Stunting is a complex issue stemming from persistent undernutrition and poor sanitation [1] [2]. It is defined as height-for-weight Z score of more than two standard deviations below the World Health Organization (WHO) child growth standards for age and sex. In recent years, the prevalence of childhood stunting has declined globally; however, in 2019, 144 million children under five years of age were stunted worldwide [3]. Stunting remains a particular challenge in Sub-Saharan Africa. Despite encouraging declines in Tanzania over the past 25 years, one-third of Tanzanian children (2.7 million) under the age of five years, still experienced stunting in 2016 [4] [5].

One of the primary causes of childhood stunting is diarrheal diseases [2]. Diarrheal diseases cause an estimated 20 percent of all deaths for children younger than five years old, making them one of the leading causes of child mortality globally [2] [6]. Furthermore, multiple episodes of diarrhea in one year can greatly increase the risk of childhood stunting [7]. Guerrant and colleagues demonstrated that five episodes of diarrhea in the first two years of a child’s life can lead to a 25 percent increase in stunting. Globally, an estimated 57 million disability-adjusted life years (DALYs) are due to preventable diarrheal diseases; 842,000 deaths annually, more than 360,000 of which are children under five years old [2].

Tanzania has experienced substantial declines in childhood mortality from diarrhea over the past three decades. Masanja et al. report declines in child diarrhea-specific mortality from 35.3 deaths per 1000 live births in 1980 to 3.9 deaths per 1000 live births in 2015. These declines are associated with increases in rotavirus vaccinations, the use of oral rehydration salts (ORS), improved breastfeeding practices, and Vitamin A supplementation [8]. Masanja and colleagues conclude that additional improvements will be made through increased access to health services and facilities; education; clean water, sanitation and hygiene (WASH); and integrated interventions focused on key childhood interventions such as the continued promotion of ORS, zinc tablets/syrup, and treatment for persistent diarrhea.

Efforts to reduce stunting and diarrhea include the use of mass media to influence key behaviors known to reduce both stunting and diarrhea incidence. Increased access to mass media, including television, radio, and social media provide relatively low-cost options for delivering child health programs. The use of mass media for health education and promotion has been well documented [9] [10]. Naugle and Hornick note that radio and television are the most frequently used channels for mass media interventions targeting diarrheal disease. To date, however, little is known about the efficacy of using mass media for stunting prevention generally, and diarrheal diseases specifically. Alexander and colleagues found an association between access to mass media and knowledge of optimal WASH practices in Tanzania but were unable to determine the impact of exposure to mass media programming on actual WASH behaviors [11]. It is also unclear if mass media campaigns alone change behavior associated with diarrhea prevention or if mass media campaigns in combination with interpersonal communication (IPC), such as home visits from community health workers (CHWs) would have a synergistic effect of positive behavior change toward diarrhea prevention and behaviors related to diarrhea treatment. The purpose of this study was to determine whether mothers, hereafter referred to as primary caregivers, and fathers, hereafter referred to as male heads of household, who benefitted from a mass media campaign, an IPC program, or both, sought appropriate care for diarrhea in children under the age of two years.

Demographic information for the 4996 primary caregivers, and 3082 corresponding male heads of household can be found in Table 1. Most households had 1 - 2 children under the age of 5. Christianity was the predominant religious affiliation (83.32%) and most women were in married, monogamous unions (77.06%). More than half of men (56.16%) and women (64.02%) had completed primary education and men were, on average, almost 6 years older than women. The wealth index score indicated the majority of participants were in the low to lower middle index score (Table 1).

Approximately 20 percent of primary caregivers reported that their child had experienced diarrhea within the last two weeks. The majority of them also reported that they sought care at a healthcare facility or hospital (Table 2).

Primary caregivers who were exposed to media messages only were significantly more likely (OR 1.66, CI 1.05 - 2.62) to seek advice or treatment for diarrhea from a healthcare facility than those with no media exposure (Table 3).

*p-value < 0.05; **p-value < 0.01. Logistic regression model controlling for wealth, maternal education and primary caregiver’s age.

Primary caregivers who were exposed to both media messages and IPC were significantly more likely (OR 2.51, CI 1.48 - 4.26) to seek advice or treatment for diarrhea from a healthcare facility. Primary caregivers exposed to both media messages and IPC were significantly more likely (OR 2.17, CI 1.39 - 3.37) to seek advice or treatment for diarrhea.

Primary caregivers who were exposed to both media messages and IPC were significantly more likely (OR 2.56, CI 1.72 - 3.79) than caregivers with no exposure to give ORS when their children had diarrhea. Primary caregivers who were exposed to both media messages and IPC were significantly more likely than primary caregivers not exposed to media nor IPC to use zinc tablets/syrup for diarrhea (OR 1.74, CI 1.18 - 2.57). Similarly, primary caregivers who were exposed to both media messages and IPC compared to primary caregivers who were not exposed to media nor IPC were more likely to treat diarrhea with homemade fluids (OR 2.02, CI 1.15 - 3.55). Complete results of regression analysis for primary caregiver’s exposure to media and IPC and care-seeking for children’s diarrhea are presented in Table 3.

Male head of household exposure to the media campaign only was not associated with any care-seeking behaviors for children’s diarrhea (Table 4).

The purpose of this study was to determine whether primary caregivers and male heads of household who benefitted from a mass media campaign, and primary caregivers who benefitted from an IPC program or a combination of mass media and IPC, sought appropriate care for diarrhea in children under the age of two years.

