Community Health Workers' Targeting of Women For Health and Nutrition Home Visits in Rural Tanzania: A Mixed-Methods Study.

Background: Community health workers (CHWs) are utilized in many health systems to provide education and messaging to families in their catchment areas. However, CHWs responsible for large geographic areas often must make important decisions about whom to visit. Factors that influence these decisions are understudied. Objectives: This study assessed coverage and targeting for home visits by CHWs within a large social and behavioral change health program in rural Tanzania. Methods: This implementation research was a cross-sectional, mixed-methods study. Data collection included a census with households and surveys with females, surveys with CHWs, and interviews with CHWs. Survey data also included the collection of household location data for females and CHWs. Quantitative data were analyzed using linear probability models, and qualitative data were analyzed using inductive thematic analysis. Results: Only 13% of eligible households in our study sites reported receiving a home visit from a CHW. Although CHWs were more likely to reach households with infants, other program priority populations, such as poor and food insecure households, were frequently missed. Global positioning system data showed that distance was 1 of the greatest barriers for CHWs in providing home visits. Qualitative data indicated that although CHWs were motivated and engaged to improve maternal and child health in their communities, they faced challenges in visiting households that were further away or lacked economic resources to improve their health behaviors. CHWs also found it difficult to provide health education during home visits to mothers with no formal schooling. Conclusions: Programs relying on community volunteers need to set realistic workloads, especially when volunteer CHWs also work full-time in their primary occupations. Implementation could also be strengthened by providing extra support for CHWs so that they can effectively provide services to community members who are more difficult to visit but may be the most in need.

Gender differences in perceptions of "joint" decision-making about spending money among couples in rural Tanzania.

Family and cultural contexts can constrain the effectiveness of evidence-based interventions designed to improve the health and wellbeing of women and their children. Unequal power relationships within the household may underlie the failure of many programs targeting women to achieve their intended impact. To reduce these unequal power dynamics within the households, many programs or interventions aim to both assess and improve the gender dynamics between husbands and wives within the household. Decision-making is one important facet of these dynamics and has been linked to health outcomes for women and children. However, household decision-making is rarely observed and often difficult to capture. This study aimed to use qualitative research to further understand one aspect of decision-making, namely on how to spend money. In two regions of Tanzania, we used surveys and interviews to explore different perspectives on spending and allocation of resources among 58 couples in rural farming households. While many men and women initially reported that they made decisions jointly, most women stated they would often concede if there was a disagreement or argument around spending. These results highlight the different perceptions of joint decision-making between men and women. We compared these results to survey responses on decision-making and found differences within and between couples across interview and survey responses. Based on the differences in qualitative and survey responses within couples and how they reported dealing with disagreement, our study found households were on a spectrum from no cooperation in decision-making to full cooperation. Our results highlight challenges for assessing decision-making on spending and ultimately improving these decision-making dynamics within the household. These challenges are especially important for maternal and child behavioral change and provide insights on why many interventions aimed at improving women's decision- making power on money may not reach their full potential.

Does Crop Diversity Influence Household Food Security and Women's Individual Dietary Diversity? A Cross-Sectional Study of Malawian Farmers in a Participatory Agroecology and Nutrition Project.

BACKGROUND: Agroecological methods have the potential to impact nutrition and food security, however, to date there is limited research evaluating this approach. OBJECTIVE: A 5-year participatory research project with farming households in north and central Malawi was designed to train farmers on agroecological practices, alongside raising awareness on nutrition and gender equity. This cross-sectional study aimed to explore the relationships between crop diversity, food security at the household level, and individual diversity for women, within the context of an agroecology, nutrition education, and farmer mentoring program. METHODS: Participating farmers were trained in and experimented with different farming methods. These farmers subsequently trained other farmers on these short-term agroecological practices and provided mentorship using community-based educational methods designed to address both household food security and nutrition. In year 4 of the intervention, a cross-sectional survey assessed farm practices, food security, and individual dietary diversity of 851 participating households. RESULTS: Households with lower crop diversity were significantly less likely to be food secure (odds ratios [OR] = 0.829, P < .001). Women in households with higher crop diversity were more likely to have higher individual dietary diversity (OR = 1.120, P < .01), eat vitamin A rich foods (OR = 1.176, P < .01), and legumes, nuts, and seeds (OR = 1.141, P < .01). CONCLUSIONS: These findings suggest that within a participatory agroecological training combined with community-based nutrition education with a focus on social equity, crop diversity is associated with less household food insecurity and poorer diet quality for rural farming households. Crop diversity may improve dietary diversity by making nutritious foods more available.

Engaging fathers to improve complementary feeding is acceptable and feasible in the Lake Zone, Tanzania.

In Tanzania, suboptimal complementary feeding practices contribute to high stunting rates. Fathers influence complementary feeding practices, and effective strategies are needed to engage them. The objectives of this research were to examine the acceptability and feasibility of (1) tailored complementary feeding recommendations and (2) engaging fathers in complementary feeding. We conducted trials of improved practices with 50 mothers and 40 fathers with children 6-18 months. At visit 1, mothers reported current feeding practices and fathers participated in focus group discussions. At visit 2, mothers and fathers received individual, tailored counselling and chose new practices to try. After 2 weeks, at visit 3, parents were interviewed individually about their experiences. Interview transcripts were analysed thematically. The most frequent feeding issues at visit 1 were the need to thicken porridge, increase dietary diversity, replace sugary snacks and drinks and feed responsively. After counselling, most mothers agreed to try practices to improve diets and fathers agreed to provide informational and instrumental support for complementary feeding, but few agreed to try feeding the child. At follow-up, mothers reported improved child feeding and confirmed fathers' reports of increased involvement. Most fathers purchased or provided funds for recommended foods; some helped with domestic tasks or fed children. Many participants reported improved spousal communication and cooperation. Families were able to practice recommendations to feed family foods, but high food costs and seasonal unavailability were challenges. It was feasible and acceptable to engage fathers in complementary feeding, but additional strategies are needed to address economic and environmental barriers.