Caregiver parenting practices, dietary diversity knowledge, and association with early childhood development outcomes among children aged 18-29 months in Zanzibar, Tanzania: a cross-sectional survey.

BACKGROUND: Many children in low- and middle-income countries fail to reach their cognitive potential, with experiences before age 3 critical in shaping long-term development. Zanzibar's Jamii ni Afya program is the first national, digitally enabled community health volunteer (CHV) program promoting early childhood development (ECD) following the Nurturing Care Framework within an integrated maternal and child healthcare package. Using program baseline data, we explored home environment, caregivers' parenting, health and nutrition knowledge and practices, and ECD outcomes in Zanzibar. METHODS: We conducted a national household survey among 499 children aged 18-29 months using two-stage cluster sampling in February 2019. The primary outcome was child development score measured using the Caregiver Reported Early Developmental Index (CREDI), with higher scores representing higher levels of child development. We analyzed CREDI scores, along with MICS questions on parenting knowledge, practices, and characteristics of the home environment. We developed multivariate regression models to assess associations between caregiver-child interactions, knowledge of dietary diversity, and ECD. RESULTS: Ten percent of children had overall CREDI z-scores 2 standard deviations [SD] or more below the global reference population mean, with 28% of children at risk of developmental delay with z-scores 1 SD or more below the mean. Cognitive and language domains were of highest concern (10.2 and 12.7% with z-score < - 2 SD). In 3-day recall, 75% of children engaged in ≥4 early stimulating activities with all caregivers averaging 3 total hours of play. CREDI scores were positively associated with greater frequency of caregivers' engagement (ß = 0.036, p = 0.002, 95%CI = [0.014, 0.058]), and dietary diversity knowledge (ß = 0.564, p < 0.001, 95%CI = [0.281, 0.846]). CONCLUSIONS: Our findings demonstrate a positive association between both the frequency of caregiver child interactions and knowledge of adequate dietary diversity, and ECD outcomes. This aligns with global evidence that promoting early stimulation, play and learning opportunities, and dietary diversity can improve developmental outcomes. Further study is needed to establish causal relationships and assess the impact of ECD programming in Zanzibar.

Applying the Community Health Worker Coverage and Capacity Tool for Time-Use Modeling for Program Planning in Rwanda and Zanzibar.

Community health worker (CHW) programs are a critical component of health systems, notably in lower- and middle-income countries. However, when policy recommendations exceed what is feasible to implement, CHWs are overstretched by the volume of activities, implementation strength is diluted, and programs fail to produce promised outcomes. To counteract this, we developed a time-use modeling tool-the CHW Coverage and Capacity (C3) Tool-and used it with government partners in Rwanda and Zanzibar to address common policy questions related to CHW needs, coverage, and time optimization.In Rwanda, the C3 Tool was used to analyze 2 well-established cadres of CHWs and 1 new one. The well-established CHW cadres were within a "manageable" workload range whereas the new cadre was projected to achieve less than half of assigned activities. This is informing ongoing changes to the CHWs' scopes of work. In Zanzibar, the C3 Tool was used to update the national community health strategy to include community health volunteers (CHVs) for the first time and determine how many CHVs were needed. The tool projected that 2,200 CHVs could achieve approximately 90% coverage of all defined services. Based on these figures, Zanzibar updated its national community health strategy, which officially launched in February 2020.We discuss lessons from these 2 experiences. Translating analysis into decision making depends not only on the programmatic will and motivation of governments but also on finding opportune timing for when policy and program processes allow for optimization of CHW investments. Further research is needed but our experience supports the value of a modeling tool to ground program plans within estimated constraints on CHW time.