studies implemented by Hellen Keller international in Baitadi and Kailali districts of Nepal and the Chittagong Hill Tracts in Bangladesh. In Baitadi, a cluster randomized control trial was used where communities were assigned to integrated interventions (Enhanced Homestead Food Production, Promotion of good nutrition and WASH), women’s empowerment, income generation and advocacy) or control. The study did not observe any impact on stunting. However, when a similar set of interventions was implemented in Kailali and Chittagong in a non-randomized control study, the Kailali district of Nepal revealed a 10.5% decline in stunting while the Chittagong Hill Tracts in Bangladesh achieved an 18% decline in stunting . Methodological approach, packaging of intervention, duration of implementation and fidelity are some of the possible explanations for the observed variations.
Description of the interventions
The government of Tanzania is aiming to eliminate stunting as a significant public health problem by 2030 . As part of several initiatives, an integrated intervention program with the aim of reducing stunting in children under 5 years was implemented in Simiyu and Ruvuma regions of Mainland Tanzania from 2016 to 2019 by an Italian organization called Doctors with Africa CUAMM. The program targeted pregnant and lactating women and children underfive years and focused on provision of nutrition education and promotion of use of health services during the 1000-day window from conception to 2 years of child life. CUAMM local project team members, health care providers and Community Health care Workers (CHW) were main actors in the management and implementation program activities. The role of health care providers on program activities was to deliver the routine services (nutrition education, education on infant feeding, Iron and folic acid supplementation and management of Severe Acute Malnutrition (SAM) at the health facility which is beyond the scope of this paper.
Stunting screening, cooking demonstration, health and nutrition education were the core project activities done during the village health days. Since stunting is a chronic condition, it was screened twice a year. Cooking demonstration and community health education sessions were done quarterly (every 3 months) in each of the study village with each session lasting for half a day. The training materials known as Mkoba wa Siku 1000 were adopted from the Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDEC) and were used during facilitation of health education sessions. The training package had materials related to health education during pregnant and lactating, infant and young child feeding, handwashing, waste product management and birth preparedness.
The program also facilitated the formation of peer support group at village level with each having a maximum of 10 members and headed by community health care workers. The purpose of the groups was to facilitate provision of health and nutrition education among group members and the community at large and promote home gardening to ensure households availability of diversified food. The actual number of peer groups formed throughout the program implementation was not documented since this was not one of the core project implementation strategy. This paper generates an evidence from an evaluation work of these community program activities.