Meals, Education, and Gardens for In-School Adolescents: A Cluster Randomized Trial of an Adolescent Nutrition Intervention Package in Tanzania

PURPOSE

This study aimed to implement and evaluate integrated, school-based nutrition intervention packages for adolescents in Dodoma, Tanzania.

METHODS

A cluster randomized controlled trial was conducted among six secondary schools in Dodoma, Tanzania. Two schools received the full-intervention package of school meals, nutrition education, school gardens, and community workshops. Two schools received the partial-intervention package without the school meals component. Two schools served as the controls and did not receive any intervention. The intervention was implemented over one academic year. The analytical sample included 534 adolescents aged 14 to 17 at baseline and 286 parents. Outcomes included nutrition knowledge, food preferences, diet quality, food insecurity, physical activity, growth, and anemia. Linear models were used to estimate mean differences, and logistic regression models were used to estimate odds ratios (ORs).

RESULTS

Compared to the control, both the partial (OR: 0.59; 95% confidence interval [CI]: 0.35, 1.00) and full (OR: 0.49; 95% CI: 0.40, 0.59) interventions were associated with lower odds of poor diet quality among adolescents. Among the parents, both the partial (OR: 0.28; 95% CI: 0.20, 0.40) and full (OR: 0.28; 95% CI: 0.13, 0.58) interventions were associated with lower odds of poor diet quality. The partial (OR: 0.29; 95% CI: 0.18, 0.47) and full (OR: 0.47; 95% CI: 0.30, 0.72) interventions were associated with lower odds of adolescent overweight or obesity.

DISCUSSION

School-based nutritional intervention packages incorporating multiple actions may improve the diet quality of adolescents and their household members and reduce the double burden of adolescent malnutrition.

Engaging Fathers for Effective Child Nutrition and Development in Tanzania (EFFECTS): study protocol for a five-arm, cluster-randomized trial

BACKGROUND

Globally, 144 million children under 5 years are undernourished and 250 million do not meet their developmental potential. Multi-input interventions, such as bundled nutrition and parenting interventions, are designed to mitigate risks for multiple child outcomes. There is limited evidence that bundled interventions have additive benefits to nutrition, growth, or development outcomes. These outcomes share common risks; therefore, designing interventions to tackle these risks using a common theory of change may optimize effectiveness. Emerging evidence suggests explicit engagement of fathers may benefit child outcomes, but few trials have tested this or included data collected from fathers.

METHODS

Engaging Fathers for Effective Child Nutrition and Development in Tanzania (EFFECTS) is a community-based cluster-randomized controlled trial that will be implemented in the rural Mara Region, Tanzania. The trial aims (1) to test a bundled nutrition and parenting program delivered to mothers' groups, with or without fathers' groups, over 12 months on child and caregiving outcomes compared to a nutrition program alone, and (2) to test nutrition or bundled nutrition and parenting programs delivered to mothers' and fathers' groups over 12 months on child and caregiving outcomes compared to programs delivered to mothers alone. The trial comprises five arms: (1) mothers' groups receiving a nutrition program, (2) mothers' groups receiving a bundled nutrition and parenting program, (3) mothers' and fathers' groups receiving a nutrition program, (4) mothers' and fathers' groups receiving a bundled nutrition and parenting program, and (5) control receiving standard of care health services. The primary outcomes are child dietary diversity and early child development (mental and motor development). Parents with a child under 18 months will be enrolled in peer groups and receive twice monthly intervention by trained community health workers. Data will be collected from mothers, fathers, and children at baseline (pre-intervention), midline, and endline (post-intervention).

DISCUSSION

EFFECTS will generate evidence on the effects of bundled nutrition and parenting interventions on child nutrition, growth, and development outcomes; determine the benefits of engaging fathers on child, caregiving, and caregiver outcomes; and investigate common and unique pathways between treatments and child outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03759821. Registered on November 30, 2018.