Primary caregivers who had heard at least one radio or TV spot on children’s nutrition and health were more likely than primary caregivers with no exposure to the mass media spots to seek care at a health clinic or hospital for childhood diarrhea. However, exposure to the media campaign alone was not associated with the type of diarrhea treatment primary caregivers sought. This finding is similar to the results of a 35-month cross-sectional radio campaign in Burkina Faso conducted to address survival rates of children under 5 years of age [13]. That campaign developed and aired 12 short spots and 79 intense radio spots which promoted healthcare-seeking or home treatment for diarrhea, including ORS and fluids. It should be noted that the NGO that conducted the mass media campaign in Tanzania (DMI) was also responsible for the media campaign in Burkina Faso.

Logistic regression model controlling for wealth, maternal education and primary caregiver’s age.

Primary caregivers who participated in IPC activities but who had not heard nor seen radio and TV spots were no more likely than unexposed primary caregivers to treat childhood diarrhea with ORS. It is not clear why IPC interventions were positively associated with ORS treatment for childhood diarrhea while exposure to mass media was not. Indeed, mass media has been used to promote the use of ORS for diarrhea for many years. Since the introduction of ORS in the 1960s [14], mass media has been a common approach for increasing the use of ORS and zinc treatment for diarrhea [15] [16]. A campaign was undertaken in India, Kenya, Uganda, and Nigeria, to increase the use of ORS and zinc. From 2012-2016, ORS and zinc coverage in Kenya increased by 2.6 percentage points per year, and 7.1 percentage points per year in Uganda [14]. Findings from the campaign in India demonstrate both the potential for media to reach mothers in rural areas and the efficacy of media compared to interpersonal outreach [14] [17].

Primary caregivers’ exposure to both mass media programming and IPC was associated with a variety of key study variables and appeared to be the most influential intervention strategy. Primary caregivers who were exposed to both the mass media campaign and IPC had more than twice the odds of having sought advice or treatment for diarrhea from any source than those primary caregivers who were not exposed to both the media campaign and IPC. This finding is consistent with previous research and subsequent program planning approaches demonstrating the use of multiple communication outlets (e.g., a combination of television ads, personal communication, and radio broadcasts) as a more effective and sustainable approach when compared to using only one health communication strategy [18] [19]. Furthermore, in a systematic review, Robinson [19] found that the combination of mass media health communication campaigns (e.g., any message intended to increase awareness of a health product, delivered through mass media, social media, or interpersonal communication) and a distribution of the product, generally at a free or discounted price, has proven more effective than mass media campaigns alone.

Findings also show that primary caregivers exposed to both mass media and IPC were much more likely to seek treatment at a healthcare facility than any other source. These results are consistent with a study conducted in Ethiopia in 2016 in which the most common choice for treatment for sick children were health facilities (74.6%), followed by home remedies (55.2%), pharmacies (27.3%) and other traditional sources. The most common sickness reported was diarrhea [20].

Mass media messaging was not associated with care-seeking behaviors or treatment approaches for childhood diarrhea among male heads of household. Mass media alone was less effective with primary caregivers than a combination of mass media and IPC. It is important to note that male heads of household were not formally involved with IPC and only had access to the mass media portion of the ASTUTE program. Research by Robinson [19] and Snyder [21], and the results of this study suggest that implementing a media campaign without a complementary intervention centered on personal communication will have a limited effect when compared to a more robust approach. Supplementing a media campaign with additional approaches that focus on person-to-person engagements, such as IPC interactions, may improve the intended impact.

Low male engagement in maternal and child health in Tanzania has been associated with the position of men in society in general, and to a health system regarded as uninviting to men, specifically [22] [23]. Increasing male involvement in maternal and child health is a public health priority and further research is needed to understand the barriers to male engagement in care-seeking behaviors and treatment for diarrhea in children. This barrier might be attributed to lack of complementary interventions or traditional care options preferred by males.

Although not addressed in this study, further studies may be needed in determining barriers for seeking treatment for diarrheal episodes for many Tanzanians which may include financial status, the number of young children in the home, and proximity of the nearest healthcare facility. In one study, financial status was also a factor that indicated what level of treatment Tanzanians sought [24]. If multiple children under five years of age are in the home, many may also opt for at-home care or no care.

This study is limited by several key factors. Far more study participants were exposed to mass media than IPC. While this is to be expected given the nature of each programmatic approach, the unbalanced exposure of participants to each approach limits comparison. Similarly, some variables yielded fewer responses than others, which may have weakened potential statistical inference. This study did not include a control group or measure key study variables prior to programmatic exposure, thus limiting significant results to correlation rather than causation. Finally, the ASTUTE program was implemented in five Lake Zone regions through cross-sectional analysis, which may not represent all Tanzanians. Despite these limitations the current study includes a large sample size, helps to evaluate a detailed and evidence-based multi-year stunting prevention program, addresses a significant public health issue in Tanzania, and can inform future health promotion efforts.

This study examined the association between the ASTUTE program and care seeking behaviors for diarrhea. The results of this study highlight the importance of using multiple program strategies to maximize impact. Exposure to the media campaign or IPC individually was associated with success in some areas, yet exposure to both types of programming was associated with more significant relationships. Program planners may consider only using one intervention for future projects if a specific behavior is targeted, or if resources are limited, but a combination program appears to be most efficacious for addressing childhood diarrheal diseases.

The authors declare no conflicts of interest regarding the publication of this paper.

Reher, B., Cooper, S., Mulokozi, G., Brown, J., Merrill, H., Linehan, M., Dearden, K., Torres, S., Crookston, B., West, J. and Hall, C. (2022) Are Participants in a Behavior Change Communication Campaign More Likely to Seek Care for Childhood Diarrhea? A Study of Caregivers of Children under 2 in Tanzania. Health, 14, 342-354. https://doi.org/10.4236/health.2022.143027