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 | BMC Public Health


In 2006, Zanzibar expanded access to pre-school education with a mandate of pre-school education for all, although in 2015 still less than half of Zanzibar’s children had access to pre-school education. [28]. Despite these initiatives to increase access to early learning, programs focused on development during the critical window of the first 3 years of life have gone unaddressed. In response, the Zanzibar Ministry of Health (MOH) and Ministry of Local Government (Office of the President, Regional Government and Local Government and Special Departments [PORALGSD]) launched the National Community Health Strategy 2019-2025, which formalized a cadre of over 2,000 community health volunteers (CHVs) under the national health system with the creation of the Jamii ni Afya (“Communities are health”). The program aims to improve early childhood development outcomes by targeting promotion, access and utilization of health care services, improved nutrition and nurturing caregiver interactions for children in utero through at age 5 and is built around the WHO/UNICEF nurturing care framework. [13] and supported by a digital system co-developed with D-tree International.

Survey frame and participants

We conducted a nationally representative cross-sectional household survey in February 2019 in all 11 districts of Zanzibar, Tanzania. We used two-stage cluster sampling to randomly select 50 clusters using probability proportional to size. The clusters and respective populations were defined by enumeration areas provided by the Office of the Chief Government Statistician. We then used systematic random sampling within each group to identify and recruit 10 child-caregiver pairs into each group, for a total sample of 500 participant pairs. Pairs of eligible participants included children aged 18 to 29 months, whose birth dates were verified from their health cards, and the child’s primary caregiver. Both the carer and the child had to have their primary residence in Zanzibar. No other exclusion criteria were applied. Therefore, the sample is representative of the whole of Zanzibar, with all eligible children equally likely to be selected to participate. Notably, this cross-sectional study is taking place as part of a larger study to compare detailed Caregiver-Reported Early Development Index (CREDI) scores at baseline to future survey implementations planned for 2023. and beyond. Power and sample size considerations for this larger study are provided in the Supplementary Materials (see Supplement 1).

Data collection procedures

In-home interviews with primary caregivers of eligible and enrolled children were conducted by trained data collectors in February 2019. The study questionnaire lasted approximately 40 minutes and was administered in Kiswahili. The tool was previously translated and tested in Kiswahili in Tanzania by the tool developers. Data was collected on tablets and smartphones using ODK Collect. Data collectors and field supervisors were independent from the Ministry of Health and collaborating organizations and participated in a 5-day training on ethical considerations, survey methodology and administration of all data collection tools. data before data collection.


The primary outcome measure was the Child Development Score as measured by the CREDI tool, which is based on caregiver reporting of easily observable and understandable child milestones and behaviors by age group. The tool has been validated in 17 low-, middle- and high-income countries, including Tanzania [29, 30]. We report z-scores and scaled raw scores by linguistic, cognitive, motor, and socio-emotional domain because z-scores are best used for comparison with other populations, and scaled scores are most suitable for linear regression. On both measures, higher scores represent greater achievement in child development outcomes. Although the CREDI was not developed as a tool for diagnosing delays in individual children, we have established a threshold to define “developmental problem” for comparison with the reference population and ease of communication. for policy and advocacy. We follow the conventions of other development assessment tools [31, 32] consider a z-score of 1 to

Our primary exposure variables of interest were caregiver reports of interactions with the child in the form of early stimulating activities and caregiver knowledge of dietary diversity. The questions were taken from the UNICEF Multiple Indicator Cluster Survey (MICS) questionnaire. Caregiver report of interactions with child was analyzed as a continuous variable defined as the total number of early stimulating activities a child engaged in with a caregiver in the past 3 days. Types of early stimulating activities included: reading or looking at picture books, telling stories, singing songs, getting out of the house, playing a game, or naming/counting/drawing together. Knowledge of dietary diversity was the number of food groups the caregiver reported as appropriate for the child to eat, and knowledge of feeding frequency was the number of times per day the caregiver reported that the child should be fed. For the diet questions, we modified the MICS questions to reflect knowledge rather than practice, as the latter was not feasible for implementation. Variables were categorized as those who named four or more food groups versus those who named fewer, and those who named the diet three or more times a day versus those who suggested fewer. Knowledge of feeding practices was only assessed in a subgroup of still-breastfed children aged 18–23 months (not = 122).

We also collected data on individual- and household-level covariates related to home environment, caregiver engagement and play, disciplinary practices, care-seeking behaviors, and health care knowledge and practices. of health and nutrition. All questions and indicators were defined and assessed using standard UNICEF indicators from MICS and a standardized monitoring and evaluation tool for the Care for Child Development checklist. UNICEF. We measured sociodemographic characteristics relevant to understanding the relationship between our independent exposures of interest and child development outcomes. Wealth was measured using the Tanzania EquityTool (, a validated tool that analyzes household wealth using a simplified version of the asset-based DHS questionnaire . Using the standard EquityTool analysis package, each household was assigned a score and then ranked according to its relative wealth against the quintile levels established by the population of Tanzania’s 2015 DHS.

statistical analyzes

We performed descriptive analyzes of overall and domain-specific CREDI z-scores and compared them to the CREDI reference population.Footnote 1, using the CREDI scoring package developed in R V3.6.0 (R Core Team, Vienna, Austria). To explore associations between individual-level covariates and global and domain-specific continuous CREDI scores (hereafter: child development outcomes), we performed bivariate analyzes for all categorical variables using Wald’s t-test and ANOVA. We fitted two multivariate linear regressions to quantify the relationship between the number of early stimulation activities and child developmental outcomes, and knowledge of adequate dietary diversity and child developmental outcomes. In both models, we adjusted for known confounding variables and those found to have a significant association in bivariate analysis (at the α = 0.05 level of significance), including: geographic region, caregiver age, child’s age and sex, whether the caregiver is married or living with their partner or not, maternal and paternal education levels, parity, wealth, whether the child has been left alone for longer than an hour in the past week, and (for caregiver engagement only) whether the caregiver believed domestic violence was justifiable in any circumstance. We took clustering into account using the svyset function on Stata. Our primary sampling unit was the enumeration area, and each individual was weighted by the probability of selection within its cluster. All tables and regression analyzes take into account the survey sample design, our standard errors have been adjusted accordingly. Given the difficulty of interpreting significant changes in the scaled raw CREDI score, we standardized the results of our multivariate model analysis. To do this, we divided the coefficient of the model-estimated CREDI outcome variable by the standard deviation within the study population for the specific CREDI domain, to express the effect size as a change in l standard deviation among the study population. Except for CREDI scoring, all statistical analyzes were performed using Stata Version 14 (StataCorp, College Station, TX).

Ethics statement

Ethical approval to conduct this study was obtained from the Institutional Review Boards of the Ministry of Health/Zanzibar Health Research Institute (Ref No.: ZAHREC/01/DEC/2018) and Boston Children’s Hospital (ref. no.: P00029981). Each child’s parent or primary caregiver provided written informed consent on behalf of the child-caregiver pair prior to study enrollment, and all research was conducted in accordance with approved study procedures and ethical guidelines. .

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