Saturday, February 25, 2012

Behavior Changes in Child Care and Feeding Practices in Makete District

Introduction

Good caring practices to child will contribute a lot in his/her growth and development especially physical growth, psychosocial and psychological development.Parents and other care givers should be close to the child so as to monitor child’s development. Love and affection are essential ingredients for a child’s growth and development. However, childcare in Tanzania which includes feeding the child, bathing and other activities related to the child’s hygiene, psychosocial and psychological development are regarded as a women’s duty.  The distance between men and their children often places unmanageable demands on women, and their children pay the price in terms of inadequate supervision and interaction which amounts to a “single parent”[1].  This chapter presents research findings on motivations and constraints to behaviour change in child care and feeding practices. Moreover, the observed opportunities for improvement or changes are enlightened.

Nutrition is essentially a component of post-natal care. Since growth rate in human life is maximum during the first year of life, child care and feeding practices [e.g., both breastfeeding and complimentary feeding], have a major role in determining the future nutritional status of any child. One of the most important things parents do to ensure the well being of their children is feeding them healthy and nutritious diets.  Nutrition can be improved through changing the current behaviors as regards child care and feeding practices. It is a fact that, nutrition and health education of mothers and efforts to trigger appropriate behavioral changes among mothers, are considered as direct interventions for improving child care and feeding practices. This greatly reduces malnutrition in children. It is also true that increasing children’s intake of nutrients and or reduction in occurrences of diseases has similar positive impact[2].

Intake of nutrients can be increased in a number of ways. This includes: motivating mothers to increase the frequency of breastfeeding; increase the amount of complimentary foods consumed by the child in his/her own; large servings; encouraging children to eat a complete serving; and, increasing frequencies of complementary feeding by giving children extra meals like nutritious snacks such as groundnuts, boiled or fried eggs between meals. Consumption of snacks compensates for missing nutrients from main meals consumed during breakfast, lunch or dinner. Energy density in foods given to young children is increased in several different ways. First, by adding a teaspoonful of oil or ghee in every feed where fat is concentrated as a source of energy, thereby substantially increasing the energy content of food without increasing the bulkiness of the food. Secondly, through the addition of sugar to a child’s food since children need more energy and hence adequate amount of sugar need be added to children’s food. Thirdly, through addition of malt or kimea to children’s foods. This reduces viscosity of the foods and hence entices the child to eat more at a particular time. Kimea or malt is made from germinated whole grain cereal or pulse, by drying it after germination and grinding. Malted food when mixed with other foods helps in reducing the viscosity of the foods[3]. Moreover, reducing the amount of watery or more solids foods to children is of most important,

Since too watery diets like porridge, mashed bananas or potatoes when consumed by the child will fill the stomach soon and its digestion will be over after 1 hour. Thereafter, stomach will be empty and child will feel hungry and majority of care givers are not able to recognize that. Therefore, it is better to give child meals which are not too light or watery. More solid foods are not good for children since it is difficult for them to chew and swallow thus they will not be able to consume adequate amount of food required for their body. Furthermore, increasing breastfeeding, improving food hygiene and prevention of micronutrient deficiencies [e.g. Vitamin A Deficiency (VAD), Iodine Deficiency Disorders (IDD), Zinc Deficiencies and Protein-Energy Malnutrition (PEM)] reduces the occurrence and severity of diseases. Vitamin and mineral deficiencies contribute to the impaired growth and development of young children[4].

Behavior challenges and needs for change.

Behavior changes is not, however simply an issue of providing caregivers with correct information. Certain conditions and enabling factors that cut across sectors must exist for changes to be effective and sustainable. They include social support systems, reduced workload and time saving from higher labour productivity and access to financial and productive resources. The practices of caretakers and families in the home and community are critical to preventing infant and child morbidity and mortality. Caretakers should practice behaviors that will prevent infant and childhood health problems before they arise. In order to change the nutritional status of populations, it is critical to change the behavior of caretakers, families, and communities. When care is sought at health facilities, health workers play an important role in providing essential services. They need to be trained to provide appropriate nutritional management and counseling for both sick and well children[5].

Nutrition behaviors which needs to be practiced regularly by care givers includes; exclusively breastfeeding for about 6 months for all infants, provision of appropriate complementary foods and continue breastfeeding until 24months for all infants and young children, For women, infants and children consumption of Vitamin A-rich foods such as paw paws, carrots, eggs, milk, and all fruits which have yellow color or to take Vitamin A supplements. Appropriate nutrition management should be administered to all sick children which include continue feeding and increase fluids during illness, increase feeding for children after illness and two doses of vitamin A are encouraged incase of measles. In the home, a number of simple household behaviors should be involved to prevent infant and childhood illness and malnutrition. This include breastfeeding, appropriate complementary feeding practices, obtaining enough micronutrients, basic hygiene practices (e.g. hand washing), and seeking a complete course of vaccines for infants in their first year of life. In addition, when child becomes sick, caretakers must feed the child appropriately during and after the illness and seek care when it is required[6]. Parents appear to leave many feeding decisions up to their children example, they wait for an indication that their child wants to eat and thus when they feed them. Refer to table 4.8 in chapter four of this report (Frequency of feeding).

During in-depth interview with mothers who breast feed their children when asked who initiate breastfeeding (mother or a baby) response were as follows; Majority of women (65%) in all villages revealed that, mother is the who initiate breastfeeding process while 8% of mothers depicted child is the one who initiate breastfeeding. Some mothers (27%) mentioned either mother or child initiate breastfeeding process depending on the availability of time mother had with her child.

Some times child may want to breastfeed but if we are busy e.g. we are in the field she/he should wait until lunch time. We cannot respond to children all the times as we have a lot of task to do”. Moreover we let the child to breastfeed until when she/he is satisfied. And  we normally breastfed both breast because when the child start suckling one breast, then milk started to be stimulated in other breast. We also believe that if the child suck in one breast the remained one may develop breast cancer”.[Mothers with children under 2 years in FGD-Kissinga and Nkondo] On the other hand, mothers fro Ikuwo, Ikete, Maliwa and Mago said they breast feed their children in both breast but they don’t have any reason of doing so.

Some mothers in Kissinga, Nkondo, Ikete and Maliwa mentioned that, “child is the one who initiate breastfeeding because if the child is not crying an indication of feeling hungry then there is no need to breastfeed. We frequently let the child decide when he or she wants to eat or had enough.” This may result to inadequate intake of breast milk to some infants and young children with less than six months. Therefore, women should be encouraged to breastfed their child as breast milk is fundamental food to infant and young children for their overall health, growth and development.