Effects of engaging fathers and bundling nutrition and parenting interventions on household gender equality and women's empowerment in rural Tanzania: Results from EFFECTS, a five-arm cluster-randomized controlled trial

Advancing gender equality and women's empowerment (GE/WE) may contribute to better child nutrition and development in low-resource settings. However, few empirical studies have generated evidence on GE/WE and examined the potential of engaging men to transform gender norms and power relations in the context of nutrition and parenting programs. We tested the independent and combined effects of engaging couples and bundling nutrition and parenting interventions on GE/WE in Mara, Tanzania. EFFECTS (ClinicalTrials.gov, NCT03759821) was a cluster-randomized 2 × 2 factorial trial plus control. Eighty village clusters were randomly assigned to one of five intervention conditions: standard of care, mothers nutrition, couples nutrition, mothers bundled nutrition and parenting, or couples bundled nutrition and parenting. Between October 2018-May 2019, 960 households were enrolled with children under 18 months of age residing with their mother and father. Community health workers (CHWs) delivered a bi-weekly 24-session hybrid peer group/home visit gender-transformative behavior change program to either mothers or couples. GE/WE outcomes were analyzed as intention-to-treat and included time use, gender attitudes, social support, couples' communication frequency and quality, decision-making power, intimate partner violence (IPV), and women's dietary diversity (WDD). Data were collected from 957 to 815 mothers and 913 and 733 fathers at baseline and endline, respectively. Engaging couples compared to mothers only significantly increased paternal and maternal gender-equitable attitudes, paternal time spent on domestic chores, and maternal decision-making power. Bundling increased maternal leisure time, decreased maternal exposure to any IPV, and increased WDD over 7 days. A combination of engaging couples and bundling was most effective for paternal gender attitudes, couples communication frequency, and WDD over 24 h and 7 days. Our findings generate novel evidence that CHWs can deliver bundled nutrition and parenting interventions to couples in low-resource community settings that advance GE/WE more than nutrition interventions targeting only women.

Design and Field Methods of the ARISE Network COVID-19 Rapid Monitoring Survey

The coronavirus disease 2019 (COVID-19) pandemic has significant health and economic ramifications across sub-Saharan Africa (SSA). Data regarding its far-reaching impacts are severely lacking, thereby hindering the development of evidence-based strategies to mitigate its direct and indirect health consequences. To address this need, the Africa Research, Implementation Science, and Education (ARISE) Network established a mobile survey platform in SSA to generate longitudinal data regarding knowledge, attitudes, and practices (KAP) related to COVID-19 prevention and management and to evaluate the impact of COVID-19 on health and socioeconomic domains. We conducted a baseline survey of 900 healthcare workers, 1,795 adolescents 10 to 19 years of age, and 1,797 adults 20 years or older at six urban and rural sites in Burkina Faso, Ethiopia, and Nigeria. Households were selected using sampling frames of existing Health and Demographic Surveillance Systems or national surveys when possible. Healthcare providers in urban areas were sampled using lists from professional associations. Data were collected through computer-assisted telephone interviews from July to November 2020. Consenting participants responded to surveys assessing KAP and the impact of the pandemic on nutrition, food security, healthcare access and utilization, lifestyle, and mental health. We found that mobile telephone surveys can be a rapid and reliable strategy for data collection during emergencies, but challenges exist with response rates. Maintaining accurate databases of telephone numbers and conducting brief baseline in-person visits can improve response rates. The challenges and lessons learned from this effort can inform future survey efforts during COVID-19 and other emergencies, as well as remote data collection in SSA in general.

Public knowledge of risk factors and warning signs for cardiovascular disease among young and middle-aged adults in rural Tanzania

Background

Improving cardiovascular health requires public knowledge and reduction of modifiable cardiovascular disease (CVD) risk factors. This study assessed knowledge of risk factors and warning signs for CVDs among young and middle-aged adults in Morogoro, Tanzania.

