Although the world has seen positive progress in improving health and nutrition indicators for children and mothers, malnutrition, especially stunts, remains high. In 2018, around 149 million children under five were slowed down [1]. The African continent is hardest hit by stunts with 30 of 41 countries worldwide. Most people suffer from more than one form of malnutrition (stunting in childhood, anemia in women of childbearing age, and obesity in women). [2]. The consequences of stunts are profound, including increased susceptibility to infection, mortality, decreased cognitive development, decreased level of education, lower economic productivity in later life, and lower birth weight of the offspring [3]. There is also a close relationship between food deprivation in early life and increased chances of developing chronic illness in adulthood [3]. The collective consequences of stunts cost up to 12% of the gross domestic product of developing countries [4].

Nearly 45% of all deaths under the age of five were attributed to malnutrition, the equivalent of around 3.1 million deaths per year worldwide. Sub-optimal infant feeding alone accounts for 800,000 deaths each year, and the prevalence of deaths was much higher in southern Asia and sub-Saharan Africa than in other parts of the world [5]. Tanzania has made tremendous strides in reducing stunts among children under five, from 43% in 1991 to 34% in 2015 [6]. However, there are differences between regions with six regions (Ruvuma, Iringa, Rukwa, Kigoma, Njombe and Songwe) of 26 with over 40% stunted children [6]. This is unacceptably high by WHO standards [7]. Several studies have linked poor nutritional status in pregnant women and women of childbearing potential to poor birth and nutritional outcomes in newborns and children [8, 9]. Evidence in Tanzania suggests that the prevalence of underweight (BMI)< 18.5) among women of reproductive age has remained low and unchanged over the past 20 years. However, overweight and obesity (BMI >18.5) has increased significantly. The 2015/2016 Demographic and Health Survey shows that one in ten women aged 15 to 49 was either underweight or obese and 18% were overweight [6]. In addition, 45% of women of childbearing age and 57% of pregnant women were anemic [6].

Several studies that focused on implementing integrated diet-specific interventions to reduce stunts found inconsistent results [10,11,12,13]. In a controlled intervention study of dietary supplements and nutritional advice on anemia and stunting, no effects on stunting in children aged 6 to 23 months were observed in China [14]. Another assessment conducted in Ethiopia in children aged 6 to 36 months showed no improvement in stunt when an integrated approach (water, sanitation and hygiene (WASH), health and nutrition education) was implemented in a food insecure population with very high stunt prevalence [15]. Haselow (2016) presented two studies carried out by Hellen Keller International in the Baitadi and Kailali districts in Nepal and in the Chittagong Hill Tracts in Bangladesh. In Baitadi, a cluster randomized control study was used in which communities were assigned integrated interventions (Improving homestead food production, promoting good nutrition and WASH), women’s empowerment, income generation and advocacy) or control. No effects on stunting were found in the study. However, when similar interventions were conducted in Kailali and Chittagong in a non-randomized controlled trial, the Kailali District of Nepal found a 10.5% decrease in stunts, while the Chittagong Hill Tracts in Bangladesh saw an 18% decrease in stunts [13]. The methodological approach, the packaging of the intervention, the duration of the implementation, and the fidelity are some of the possible explanations for the observed deviations.

Description of the interventions

The Tanzanian government aims to eliminate stunts as a major public health problem by 2030 [16]. As part of several initiatives, from 2016 to 2019 in the Simiyu and Ruvuma regions of mainland Tanzania, an Italian organization called Doctors with Africa CUAMM introduced an integrated intervention program with the aim of reducing stunting in children under 5 years of age. The program was aimed at pregnant and breastfeeding women and children under the age of five and focused on providing nutritional education and promoting the use of health services during the 1000-day window from conception to the child’s second year of life. Members of the local CUAMM project team, health care providers and community health care workers (CHW) were key players in the activities of the management and implementation program. The role of health care providers in the program activities was to provide the routine services (nutrition education, infant nutrition education, iron and folic acid supplementation, and management of severe acute malnutrition (SAM)) in the health facility that are beyond the scope of this document.

Stunt screening, cooking demonstrations, health and nutrition education were the core activities of the project during the health days in the village. Because stunting is a chronic condition, it was examined twice a year. Cooking demonstrations and educational sessions were held quarterly (every 3 months) in each study village, with each session lasting half a day. The educational materials known as Mkoba wa Siku 1000 were adopted by the Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDEC) and used during the moderation of health education sessions. The training package included materials on health education during pregnancy and breastfeeding, feeding infants and young children, washing hands, waste product management and childbirth preparation.

The program also facilitated the formation of a peer support group at the village level, each with a maximum of 10 members, led by community health workers. The aim of the groups was to facilitate the provision of health and nutrition education for group members and the entire community, and to promote horticulture to ensure the availability of diversified food for households. The actual number of peer groups formed during the program implementation was not documented as this was not part of the core strategies of the project implementation. This paper provides evidence from an evaluation work of these community program activities.