Table 5.1
Who initiate breastfeeding process (mother or a baby?)
[In-depth interview N=60]

Incidence of malnutrition
Low incidence area
Middle incidence area
High incidence area

Total
%
Researched areas
Kissinga
 n=10
Mago
n=10
Nkondo n=10
Ikuwo n=10
Ikete n=10
Maliwa
n=10
Mother
5
9
7
6
7
5
65
Child
1
0
1
0
1
2
8
Either
4
1
2
4
2
3
27

Source: UNICEF Supported Formative Research, 2006

Appropriate feeding is crucial for the healthy growth and development of young children. The quantity and quality of food to be given to young children should be equal, since their body grows rapidly, both structurally and functionally. This does not depend on the sex or race of the child. Therefore; in order to achieve optimum growth and development of children; demand for regular provision of nutritious food should be increased.[7] From the research,   when old women asked if the young boy eat/need same amount of food as young girl, their response was as follows;

They all eat the same amount of food because they both still young. When they grow up, male children need more food because they grow up very fast.  ” [Kissinga and Mago]

“Male children eat more food than female because; the hunger of male are greater than for females and the ribs of male children are small.”[Ikete and Maliwa]]

“When they are young, the need/eat the same amount of food. When they grow up, male children need more food because they cannot cook for themselves   as girls can.”[Nkondo and Ikuwo]

Good support to mothers from family members, communities, and health care system contribute a lot to good child care and feeding practices to young children. As mothers will get support in terms of advice on how to feed the bay and other related child care practices. During in-depth interview with mothers of children less than 5 years, when asked what support do they get to ensure good nutrition to their children, the response were as follows;

We don’t have any support to ensure good nutrition to our children. Even our husbands they just leave all the responsibilities to us women. Some of them who are farmers may try to work together on field thereafter they went to drink local liker. For those who produces timber they may leave home for more than one month without caring what is available in the house as food for children”.[Women from Nkondo, Ikete, Ikuwo and Maliwa]

In low incidence of malnutrition, women depicted to receive some assistance in either food or agricultural inputs. They said,

 We got some foods from friends and relatives which help to increase the amount of food in our families. Some times we also received fertilizers from government for nourishment of food crops thus high production. They even look after our children while we are in the field”. [Kissinga and Mago] 

They all get free health services for their children in health centers available, including vaccination and immunization. 
Table 5.2
Support to ensure good nutrition status of their children. [In-depth interview N=60]

Incidence of malnutrition

Low incidence area

Middle incidence area

High incidence area

Researched areas

Kissinga
n=10

Mago
 n=10

Nkondo
n=10

Ikuwo
n=10

Ikete
n=10

Maliwa
n=10
Fertilizers
ü  
ü  




Foods from relatives
ü  





Health education






Free health services
ü  
ü  
ü  
ü  
ü  
ü  
Take care of the child

ü  




No other support.


ü  
ü  
ü  
ü  

 Constraints  to Behavior Change in Child Care and Feeding Practices

There are many constraints or issues that reduce likelihood of families adopting better child feeding behaviors can be classified as environmental or attitudinal constraints. Environmental factors include the unavailability or seasonal variation in the accessibility of certain foods, the need to work outside the home, a scarcity of cooking fuel or inadequate reception of information about child feeding given by health care workers. Attitudes that prevent improvements in child feeding are numerous. They will vary by culture, but certain issues are common. Perceived insufficient quantity or quality of breast milk; Perceived inability of child to swallow or digest particular foods preparations; Lack of maternal self – confidence or feeling of powerlessness in the face of resistance from the child; Perception of time constraints for food preparation and feeding; Traditional rules for food distribution within the family; and Fear of spoiling the child with too much food or special foods[8].

Patriarchal  system

Majority of families in Makete District depends on father’s decision on what to feed the baby. As a result the child eats the similar type of foods several times. This was observed in high incidence areas (Ikete and Maliwa villages) when mothers with children less than two years were asked. Who makes decision in the family? The response to this query differs from one village to another. Women from Ikete, Nkondo and Ikuwo said; “father is responsible for all financial matters in the family including what to be eaten. It does not matter who is the source of that money. Also father is responsible for decide upon health services incase illness to adults and other family member”. On the other hand, women from Mago, Kissinga and Maliwa added, mother is responsible for buying food and health services for young children.

Table 5.3        
Constraints in Provision of Complementary foods N=60


Constrains

Low incidence of malnutrition

Medium incidence of malnutrition

High incidence of malnutrition
Kissinga     n=15
Mago n=15
Nkondo n=15
Ikuwo
 n=15
Ikete n=15
Maliwa
n=15
Inadequate food in household
ü  


ü  
ü  
ü  
Low Income

ü  
ü  
ü  
ü  
ü  
ü  
Drunkedness on the part of parents
ü  
ü  

ü  
ü  
ü  
High women
Workload

ü  
ü  
ü  
ü  
ü  
ü  
Lack of nutritional knowledge
ü  
ü  
ü  
ü  
ü  
ü  
Seasonal variation on accessibility of certain foods
ü  
ü  
ü  
ü  
ü  
ü  
HIV/AIDS
ü  
ü  
ü  
ü  
ü  
ü  

Source: UNICEF Supported Formative Research, November 2006

Inadequate food in the household

Inadequate food in the households was observed to contribute much to poor nutrition status of majority of children in Makete District. Over 80% of District management team, CORPS, Extension and VEOs stated this as a cause of malnutrition to young children in their District. They said, household food insecurity is a major problem in our district. As majority of people depends on their agricultural produce, they tend to consume what is available. This resulted to inadequate and un balanced food to family members particularly children. Some foods become too monotonous to children and some times refused to eat as a result of malnutrition. This was observed more in high incidence area of malnutrition (Maliwa and Ikete).Leaders from these villages depicted that, “due to inadequate food in many households, most of children suffer from kwashiorkor and marasmus”.

 Seasonal variation in the accessibility of certain foods

Seasonal variation in the accessibility of certain foods contributes to food insecurity in households, as results children will lack adequate and variety of food to nourish their body. Many women do have adequate information on appropriate feeding which is crucial for the healthy growth and development of the young children[9].But due to seasonal variation most families tend to feed their children foods which are available without considering its nutritional value. As a result they tend to consume similar type of food for long time and it’s become too monotonous for children. Results from table 5.3 showed that, respondents from all six villages complained to this as a constraint during provision of complementary food to their children. For stance, during structured and un-structured observation, most of families were observed to consume boiled potatoes and stiff porridge made with potatoes flour with green vegetables commonly known as usuge because it was a season for Irish potatoes. In nutrition point of view, that person gets only carbohydrate and some vitamins but they lack other macro nutrients like protein and fat.

