Benjamin T. Crookston

Faith-based organizations (FBOs) and faith-based service providers play a critical role in public health prevention, promotion, treatment, and community development. Effective capacity strengthening efforts through FBO partnerships can make a vital contribution toward effective localization. This case study details the efforts and results of a writing and publishing workshop provided in partnership with Corus International (IMA World Health) and the Africa Christian Health Associations Platform (ACHAP) in March of 2023. This case study also reports on workshop participantsʼ perceptions of the partnershipʼs approach to capacity strengthening. Three major and related themes emerged from the workshopʼs informal Focus Group Discussion transcription: 1) a safe and nurturing environment, 2) openness and shared decision-making, and 3) organizational humility.

Background & Aims. The COVID-19 pandemic had a significant impact on health in countries of every income level. While much is known about risk factors for COVID-19 severity, less is known about the relationship between COVID related risk perceptions and behaviors, particularly in low-income settings. The purpose of this study is to investigate the relationship between existing health status and COVID-19 risk perceptions and behaviors in Sierra Leone and Zimbabwe. Methods. Data for this study came from a cross-sectional survey conducted simultaneously among 1158 adults in Sierra Leone and 1154 in Zimbabwe during July and August of 2022. Respondents were recruited from among communities served by the Christian Health Association of Sierra Leone (CHASL) and Zimbabwe Association of Church-Related Hospitals (ZACH), both members of the Africa Christian Health Associations Network (ACHAP). Results. The relationship between health status and COVID-19 risk perceptions and behaviors varied significantly by health condition. Cardiovascular disease was significantly associated with heightened perceptions of COVID-19 risk, heightened perceived safety of COVID vaccines, and subsequent greater vaccine acceptance while cancer was likewise statistically significant in each of lower perceived susceptibility, perceived safety, and vaccination uptake. Similarly, obesity was associated with both lower perceived susceptibility of COVID-19 and decreased perceived safety of COVID vaccines. Conclusion. Results suggest that the association between health conditions and COVID perceptions and behaviors is neither clear nor consistent across a variety of NCDs. Hence, findings from this study may inform public health interventions aimed at reducing COVID-19 morbidity and mortality, including increasing vaccine acceptance and uptake in Sierra Leone and Zimbabwe. Further, findings potentially have broader implications for understanding how health status is associated with COVID-19 risk perceptions in other LMICs.

Background & Aims. The coronavirus disease 2019 (COVID-19) has caused millions of deaths worldwide, making the uptake of effective vaccines critical to saving lives. In Sierra Leone and Zimbabwe, two countries selected for focus in a privately funded project to boost COVID-19 vaccination coverage through interventions carried out by faith-based networks in Africa, both supply- and demand-side challenges have made high rates of vaccination difficult to achieve. The current study seeks to describe vaccination rates and reasons for vaccine hesitancy in both Sierra Leone and Zimbabwe. Methods. A cross-sectional survey was conducted face-to-face in Sierra Leone and Zimbabwe. This study uses frequency statistics and multivariate regression analysis to identify key demographic predictors of COVID-19 vaccination acceptance and to examine perceived COVID-19 infection vulnerability in both countries. The Health Belief Model was used as a framework for sorting and understanding findings. Results and Conclusions. Individuals who were older, from Zimbabwe, and were healthcare workers or community leaders were more likely to be vaccinated. Those who were from Zimbabwe, had secondary or tertiary education, and were community leaders were more likely to be concerned about catching COVID-19 than community members. Faith leaders were less likely to be concerned about catching COVID-19 in public. These findings add to our understanding of attitudes that lead to vaccine hesitancy and uptake.

