The Impact of a Large-Scale Social and Behavior Change Communication Intervention in the Lake Zone Region of Tanzania on Knowledge, Attitudes, and Practices Related to Stunting Prevention

"Many changes in KAP [knowledge, attitudes, and practices] were observed from baseline to midline and baseline to endline and corresponded with SBCC [social and behaviour change communication] programming in the region. These results provide support for the value of large SBCC interventions. Public health efforts in settings such as Tanzania may benefit from adopting these approaches."

Undernutrition remains a serious public health problem in Tanzania. Social and behavioural change communication (SBCC) interventions have been widely implemented for childhood nutrition and stunting prevention purposes. Addressing Stunting in Tanzania Early (ASTUTE) was a large-scale, 5-year SBCC programme implemented by IMA World Health, along with consortium partners, in Tanzania's Lake Zone region. The purpose of this study was to examine if this SBCC intervention was associated with changes in knowledge, attitudes, and practices (KAP) related to key maternal, newborn, and child health (MNCH) indicators comparing midline and endline data to baseline data.

As detailed at Related Summaries, below, ASTUTE featured: mass media communication (e.g., television, radio); interpersonal communication (IPC) interventions (e.g., home visits, home-based health education); and group-based approaches (e.g., support groups for women, positive deviance/hearth, community mobilisation days, community outreach, health facility-based counseling, and multisectoral capacity building). ASTUTE activities focused on standard MNCH indicators, including: making regular health facility visits to receive antenatal care (ANC); infant and young child feeding (IYCF) practices; water, sanitation, and hygiene (WASH) practices; measures of early childhood development (ECD); and indicators of male involvement. ASTUTE was funded by UKaid and the Foreign, Commonwealth and Development Office (FCDO), and Development Media International (DMI) partnered with IMA World Health in particular to assess programme impact.

A consistent tagline was used at the end of each theory-based radio spot, which was broadcast a total of 70,000 times. TV spots were aired before and during the evening news on national and regional stations a total of 1,198 times. The programme trained more than 6,000 community health workers (CHWs), facility workers, staff, and volunteers from 50 civil society organisations. CHWs used a problem-based negotiated behaviour change approach during in-home visits to implement IPC components of the intervention. They counseled mothers and referred children with growth faltering to health facilities. They also encouraged both mothers and male partners to engage in stimulation activities (e.g., drawing, playing, playing, naming objects, or talking with them) for their children by providing education and support.

Baseline (2016), midline (2019), and endline (2020) surveys were conducted with a total of 14,996 female caregivers and 6,726 male heads of household. Regression analyses were used to estimate differences in KAP from baseline to midline and endline.

Women's knowledge of handwashing and IYCF practices, as well as attitudes related to male involvement, consistently improved from baseline to midline and baseline to endline. (See Table 3 in the paper.) Women reported eating significantly more types of food, attending more ANC visits, having a partner help with chores during the most recent pregnancy, singing more to the child, and drawing more with the child from baseline to midline and baseline to endline. (See Table 4.) Improvements in KAP among male heads of household were varied across indicators, with consistent improvement in practices related to child feeding practices from baseline to midline and baseline to endline. Notably, several significant improvements in knowledge and attitudes were related to male involvement. For example, male heads of household perceived that most men in the community helped wives with household chores during pregnancy at midline compared to baseline. These shifts in knowledge and attitudes are especially promising if they are indicative of shifting societal and gender norms leading to greater equity in gender relations through male involvement in household and parenting duties.

While not all changes were significant, and not all changes were consistent at the different data collection periods, the results were positive overall. Both midline and endline results for 26 indicators were compared to baseline, for a total of 52 comparisons. Of these 52 comparisons, 33 (63%) demonstrated statistically significant improvement. For female caregivers, improvement among practices indicators was more impressive than improvements in both knowledge and attitudes. For example, of the 12 practices indicators measured for female caregivers, 9 (75%) significantly improved by midline, and 10 (83%) significantly improved by endline when compared to baseline. In terms of practices among men, among the 5 practices measured for male heads of household, 3 (60%) had significantly improved by midline, and 3 (60%) had significantly improved by endline when compared to baseline.

It is noteworthy that the knowledge and attitudes indicators that did not show significant improvements from baseline to midline or baseline to endline were generally already very high at baseline (e.g., "agree child should only be given breastmilk for first 6 months"; and "How soon after birth should a child be put to the breast?"), rendering any additional significant improvements in the population statistically challenging.

The researchers point out that evaluation of SBCC interventions, including this one, is impeded by the challenge of measuring and determining the dose and response to various programme interventions. Indeed, the current study did not attempt to correlate SBCC exposure to study indicators; nor did it quantify an individual participant's exposure (dose) to mass media or IPC programming with respect to KAP surrounding MNCH (response). Rather, it addressed the combined impact of SBCC programming on the population represented by a large, randomly selected cohort at midline and endline compared with a similar cohort at baseline. Thus, variations in the improvement of different indicators at different time periods, as in this study, are to be expected.

In conclusion: "Study results support the use of SBCC programming for improving KAP generally....These findings can help to inform future SBCC interventions targeting key indicators associated with stunting prevention."