It was further observed in quantitative survey when mothers of children with less than five years asked to list typed of foods they normally use. The response was as follows;

We normally eat all foods which are available for example this is a season for Irish and sweet potatoes thus we ate potatoes every day. For example, we ate stiff porridge made with Irish potatoes and green vegetables last night and we are eating the same kind of food this afternoon. This is because it is the only food available in this season. . [Mother from one household visited in Nkondo village].

We eat a lot of vegetables this time because majority of people planted and now it is the time for harvest. Even in the market its price is reasonable everyone can afford but during the off season we real suffer. We had plenty of cassava, sweet potatoes and Irish potatoes because it is its season”. [Mothers from Kissinga and Mago Village]

 Low income

Low Income was found to be a major constrain for improving child care and feeding practices in all surveyed villages in Makete District. It was not only in sighted in high incidence of malnutrition areas but also in medium and low incidence areas. Research findings indicated that, majority (92%) of the mothers with children below the ages of two years and their spouses were farmers. In addition to farming some men in low incidence areas of malnutrition, were involved in timber production, masonry and carpentry at the rates of 5%, 2% and 1% respectively as indicated in Table 3.28.  Few mothers (30%) in Kissinga village were involved in petty trade and other small business. This help to raise their standard of living, thus low incidence of malnutrition compared to other villages. Areas with high incidence of malnutrition (Ikete and Maliwa) seem to be occupied with farming activities and not to have any other economic activities. This might be a reason to why Ipepo ward had higher incidence of malnutrition than Lupalilo and Ikuwo wards.

Moreover, mothers of children under 2years (FGD) when they were asked to mention constrains in provision of complementary foods to their children, they responded as follows:

We had adequate information about child feeding given by health care workers when we attend clinics. The problem is capital since almost all nutritious foods are expensive. For stance meat, eggs, cow’s milk, fish and cooking oil. Without money you cannot afford to purchase those foods. We thank you very much our health workers, they teaches us well, but when we come back into really life situation it is difficult to practice all”. [Mothers with children under 2years FGD in Mago and Nkondo]

 “We are from families with low income thus we failed to buy enough foods for our children. Majority of us are farmers and we don’t have any income generating activity where we can depend on source of money. We just use the little amount we get after selling our produce then we buy some of basic needs. We can buy sugar at least children could drink porridge with sugar as most of the time they eat porridge without sugar/butter/milk”. [Maliwa]

“We can not afford to buy sugar, eggs and lishe flour due to low income status and we depend on production of food (crops). But we failed sometimes because those crops for example maize needs fertilizers the soil is exhausted”. [Old men- Ikuwo and Nkondo]


Less capital contributes to a lot of family problems. Sometimes we failed to go to church or clinics because our clothes are dirty. We fail even to buy a piece of soup for washing clothes. Life is for sure terrible”. [Ikete]

“The economic status of many people in this area is extremely poor; in such a way that they can not afford to buy good food, paying for the good health services, buying clothes for their children and so many others”.[Key Informants-Ikete].

“Low income which results from low production of food crops such as maize, millet, and fruits forces us not to have enough food crops to feed their children till the next harvest. We also argued on lack of fertilizers to increase our food productions”. [Old women-Maliwa]

This constrain was observed also during in-depth interview with mothers with children under two years. When asked if they change the mode of feeding to convalescence child, most of they reveled that; “A convalescing child was fed the same food as a normal child. There were no changes we made in food pattern because we don’t have money to buy nutritious foods for them.”[Mago and Ikuwo In- depth interview] See box 5.1
.
Poor distribution of food in the family

Food distribution in the household determines the amount of food intake by every household member. If each member consume adequate amount of food, he/she will have adequate recommended daily allowance to meet their body requirements. During FGD with old women when asked who eat first in the family, the response were as follows;

“Normally father eats first with male children and then mother and female children follow”. [Ikuwo and Mago]

“Father starts to eat always followed by mother and then children eat last”. [Maliwa, Ikete and Kissinga]

“Father eats first followed by children lastly mother”. [Nkondo]


At the same time when old women kindly to state the distribution of food in the households they mentioned;

“There is no distribution of food, boys eat with father and girls eat with mothers”. [Maliwa, Ikete ,  and Kissinga]

“Mothers eat with children and both girls and boy eat together and sometimes they share the same plate”. [Mago]

“If it is time for eating, the whole family sits together but everybody eats in his/her own plates. But sometimes we save food for girls and boys in their separate plates.”[Ikuwo]

From the research findings, children are the one who eats lastly. This may result to inadequate food intake to meet their body requirements. Therefore, communities should change their attitudes towards food distribution. Children should be considered first as they need adequate nutrients for their growth and development.

Heavy women workload:

Despite of having relevant current up to date information on how to take good care of their children, yet there is inadequate breastfeeding and care for infants/young children of heavily working mothers. There are social and cultural aspects of women’s lives in Tanzania particularly in rural areas, as in many other countries which put a great deal of strain on them. The strain is most visible physically as a result of the work burdens they carry and the children they bear, breastfeed and care for[10]. Care provided to children in all its manifestation is directly affected by the workload and time constraints of the attending caregiver who are mostly women. Women workload result into inadequate time for feeding young children during the first two years which is the main cause of malnutrition. Women are often the main food producers and undertake a disproportionate amount of work in rural arrears of Tanzania. This burden in combination with their limited control of over household assets and resources typically places them under enormous strain. Such strain prevent them to practice good care and feeding to their children including good hygiene practices. In most surveyed families the work load are left for the women, and the fathers spend most of their time at the local pubs. This led in a heavy and compressed routine for mothers in other responsibilities rather that taking good care of the child which is also her responsibility. This was found in all researched areas i.e. high, medium and low incidence of malnutrition, since women were complaining to fail to practice good hygiene practice to their children.