Methods

We conducted a community-based survey as part of cluster randomized controlled study of community health workers (CHWs) intervention for reduction of blood pressure among young and middle-aged adults in rural Morogoro. Information on socio-demographic characteristics, knowledge of risk factors and warning signs for CVDs was collected using an interviewer administered questionaire. Knowledge was assessed using open-ended questions followed by closed-ended questions. Descriptive statistics were used to describe knowledge of risk factors and warning signs. Logistic regression analysis was used to investigate factors associated with adequate knowledge of risk factors and warning signs for CVDs.

Results

Two-thirds (65.7%) of the participants had heard about CVDs. The main sources of information were mainly relatives/ neighbors (64.8%) and radio (53.0%). Only 28.3% of the participants reported health care providers as source of information about CVDs. More than half of the participants (52.4%) did not mention even one risk factor spontaneously while 55.2% were unable to mention any warning sign. When asked to select from a list, 6.9% were unable to correctly identify any risk factor whereas 11.8% could not correctly identify even a single warning sign. Quarter of participants (25.4%) had good knowledge score of risk factors, 17.5% had good knowledge score of warning signs and 16.3% had overall good knowledge of both risk factors and warning signs. Residing in Ulanga, having higher education level, having ever checked blood pressure and being overweight/obese predicted adequacy of knowledge score for both risk factors and warning signs.

Conclusion

Knowledge of risk factors and warning signs in this rural population of young and middle-aged adults was generally low. Health care providers were less likely to provide health education regarding risk factors and warning signs for CVDs. Health promotion interventions to increase population knowledge of risk factors and warning signs should be implemented for successful reduction of CVDs in Tanzania.

Prevalence, Awareness, Treatment, and Control of Hypertension among Young and Middle-Aged Adults: Results from a Community-Based Survey in Rural Tanzania

BACKGROUND

Hypertension, which is the single most important risk factor for CVDs, is increasing at an alarming rate in most developing countries. This study estimated the prevalence, awareness, treatment, and control of hypertension among young and middle-aged adults in rural Morogoro, Tanzania. Furthermore, it explored factors associated with both prevalence and awareness of hypertension.

METHODS

A cross-sectional survey was conducted as part of the cluster randomized controlled study of community health workers (CHWs) interventions for reduction of blood pressure in a randomly selected sample of young and middle-aged population in rural Morogoro. Sociodemographics, lifestyle-related factors, history of diagnosis, and treatment for hypertension were collected using a questionnaire adopted from the STEPS survey tool. Blood pressure, height, and weight were measured at home following standard procedures. Descriptive statistics were used to estimate prevalence, awareness, treatment, and control of hypertension. Multiple logistic regression models were used to assess determinants of hypertension and awareness.

RESULT

The prevalence of hypertension was 29.3% (95% CI: 27.7-31.0). Among individuals with hypertension, only 34.3% were aware of their hypertension status. Only around one-third (35.4%) of those who were aware of their hypertension status were currently on antihypertensive medication. Hypertension control was attained in only 29.9% among those on medications. Older age (p < 0.001), use of raw table salt (p < 0.001), and being overweight/obese (p < 0.001) were associated with hypertension. Predictors of awareness of hypertension status were older age, being a female, higher socioeconomic status, use of raw table salt, a history of diabetes, and overweight/obesity (all p < 0.001). Alcohol drinking was associated with low awareness for hypertension status (p < 0.001).

CONCLUSION

There is high prevalence of hypertension with low rates of awareness, treatment, and control among young and middle-aged adults in rural Tanzania. Community-level health promotion and screening campaigns for hypertension and other CVD risk factors should be intensified.

Prevalence and risk factors associated with malnutrition among adolescents in rural Tanzania

OBJECTIVE

To determine the prevalence and risk factors associated with malnutrition among adolescents in a rural Tanzanian community.

METHODS

Cross-sectional survey of 1226 randomly selected adolescents from the Dodoma Health and Demographic Surveillance System (HDSS) in the Chamwino district in the Dodoma region. Anthropometric measurements for weight and height were collected. Height-for-age-z-scores (HAZs) and body mass index (BMI)-for-age-z-scores (BAZs) were computed. Descriptive estimates were documented in graphs and tables, and weighted linear regression models were used to examine predictors of malnutrition.