Background: Large-scale social and behavioral change communication (SBCC) approaches can be beneficial to achieve improvements in knowledge, attitudes, and practices (KAP). Addressing Stunting in Tanzania Early (ASTUTE) included a significant SBCC component and targeted precursors to stunting including KAP related to maternal and child health, antenatal care, WASH, childhood development, and male involvement. METHODS: Baseline, midline, and endline surveys were conducted for a total of 14,996 female caregivers and 6726 male heads of household in the Lake Zone region of Tanzania. Regression analyses were used to estimate differences in KAP from baseline to midline and endline. Results: Women’s knowledge of handwashing and infant/child feeding practices, and attitudes related to male involvement, consistently improved from baseline to midline and baseline to endline. Women’s practices related to antenatal care, breastfeeding, and early child development improved from baseline to midline and baseline to endline. Improvements in KAP among male heads of household were varied across indicators with consistent improvement in practices related to child feeding practices from baseline to midline and baseline to endline. Conclusion: Many changes in KAP were observed from baseline to midline and baseline to endline and corresponded with SBCC programming in the region. These results provide support for the value of large SBCC interventions. Public health efforts in settings such as Tanzania may benefit from adopting these approaches.

Objectives: Stunting remains a prevalent issue in Tanzania. The consequences of stunting include reduced height, greater susceptibility to disease, and diminished cognitive ability throughout the lifespan. Lack of psychosocial stimulation is associated with increased stunting, particularly in terms of its cognitive impact. The Addressing Stunting in Tanzania Early (ASTUTE) program was a large social and behavior change communication (SBCC) intervention that aimed to reduce childhood stunting in the region by targeting early childhood development (ECD) behaviors. The purpose of this study is to report on the extent to which exposure to ASTUTE might be related to ECD behaviors. Methods: ASTUTE disseminated program messages via a mass media campaign and interpersonal communication (IPC). Logistic regression models were used to explore the relationship between exposure to TV, radio, IPC messages, and key ECD behaviors of female primary caregivers and male heads of household. Results: Among primary caregivers, IPC was positively associated with all ECD behaviors measured. Radio was associated with all behaviors except drawing with their child. TV was associated with all behaviors except playing with their child. Among heads of household, only the radio was positively associated with the ECD behaviors measured. Conclusions for practice: Findings indicate that SBCC interventions that include mass media and IPC components may be effective at promoting parental engagement in ECD behaviors. Significance: We know that ECD is important for a child’s development. We know that parents play a critical role in promoting ECD behaviors. We are still exploring ways to influence parents so that they are more involved in ECD behaviors. The results presented here provide evidence for successful mass media and IPC efforts to improve parents’ ECD behaviors. We hope this study will add more evidence for large interventions such as these to the literature, and we are very hopeful that governments and large international NGOs will prioritize SBCC approaches in the future, especially in locations where face-to-face interventions may be challenging.

Background: Optimal infant and young child feeding practices (IYCFP) reduce childhood stunting and are associated with additional health benefits. In Tanzania, IYCFP are far from optimal where 32% of children under the age of 5 years are stunted. The purpose of this study was to examine whether behavior change communication focused on reducing child undernutrition was associated with improved IYCFP in Tanzania. Methods: A cross-sectional survey was administered to approximately 10,000 households with children under the age of 2 at baseline and endline. Bivariate analyses and logistic regression was used to examine the relationship between exposure to behavior change communication and timely initiation of breastfeeding, exclusive breastfeeding, continued breastfeeding at one year, timely complementary feeding (CF), minimum meal frequency (MMF), minimum dietary diversity (MDD), and minimum acceptable diet (MAD). Results: Mothers who heard a radio spot about IYCFP were more likely than mothers who had not heard a radio spot about IYCFP to begin complementary foods at six months. Their children were also more likely to achieve MMF, MDD, and MAD with odds ratios of 2.227 (p = 0.0061), 1.222 (p = 0.0454), 1.618 (p = < .0001), and 1.511 (p = 0.0002), respectively. Mothers who saw a TV spot about IYCFP were more likely to have greater odds of knowing when to begin complementary feeding, feeding their child a minimally diverse diet (4 food groups or more), and serving a minimum acceptable diet with odds ratios of 1.335 (p = 0.0081), 1.360 (p = 0.0003), and 1.268 (p = 0.0156), respectively. Conclusion: Exposure to behavior change communication in Tanzania was generally associated with some increased knowledge of optimal IYCFP as well as practicing IYCF behaviors. Behavior change communication planners and implementers may want to consider conducting similar campaigns as an important component of behavior change to reduce undernutrition and poor health outcomes in developing settings.