We really don’t have enough time to ensure cleanliness to our children. As we wake up early try to prepare something foe breakfast quickly and then we go to the farm. So how can we manage to ensure good hygiene to our children? You can see most of children are dirty, with a lot of mucus in their nose, worn dirty clothes and many more. All these are because of limited time we have to look after them.”[Mothers with children under 2 years during FGD-Nkondo Village]

A high workload on the part of women has been found to be detrimental to the health of a young child. This is particularly true during the farming season when mothers are forced to leave the child to the care of an elder sibling who may not observe the feeding portions and the hygiene required. This hinder that woman to practices better child care and feeding practices as she will try to accomplish other  tasks within a shorter time even though some will not done effectively then they went to the farm.[11]It was observed that, majority of women spend 5-12 hours in the agricultural activities during farming season. When asked why they spend such long time they said;

“What can we do, we all depends food from crops we cultivate. If you spent less time in the farm then you will end up with little harvest. Then what shall we and our children eat?”[FGD and In-depth interview_Ikuwo and Nkondo villages]

In addition to the time spent agricultural activities women from Makete District reported that, they are responsible for other key household tasks (fetching water and fire wood, preparing foods, etc) as well as for many other productive and remurative activities. These women will try to accomplish all these tasks per day some will not be done effectively. Information from those women during focus group discussion yields several interesting insights about the relationship between women’s workload and child care. Women from Nkondo, Kissinga, Maliwa and Ikuwo villages stated that; heavy demands on their time for agricultural activities limit time available to properly care for their children including good hygiene and feeding practices.  Refer to box 5.2

The need to work outside the home.

Research findings showed that, generally women (mothers) in Makete district spent more (90%) of their time on economic activities than in caring for their children. About 60% of the mothers with children below the age of two years who participated in the in-depth interview and focus group discussion  said that, they spent 5 to 8 hours on economic activities (mainly farming), while some 30% claimed to spend 9 to 12 hours. This may result to poor childcare practices as they left some older children (2-4 years) alone at home and then took young child in the field. They work in field while they carry or sit their babies beside. During lunch time, they breastfed and eat together the little amount of food they have. For the case of older children they eat the leftover until when their mothers are back from field. This is not good since children needs supervision while eating in order to ensure they eat enough food. To ensure adequate intake of food for these children, depends on how faster the child she/he is when eating with others. Some eat slowly while others eat faster as a result inadequate intake of food to some children. The implication is that mothers hardly have limited time to breastfeed and care for their children properly. It is obviously that, mothers who are overloaded with work are likely to have less time to spend for caring young children. Thus, their children are likely to suffer from malnutrition. It was further observed in focus group discussion with District management team that “engagements of mothers in their agricultural activities reduce their time to take care of their babies. This result to increased number of malnourished children aged 2-4 years in our community”. [FGD-DMT] Refer to table 5.3

Table 5.3        
Constraints to good hygiene practices N=60




Constrains
Low incidence of malnutrition
Middle incidence of malnutrition
High incidence of malnutrition
Kissinga
n=15
Mago
n=15
Ikuwo
n=15
Nkondo n=15
Ikete n=15
Maliwa
n=15
Poor access to water sources.
ü  
ü  



ü  
The need to work outside the home.

ü  
ü  
ü  
ü  
ü  
ü  
High workload to mothers
ü  
ü  
ü  
ü  
ü  
ü  

Source: UNICEF Supported Formative Research, November  2006

Poor accessibility to clean and safe water.

Presence of portable water close to the homesteads has close association with better nutrition among the under-fives. Since it facilitates better hygiene and reduce workload on the part of women since they do not have to walk far in search of water. Poor access to water is an obstacle to children and women achieving good health outcomes. Inaccessibility to water services is detrimental to the survival and growth of children. Poor water and sanitation facilitate the occurrence of the most common infectious and morbidities among children. Based on government data, clean and safe water is available to 53% of the rural and 73% of the urban
population, but disruptions of supply do occur[12]. Data from Makete District Water Department, 2005 showed that; available water in Makete District is inadequate both in terms of quality and quantity. On average 9,970 households have access to tap /gravity water while 11,242 are accessible to streams/rivers. The average population with access to clean water is 48%. Thus, the majorities of Makete residents has no access to tap water and, as a result, rely mostly on stream and rivers which are unfortunately unsafe.

During transect walk and in structured and un-structured observation when research participants were required to observe the accessibility to clean and safe water for domestic use, results were as follows, Majority of people (52%) had access of water from river and streams for domestic use. This comprise of people with low and medium incidence of malnutrition (Lupalilo and Ikuwo wards) respectively. About 49% of people in high incidence areas (Ipepo ward) have good access to clean water from taps. Distance to water and time taken to fetch may contribute to poor hygiene practices particularly cleanliness of the children in of children in low and medium incidence areas (Kissinga, Mago, Nkondo and Ikuwo). Refer to table 5.4

Table 5.4
Accessibility to clean and safe water for domestic use N=60

Researched Area
Kissinga
[n =10]
Mago
[n = 10]
Nkondo
[n =10]
Ikuwo
[n =10 ]
Ikete
[n = 10]
Maliwa
[n = 10]




Total


Total in %
incidence of malnutrition
Low incidence areas
Middle
incidence areas
High
incidence areas
Tap
4
5
4
3
7
8
29
49%
River and streams
6
5
6
7
3
2
31
51%

Source: UNICEF Supported Formative Research, November 2006

Poor access to Health Services: 

There are  number of obstacles in accessing health services, including health care charges and long distances to the location of services, poor transport systems, poor quality of care and poorly implemented exemption and waiver schemes meant to protect the most vulnerable and poor people. Although maternal and child health immunisation services are exempted, other services example if the child is sick with malaria, the cost of malaria drugs has to be borne by the parents, most often by the mothers most of who may be poor. Moreover, women lack of control and decision making power over, the use of resources in the household makes it more difficult for them to access medical services[13]Children may not be treated properly when they become sick because many families do not have access to health facilities, or, even if they do, do not seek care regularly.  When mothers with children under five years were asked if the health services in their community is adequate they said;

The heath centers are few and even those few allocated very far away from our residence.
Also the services we get from these centers, (small dispensaries) are inadequate in the sense that they lack necessary equipment and supplies like laboratory equipments and its supplies. Some times you may find that, the child is sick from malaria and when you send him/her to the nearby dispensary, what they did I just to check the body temperature. When you ask why, they said there is no other laboratory instrument for further check up. After being told so they we shift to Ikonda hospital which is very far from here. [Kissinga-In-depth interview]

“I remember my first born got fire accident; she was bunt on her backside when she was playing with her friends near by a pot with boiled water. After sent her to Lupalilo hospital they referred us to Ikonda hospital with reason that, at Ikonda we get good services than that we can get from them. [Mago]

“For sure our healthy facilities need to be improved. First of all in terms of quality of service and their numbers. As you can see, we living in rural areas we need health services day and night. Because of those facilities being located far from our residents, sometimes mothers may deliver at home which is very dangerous”.[Key informants-Nkondo village]