RESULTS

Stunting prevalence was 18%, and thinness prevalence was 14%. Overweight and obesity affected 5.23% of participants. Girls had higher HAZs (β: 0.46, 95% CI 0.33, 0.59, P < 0.0001) and BAZs (β: 0.20, 95% CI 0.05, 0.35, P = 0.0098) than boys. Age was inversely associated with HAZs (β: -0.13, 95% CI -0.17, -0.08, P < 0.0001) and BAZs (β: -0.05, 95% CI -0.10, -0.004, P = 0.0327). Wealth score (β: 0.10, 95% CI 0.04, 0.16, P = 0.0009) and dietary diversity score (β: 0.04, 95% CI 0.01, 0.07, P = 0.0080) were positively associated with HAZs and BAZs. Out-of-school adolescents had higher HAZs (β: -0.49, 95% CI -0.75, -0.23, P = 0.0003) and BAZs (β: -0.68, 95% CI -0.99, -0.37, P < 0.0001) than adolescents who attended school.

CONCLUSION

There are substantial variations of HAZs and BAZs across gender, age, education and wealth, with an emerging burden of overweight and obesity among adolescents in this rural population. Interventions are urgently required to curb both ends of the malnutrition spectrum.

Big Sister, Big Brother: A Mixed Methods Study on Older Siblings’ Role in Infant and Young Child Feeding and Care in Rural Tanzania (P10-020-19)

Objectives

Nutrition interventions to improve infant and young child feeding (IYCF) and care in developing countries usually target mothers, while critical roles of other family members, particularly older siblings, are not well known. As part of the Engaging Fathers for Effective Child Nutrition and Development in Tanzania (EFFECTS) cluster-randomized trial (ClinicalTrials.gov: NCT03759821), we examined the roles of older children and adolescents in IYCF and care in rural Tanzania to develop and administer informed quantitative questionnaires on IYCF and care by older siblings.

Methods

Twelve mothers, 12 fathers, 4 grandmothers, and 4 older siblings (7–17 years of age) were purposively sampled for qualitative interviews conducted July-August 2018. Open-ended questions explored older siblings’ roles in IYCF and care, managing time for child care, and responsiveness to young children's hunger cues. Inductive and deductive approaches were used to identify themes from transcribed interviews. Findings supported development of two questionnaires on older children's roles in IYCF and care (14 questions each) that were administered to mothers and siblings in the EFFECTS baseline.

Results

Qualitative data indicate older siblings (male and female) are involved in food preparation (e.g., starchy staples), daily feeding, hygiene (e.g., washing baby after toileting) and care when the mother is unavailable due to other household activities. The EFFECTS study enrolled 960 households across 80 villages in Mara, Tanzania, and 53% of households identified at least one sibling who cares for an index child aged 0–18 months. Baseline data collection is ongoing and indicates prevalence and types of child care (e.g., feeding, playing, hygiene, responding to crying) provided by older siblings.

Conclusions

To our knowledge, this is the first mixed methods study developing instruments to investigate the role of older siblings in providing IYCF and care in a rural, developing country setting. As parents seek to meet household and livelihood needs, older siblings are often engaged in child feeding and care. Nutrition interventions should consider roles of all family members, including older children, in child feeding and care. Further research is needed to evaluate the effect of family-based interventions.

Funding Sources

Eleanor Crook Foundation and Conrad N. Hilton Foundation.

Development and Feasibility of Tablet-based 24-hour Recall for Dietary Intake and Recipe Collection Among Adults and Children in Tanzania (P10-018-19)

Objectives

In many regions of the world, little is known about food consumption, meal structures, meal patterns, and nutrient intake. Collection of these data using quantitative dietary intake is expensive and labor intensive. Thus, many programmatic and routine surveillance studies resort to simplified indicators to measure dietary quality. Based on a previous study conducted by Caswell et al. on tablet-based data collection of 24-hour dietary recall (24hr-DR), we have developed and adapted a mobile tool collecting 24hr-DR among adults and children in Tanzania.