“No enough health services in our village, for stance measurements and other instruments. There is only Thermometer. No registration cards, thus we are demanded to recall the last dates we attend to that dispensary. This sometimes results into delay to get treatment to most of the patients.” [Ikete]

Cost of treatment in terms of buying medicines was ranked as the most serious problem in their areas. This was observed during Focus group discussion made with key informants from different Villages in Makete District.  Consequently, quality of health services is extremely poor in all surveyed areas and they are forced to travel to better equipped hospitals located far away. Refer box 5.4

Un health environment and poor hygiene practice

Results from Structured and un-structured observation in all six villages in Makete District showed that, unhygienic practices are likely to be the cause of number of diseases including cholera, diarrhoea, respiratory infections and other. Many children were extremely dirty with a lot of mucus in their nose and wore very dirty clothes. Environmental sanitation was not so bad but due to poor construction of houses some areas were not clean. The situation differs from Temeke Municipality as almost all areas were dirty with a lot of solid waste spread in the streets. Poor hygiene practices observed in this District is due to poor economic status. Many families their houses were of low quality thus poor storage facilities. They store cereals in plastic bags, sucks and in buckets. For the case of food remained after eating, they just leave it on the pots nearby fire. For example in low incidence area [Kissinga] other houses were grass thatched, so during rain they leak and pollute the hygienic environment. In areas with medium incidence of malnutrition [Nkondo] research participants came across one household where rats were eating in the food kept in a pot and at the same time mother came and start feeding the child that food. Possibility of contamination to occur is great as environment which is not clean can be good area for insects and vectors to reproduce.

Moreover, mothers in Low incidence areas mentioned opportunistic diseases make them weak thus fail to clean their houses and general environment. This is what we research participants observed in some houses where utensils were not washed they were just kept outside the house.  Toilets were not clean despite of being of poor quality and they are very close to the house in all areas. Personal hygiene was not practiced thourally. For example, hand washing before and after eating was found to be common across areas low incidence of malnutrition. This was much lower practiced in medium and high incidence of areas malnutrition (Ipepo and Ikuwo) e.g. after defecation or after attending a child who had defecated. Food was not prepared in hygienic condition. This was observed in some areas of medium incidence [Nkondo] where mothers just cook food in dirty pots; they just pour some water and rinse partially then put something and starts cooking. Also they save meals while children sit on the ground with a lot of dirty utensils around. Animals were kept in the same house where people sleep. Table 5.5 summarize these results.

Table 5.5
Hygiene Condition [N = 60]

Researched Area
Kissinga
[n = 10]
Mago
[n = 10]
Nkondo
[n =10]
Ikuwo
[n =10 ]
Ikete
[n = 10]
Maliwa
[n = 10]
Incidence of malnutrition
Low incidence areas
Middle
 incidence areas
High
incidence areas
Long grasses around the house

ü  
ü  
ü  
ü  
ü  
Cleanliness of areas surrounding the houses were not satisfactory

ü  
ü  

ü  
ü  
Poor storage facilities
ü  

ü  
ü  
ü  
ü  
Toilets were not clean and were poor quality
ü  
ü  
ü  
ü  
ü  
ü  
Poor personal hygiene
ü  
ü  
ü  
ü  
ü  
ü  
Poor storage of cooking utensils
ü  

ü  
ü  

ü  
Animals were kept in the living house
ü  

ü  
ü  
ü  
ü  
Total
5
4
7
6
7
7

Source: UNICEF Supported Formative Research, 2006

 Poor practices in feeding the child nutritious foods.

Despite of efforts made by health workers in providing nutrition education to some women, yet majority of mothers in surveyed areas were not feeding their children nutritious food due to low income status. Most of women are taught in the clinics how to feed the child nutritious food but they don’t do that due to poverty and heavy workload. They just acquire that knowledge on how to prepare and feed the child nutritious food and less practices in really life. This was observed to be a factor which causes malnutrition to people particularly children in researched areas. Box 5.5 indicates the response of mothers during focus group discussion about causes of nutrition problems in their societies.

Further more, when asked what are the good healthy behaviours mothers should practices to ensure good health status of the child; they revealed that, “to ensure hygiene and cleanliness of the child including to bath him, frequently, to feed him with clean food, to make sure the child sleeps in a clean environment, to prepare foods in clean environment and to feed them fresh and nutritious foods.”[Kissinga]. This is to prove that they know but circumstances make them unable to practices that.  District planning Officer added that; nutrition status of children changes from year to year. For example last year Matamba ward had plenty of food yet the children were malnourished. It was observed that, mothers had high workload therefore had no time to feed their children frequently as is required.

Taboos and superstition in food consumption.

Traditions and cultural believe on caring practices sometimes are good and contribute to good nutrition. But some traditional and cultural practices have contributed more to erosion of good child caring practices thus malnutrition and inappropriate caring practices. Some people refuse to consume certain types of food due to local believes and their taboos. This may contribute to nutrient deficiencies which resulted to several nutrition problems such as, anaemia to pregnant women, toxaemia, premature birth, neural tube defect to infant, low-birth weight and other neurological defect to infants. For example in some culture pregnant women are restricted to eat certain types of foods such as eggs, fish and offal’s[14]. Results from research stipulated difference answers from old women during focus group discussion.

It is forbidden for men to go near a nursing mother until the child is 2 years old.[. In the past  married men were forbidden from making fire for their wives or even to touch anything be it food item or whatever which has been in contact with a wife who has a newly born child until one  month after delivery  and a cleansing ceremony is performed. This taboo is not much practiced nowadays. A woman is forbidden from slaughtering a goat A woman who has given birth is restricted  from bathing until after 3 weeks and before that she is not allowed to getting in contact with other family members.”[FGD with old women -Ikete and Maliwa]

We believe that the best first food for a young child soon after birth is maize porridge because it is light and easily digestible”. [Mago and Ikuwo]

“Pregnant mother from six month to delivery is completely prohibited to do any heavy task. More over they belief that activities such as to giving bath to a baby, chopping and fetching fire woods, fetching water remain to be the women’s works. If at any particular moment a man is seen to do any of these jobs, the whole clan belief that he has no say to his wife”. [Old men- Kissinga and Nkondo].

Majority of mothers in all villages believe that foods like Irish and Sweet potatoes, Boiled rice, Millet/Wheat Stiff Porridge, and Makande are not good for the heath of the young children. The reason being the child will get diarrhea or constipation. There was some believes observed in consumption of food by pregnant mothers. See table 5.6 bellow.
  
Motivations for Improving Child Feeding Practices

No one changes established behavior patterns without a good reason. The strongest and most universal motivation for improving child feeding practices is, of course parents’ desire to do what is best for their children. But motivations are complex, with a basis of psychology, belief and emotion, not just knowledge in scientific facts[15]. Because motivation is critical to effective communication strategies and messages, formative research must not neglect these issues. Motivation may also include personal beliefs about benefits or personal aspirations, or it may reflect the influence of others who are important sources of information or support. The following are possible motivations and influences:

 Parent’s aspiration to their children.

This includes hope and dreams do parents have from their children in the future. Almost all societies value children and that wish to see children grow to be healthy, intelligent and productive adults.  Results from table 5.6 shows different aspirations do mothers have in the future. In the focus group discussion, mothers from high incidence areas said “We hope our children will grow well, healthier, thus they can help us when we get old and grow our clan name”. On the other hand, mothers from low incidence areas [Lupalilo] stated that; “We wished and hope that our children to be healthy, to study hard in order to be educated and grow up so that they can help the parents with house duties. In addition, people from medium incidence areas hope their children to study in order to become drivers, doctors and teachers.

 Parents’ images of themselves and their roles in caring for the child.

The role of caring for children is the responsibility of both parents. This should not be left just for women as they have so many tasks to do at home. They need assistance from their husband and other family members. Fathers/husbands can support their wives in so many ways. For instance, assisting in ensuring adequate amount of food in the family, escorting wife to clinic during pregnancy and after delivery, treatment for children, cook foods, bath the child, wash clothes, and other agriculture activities. By so doing women workload will be reduced and mother can have enough time for caring the children. However in our culture, caring for children remained to be women’s role.

In the focus group discussion with old women when asked what responsibilities do parents have to their children, responses  were are follows, see box 5.7.

On the other hand, old men revealed to support their wives in taking care of children including ensuring availability of food in their households and taking children to hospitals.” [Ikuwo] “Some time we feed the child if mother is not around or is sick.” [Ikete] “We normally provide shelter, clothes, food, taking children to hospital, cooking and taking care of children when mother is not around.” [Kissinga] “We provide financial support to our wives”. [Maliwa].

  Activities conducted to improve nutrition status of community members.

The following are some other activities conducted in improving nutrition status of community members particularly children in Makete District.

Village Government:

  • They encourage household members to keep small livestock’s e.g. goats, pigs and poultry, thus increase access of protein rich foods in the family.[All villages]
  • They encourage each house hold to improve food crop production so as to have adequate food i.e. self sufficiency in food with all nutrients. Improve timber production and sale so that people will earn more money to meet other family needs including food.[All villages]
  • Vegetable gardening (mobilization)- [Ikete]
  • Encourage people to conduct small business. [Kissinga]
  • They encourage villages to purchase oxen (animal driven ploughs).- [Ikuwo]
  • They support most vulnerable children in cultivating their farms and contributed money (100 Tshs. Per each household) for them to buy essential foods and other items.-[Mago]
District Management Team:

  • They distribute micronutrients such as Vitamin A, Folate, Iodine
  • De- worming ( by providing antihelminthic medicines)
  • Monitoring of food security especially in children headed households.
  • Provision of improved seeds ( cereals and vegetables)
  • Provision of bulls and cocks of good quality.
  • Education of food preservation and storage, they have succeeded with 8 wards so far.
  • They conduct community level advocacy meetings on household food security.
  • Conduct participatory study on bets storage facilities, and Training of farming communities on food preservation skills but these is carried over to next year 2007 under CSPD program.
 Criteria used in planning nutrition development activities.

Criteria used in planning and directing nutrition development activities include; selecting and gave first priority to areas where malnutrition is more acute. Also areas with many most vulnerable children. By using clinic records (growth monitoring cards of children) to identify areas with many malnourished children. Further, more efforts are directed to areas with poor environment sanitation. They also gave priority to areas where the specific need was more acute. E.g. areas with less harvest they provide improved short-term seeds.

 How far have they reached in implementing those activities?

At District Level:

  • They have distributed improved seeds and fertilizers to most vulnerable children areas.
  • They have distributed improved breed of bulls and cocks to eight wards and dairy goats to eleven villages.
  • Heifer Project international has distributed improved breed of cocks to every village in this district.
  • Five wards have started production of improved maize, beans, onions and tomatoes this season since they used improved seeds distributed.
At Village level:

  • Regarding food self-sufficiency, forty one [41] households have completed digging trenches (mashimo) for demonstration farming with the support of CARITAS.
  • Six households have received demonstration pigs and timber production activities have been improved and sales continuous.[Kissinga]
  • They are continuing with contributions of one hundred shillings for supporting most vulnerable children in this village.[Mago]
  • Until now there are three animal ploughs in use.[Ikuwo]
  • Have started with implementation and are making good progress.[Nkondo]
  • They have sent their request for Dairy cows to TASAF.[Maliwa]
  • Nothing has been implemented.[Ikete]
What is needed to be implemented by Government and Agencies?

From Government:

  • To supply agriculture inputs and subsidize the prices of fertilizers and seeds.
  • Funds to facilitate seminars and training of extension workers.
  • Funds for salaries of health workers and for buying medicines.
  • Starting capitals for establishment of loans (SACCOS)
  • Refresher courses  for all extension staff on nutrition
  • Provide funds for follow-up of households that have poor nutrition status.
  • To employ a District Nutritionist.
  • To provide a special vehicle for nutrition activities. E.g. for training and follow-up (AIDS/LISHE projects).
 From Agencies:

  • To reduce price of their products e.g. fertilizers and seeds
  • To provide loans for ploughs
  • To provide lishe flour for most vulnerable children.
  •  Assistance in acquisition of Dairy cows.
  • Training on Food Preservation including Packaging and machinery used. 
Obstacles that prevent activities planned for improving child care and feeding practices.

During focus group discussion with key informants stated the following obstacles in their which they face in their villages. Problem of poor economic status was stated by key informants in all villages despite of having different rates of malnutrition. Poor access to clean and safe water was stated by people in low and medium incidence areas. [Mago, Kissinga, Ikuwo and Nkondo] Results further showed that there was no significance different in applying nutrition knowledge about child feeding received from health workers in all areas. This was mentioned by key informants from surveyed villages as a contribution factor to malnutrition to their children.