Methods

Using the Tanzanian food composition table (FCT), the 24hr-DR was developed on an Android platform in Open Data Kit. The module provides food groups, food lists, meal list, ingredient list, quantity and amount consumed, breastfeeding frequency, and a recipe feature to collect detailed information (such as cooked and uncooked weights). Similar to the USDA Automated Multiple Pass Method, to accurately capture the dietary intake the tool contains summary features such as time in between meals and review of meals and portion size consumed in the previous day.

Results

The mobile tool is currently used to collect dietary intake (1) among 960 children 0–18 months of age enrolled in the EFFECTS trial (ClinicalTrials.gov Identifier: NCT03759821) in Mara, Tanzania, and (2) among adult families enrolled in the DECIDE study in Dar es Salaam. Field workers were first trained on paper-based methods with food models followed by training on tablet-based collection. Because the tool was tailored with the Tanzanian FCT, conversion to nutrient intake for the individual are readily linked. This enables the investigators to look at dietary intake data in real time for quality assurance and analysis. Demonstration of the tool along with dietary profiles and analysis will be compared with the literature. The tool will be made available to the public in December 2019, and can be adapted to different contexts.

Conclusions

Using mobile-based flexible platforms linked to a pre-existing FCT demystifies the “black box” processes of converting dietary intake to nutrient intake, thus reducing the time and labor needed using the traditional paper-based 24hr-DR method.

Funding Sources

This study is funded through the Drivers of Food Choice Grants Program by Bill and Melinda Gates foundation and UK AID.

Antiretroviral Therapy in Relation to Birth Outcomes among HIV-infected Women: A Cohort Study

Although the beneficial effects of antiretroviral (ARV) therapy for preventing mother-to-child transmission are indisputable, studies in developed and developing countries have reported conflicting findings on the association between ARV exposure and adverse birth outcomes. We conducted a prospective observational study at 10 human immunodeficiency virus (HIV) care and treatment centers in Dar es Salaam, Tanzania. Multivariate log-binomial regression was used to investigate the associations between ARV use and adverse birth outcomes among HIV-negative HIV-exposed infants. Our findings demonstrate an increased risk of adverse birth outcomes associated with the use of highly active antiretroviral therapy during pregnancy. Further studies are needed to investigate the underlying mechanisms and identify the safest ARV regimens for use during pregnancy.

Community health workers to improve antenatal care and PMTCT uptake in Dar es Salaam, Tanzania: a quantitative performance evaluation

BACKGROUND

Home visits by community health workers (CHW) could be effective in identifying pregnant women in the community before they have presented to the health system. CHW could thus improve the uptake of antenatal care (ANC), HIV testing, and prevention of mother-to-child transmission (PMTCT) services.

METHODS

Over a 16-month period, we carried out a quantitative evaluation of the performance of CHW in reaching women early in pregnancy and before they have attended ANC in Dar es Salaam, Tanzania.

RESULTS

As part of the intervention, 213 CHW conducted more than 45,000 home visits to about 43,000 pregnant women. More than 75% of the pregnant women identified through home visits had not yet attended ANC at the time of the first contact with a CHW and about 40% of those who had not yet attended ANC were in the first trimester of pregnancy. Over time, the number of pregnant women the CHW identified each month increased, as did the proportion of women who had not yet attended ANC. The median gestational age of pregnant women contacted for the first time by a CHW decreased steadily and significantly over time (from 21/22 to 16 weeks, P-value for test of trend <0.0001).

CONCLUSIONS

A large-scale CHW intervention was effective in identifying pregnant women in their homes early in pregnancy and before they had attended ANC. The intervention thus fulfills some of the conditions that are necessary for CHW to improve timely ANC uptake and early HIV testing and PMTCT enrollment in pregnancy.