Inadequate number of schools and its facilities was further revealed by key people in Kissinga, Ikete, Maliwa and Ikuwo. They added that, in some villages schools are constructed very far from their residents and children are supposed to walk for long distance to reach their schools. For example, during rain season only few students who live nearby schools are capable to attend school. This contributes to some extent the increased number children who drop-out the school and big burden of un-educated person in our community. Poor infrastructure system was also mentioned, that, many problems are encountered by poor roods. They said; “we normally walk to very long distance to seek for services like market, hospitals, etc. For stance in this ward (Ikuwo) we do not have good roads to reach Makete town, if we want to go to that place we either use our Donkey or walk. Normally donkeys help us much e.g. to carry big luggage’s of commodities like maize, wheat, beans and many more to the Makete market.

Moreover, Lack of nutrition expertise is another obstacle in this District. This was revealed by District Management Team that, some nutrition planned activities delays due to lack of Nutritionist in their Council. Lack of agricultural inputs such as fertilizers for crops was also mentioned by Village Government Council in low, medium and high incidence areas of malnutrition. They said, “we have requested the government to subsidize price in fertilizers, seeds and others Agriculture appliances inoder for us to afford the cost. We requested TASAF to support us to get dairy cows of good quality but they do not reply. In addition Village leaders in Kissinga said, fertilizers are sold at a high price e.g. 50kg bag costs 35,000 Tshs.Livestock fodders (concentrates) is expensive. Also requested fertilizers from the government delays thus should be used in next season. [Nkondo] These results are summarized in table 5.7.

Table 5.7
Obstacles exist in the villages


Incidence of malnutrition
Low incidence area
Middle incidence area
High incidence area
Total
Kissinga
Mago
Nkondo
Ikuwo
Ikete
Maliwa

Poor economic status
ü  
ü  
ü  
ü  
ü  
ü  

Lack of nutrition expertise.
ü  
ü  
ü  
ü  
ü  
ü  

Inadequate number of schools
ü  
ü  





Problem of electricity
ü  






Poor infrastructures e.g. roods


ü  
ü  
ü  
ü  

Inadequate healthy facilities
ü  
ü  

ü  
ü  
ü  

Poor access to clean  water

ü  

ü  
ü  
ü  

Problem of HIV/AIDS

ü  

ü  
ü  
ü  

Lack of agriculture inputs
ü  
ü  
ü  

ü  
ü  

Poor quality of Houses




ü  
ü  

Poor access to market


ü  

ü  


Health facilities are located far from people’s residence




ü  



Source: UNICEF Supported Formative Research, 2006

 Observed opportunities for improving child care and feeding practices.

Research findings showed some opportunities in Makete District which could help to improve child nutrition status. Results from table 5.7 shows that, private dispensaries (Mission) were stated to be an opportunity to people with low incidence of malnutrition [Kissinga and Mago]. This help community member to get free health services (MCH) for their children and their mothers. Good access to water sources (tap and streams) was observed to reduce workload for majority of women in high incidence areas [Maliwa and Ikete] as compared to areas with low and medium incidence malnutrition [Ikuwo and Lupalilo wards]. This might be one of the reasons of poor hygiene condition to children in those areas.

Good access to market helps people of Kisinga, Ikete and Maliwa to get foods for family members, particularly children. Also they get an opportunity to conduct some small business in that market as majority of people had low income status. Moreover people in medium [Nkondo] had Art groups for educating the society and discover unknown problems exist in their community.  Small business activities conducted in low and medium incidence areas helped people to increase their income and meet some of their basic needs. Despite of both having high incidence of malnutrition, people from Maliwa was observed to have many opportunities compared to Ikete. For stance; good access to healthy facilities. Livestock keeping was also an opportunity for many families to get milk for their children. Not only milk but also manure for crops, meat, and money for other family needs if they will sale their animals. Refer table 5.8 

Table 5.8
Opportunities for Improving Child Care [N=35]


Response
High Income earners
Middle Income earners
Low Income earners

Total
Kissinga n=7
Mago n=6
Nkondo n=4
Ikuwo n=6
Ikete n=6
Maliwa
n=6
Private dispensaries
ü  
ü  



ü  
3
MCH-clinics
ü  
ü  



ü  
3
Schools (nursery, primary & secondary)
ü  
ü  
ü  
ü  
ü  
ü  
6
Good access to  tap water


ü  

ü  
ü  
1
Arts groups


ü  



1
Fertile land for agricultural activities.
ü  
ü  
ü  
ü  
ü  
ü  
6
Small business
ü  
ü  

ü  
ü  

5
Good access to market
ü  



ü  

2
Forest
ü  

ü  
ü  
ü  
ü  
4
Livestock keepers
ü  
ü  
ü  


ü  
4
Human resources



ü  




Source: UNICEF Supported Formative Research, 2006
  
Number of extension workers in supporting planned nutrition development activities.

When asked how many Extension and Community health workers are present in their villages and how they assist them in nutrition issues response were are follows; there were many extension and health workers in low and medium incidence areas compared to areas with high incidence of malnutrition.[Ikete and Maliwa] . This might be a reason of increased malnutrition problems in Ipepo ward and fewer problems in Lupalilo and Ikuwo wads. Refer table 5.9
Table 5.9
Number of extension and community health workers and
how they assist on nutrition related issues. [N=36]

Researched areas
Kissinga
n=6
Mago
 n=6
Nkondo n=6
Ikuwo
n=6
Ikete
n=6
Maliwa
n=6
Incidence of malnutrition

Low incidence of malnutrition

Middle incidence of malnutrition

High incidence of malnutrition
Number of extension and health workers present

5

5

4

6

2

0

Source: UNICEF Supported Formative Research, 2006

From the in-depth interview when mothers with children less two years asked to explain how do village healthy workers/extension workers  support them in nutrition activities they revealed that; “They help in monitoring children growth by measuring weight. They also gave us techniques on good child feeding practices especially parents whose children fall under red or grey in children clinic card. [All villages] In low incidence area [Kissinga] they make follow-up on environmental condition under which children who marked red on their cards so as tom know what the causes are. In addition to nutrition education we get in the clinic, extension workers mobilize farmers groups and provide basic education on farming. [Mago]. In medium [Nkondo] and high incidence areas [Ikete and Maliwa] children also received vaccination from health workers, such as measles and Vitamin A. Provide statistics for children requiring supplementation and Sensitization the community on proper child care. Tables 5.8 summarize these results.

Table 5. 8       
Support mothers get from health/extension workers to improve nutrition status of children. [N=60]

Researched areas
Kissinga n=10
Mago n=10
Nkondon=10
Ikuwo
n=10
Ikete
 n=10
Maliwa
n=10
Level of income.
High income earners
Middle income earners
Low income earners
Response
ü  
ü  
ü  
ü  
ü  
ü  
Nutrition education i.e. advice on proper ways of feeding the children
Health education and counseling to mothers on Family planning.
ü  
ü  


ü  
ü  
Basic farming education.

ü  



ü  
Child growth monitoring


ü  
ü  
ü  
ü  
Vaccination to children


ü  

ü  
ü  

Source: UNICEF Supported Formative Research, 2006

Kind of support District Management Team and Village government leaders requested.

When thinking of what kind of assistance do they need in order to achieve their goals on nutrition activities, District management team came up with the following insights;
·         Support to establish food preservation factories.
·         Facilitation of nutrition, food preservation and storage education.
·         Improve small livestock production through increase distribution of cocks.
·         Continue with provision of Agriculture inputs and supplies but at subsidized prices.

On the other hand, village government leaders said;

  • Provision of education on good nutrition, livestock husbandry and modern agricultural techniques.
  • Assistance for most vulnerable children for food, medical expenses, education, clothing and housing. [Kissinga and Ikuwo]
  • Agricultural inputs supplies e.g. fertilizers, improved seeds (maize, beans, potatoes and sunflower).
  • Loans for running income generating activities.
  • To establish a centre for orphan children.[Mago]
  • Build hospital so that they can have good access to healthy facility.
  • To improve transport system.
  • To have electricity [Nkondo]
  • To establish Dairy and poultry project.
  • To improve health services since they have one dispensary and there is no doctors only nurses.
  • Irrigation scheme during dry season.[Maliwa]
  • Improve piped water system to prevent breakage and wastage of water.
  • Help to control vermins like baboons and monkeys who destroy crops.[Ikete]
Support Village Health Workers get from District Management Team

Village health workers need support in order to provide their services effectively. They need advices and working facilities so that they can provide good services to the community. During focus group discussion with District Management Team (DMT), they include the following supports;

  • Exempts VHW from other Community development activities so that they can get enough time to provide health services.
  • Provide them with working gears such as weighing scales, bicycles, report forms etc.
  • Provide seminars in order to improve their knowledge.
  • They are given some token money (Tshs. 10,000) per month as motivation.- in some villages
  • Advice from Medical Assistants and vaccines from District hospital staffs
  • Emphasize village chairpersons, VEOs, and health committee to give them moral support and cooperation. Here Village leaders are encouraged to work closely with ward/village health workers.
  • They are also exempted from paying development contributions.

[Extracted from a report titled “Field Research Summary on Child Care and Feeding Practices in Makete District.” The study was carried out by a team from GAD Consult in November 2006.]
References
    
1.                  National Guideline on Infant and Young child feeding, Ministry of Human Resource Development. Department of women and child Development (Food and Nutrition Board), Govement of India 2004.
2                        World Health Organization (WHO), 1999. IMCI Information, Integrated Management of Childhood Illness, WHO/CHS/CAH. Geneva: World Health Organization. 2001. World Health Report.
3.                               Temeke Municipal Council Environmental Profile, 2005
4.                               BASICS Nutrition essentials. Forthcoming
5.                               TFNC, A Study Report on Infant Feeding Practices in the Context of HIV/AIDS. TFNC Report no 2026, July 2006.
6.                               URT, Poverty and Human Development Report 2005, page 37
7.                               UNICEF/WHO. Joint nutrition support programme in Iringa, Tanzania, 1993-98. Evaluation report. New York: UNICEF, 1998
8.                               UNICEF. Strategy for improved nutrition of children and women in developing countries. New York: UNICEF, 1998
9.                               TFNC, A Study Report on the relationship of eating frequency and caloric density to energy intake among rural children. 2002
10.                            Engle PL. Care and child nutrition. Theme paper for the International Conference on Nutrition. New York: UNICEF, 1992
11.                            http://wcd.nic.in.national_guidelines.html.
12.                            UNICEF. 2004. The Progress of Nations 1996.
13.                            Foy 2003, Cost Benefit Analysis of Nutrition Programme Interventions in Tanzania.
14.                            TFNC/UNICEF, Report on Low Birth Weight Baseline Survey. Prevalence of Low Birth Weight, Risk Factors for Low Birth Weight, and Levels of Service and Care Provision in Seven Districts Implementing Prevention of Low Birth Weight Project TFNC/UNICEF 2003.
15.                          Tanzania National Strategy on Infant and Young Child Nutrition Implementation Plans, 2004


[1] UNICEF/WHO. Joint nutrition support programme in Iringa, Tanzania, 1993-98. Evaluation report. New York: UNICEF, 1998.  
[2] National Guideline on Infant and Young child feeding, Ministry of Human Resource Development.    Department of women and child Development (Food and Nutrition Board), Govement of India 2004.
[3] TFNC. A Study Report on the relationship of eating frequency and caloric density to energy intake among rural children. 2002
[4] Engle PL. Care and child nutrition. Theme paper for the International Conference on Nutrition. New York: UNICEF, 1992.
[5] UNICEF. 2004. The Progress of Nations 1996.
[6] BASICS Nutrition essentials. Forthcoming
[7] Tanzania National Strategy on Infants and Young Child Nutrition Implementation Plan.
[8] Wise, Victoria et al, Knowledge, Attitudes and Practices on Child Feeding and Care, Preliminary Linkages between Child Nutrition and Agricultural Growth. USAID 2002
[9] http://wcd.nic.in.national_guidelines.html.
[10] URT& UNICEF 1990.”Child care and Development” Background paper prepared by Government of Tanzania and Unicef Dar Es Salaam. Task on Childcare.]
[11] UNICEF. Strategy for improved nutrition of children and women in developing countries. New York: UNICEF, 1998.
[12] TRCHS (Tanzania Reproductive & Child Health Facility Survey) 1999.National Bureau of Statistics, 2000. Dar es Salaam.
[13] URT (MOH), National Policy Guidelines for Reproductive and Child Health Services, May 2003.
[14] TFNC/UNICEF, Report on Low Birth Weight Baseline Survey. Prevalence of Low Birth Weight, Risk Factors for Low Birth Weight, and Levels of Service and Care Provision in Seven Districts Implementing Prevention of Low Birth Weight Project TFNC/UNICEF 2003.
[15] Foy 2003, Cost Benefit Analysis of Nutrition Programme Interventions in Tanzania