Background: Stunting affects 37% of Indonesian children and has lifelong consequences for the affected child. Childhood stunting can be prevented by promoting exclusive breastfeeding (EBF) and helping mothers overcome barriers to EBF. This study aimed to examine the effect of a National Nutrition Communications Campaign (NNCC) on stunting awareness and promotion of exclusive breast­feeding behavior among rural Indonesian mothers. Subjects and Method: Data came from interviews and a cross-sectional survey of 1,740 mothers with children under the age of 2 in three Indonesian districts, from November 2015 to March 2018. Measures included exposure to two different NNCC interventions: multi-media messages (media) and interpersonal communication strategies (IPC) and associations with stunting knowledge, breast­feeding knowledge, and breastfeeding perceptions/intentions. The data were analyzed by a multiple logistic regression. Results: Exposure to NNCC was positively associated with knowledge toward EBF (OR= 1.56; 95% CI= 1.10 to 2.19; p= 0.043), awareness of the importance of nutrition during the first 1000 days of life (OR= 1.90; 95% CI= 1.43 to 2.52; p<0.001), and having heard of stunting (OR= 1.93; 95% CI= 1.41 to 2.63; p<0.001). Exposure to IPC was positively associated with knowledge toward EBF (OR=1.78, CI95% 1.37 to 2.30, p<0.001), awareness of the importance of nutrition during the first 1000 days of life (OR= 3.02; 95% CI= 2.40 to 3.80; p<0.001), knowledge of EBF benefit to prevent stunting (OR= 3.05; CI 95%= 2.33 to 3.98; p<0.001), and having heard of stunting (OR= 3.15; CI 95%= 2.49 to 3.98; p<0.001). Exposure to IPC was a significant predictor of an intention to engage in EBF (p <0.050). Conclusion: These findings point to practical recommendations for national level social and behavior change communication efforts. Future campaigns should aim to be inclusive of: 1) mass media (tele­vision, radio, billboards, and social media) to promote health as these efforts provide for wide exposure while maintaining impact; and 2) IPC (face-to-face communications, classes, and support groups) as these efforts increase knowledge and impact on behavior, beliefs and intentions.

Anemia and underweight among women are major public health challenges. Access to health services can improve dietary behaviors and women’s nutritional status. We examined whether exposure to health services is associated with women’s dietary practices in Tanzania. Data come from a cross-sectional baseline survey among 5000 female primary caregivers who were randomly selected via two-stage sampling, prior to implementing a maternal and child nutrition program. We ran frequencies on women’s exposure to existing health facility-based counselling, community health worker visits, and attendance at women’s support groups. We examined associations between exposure to these interventions and maternal diets and adjusted for sociodemographic covariates using ordinary least squares regression and ordered logistic regression. A third of the sample (34.1%) had received any antenatal care (ANC) during their most recent pregnancy or had been advised by anyone about nutrition (37.0%). 68.0% had never had a community health worker (CHW) speak to them about their children’s health and 9.4% had participated in a women’s group. Only 8.0% of mothers ate more than usual during pregnancy and 7.1% ate more types of foods. After adjusting for mother’s age, education and household assets, women who received nutrition advice were 1.3 times (95% CI: 1.1, 1.7) more likely than mothers who did not to eat more during pregnancy. Receiving antenatal care (ANC) and advice on nutrition before, during, and after pregnancy and delivery were highly associated with the mother eating more types of foods. Hearing from a CHW about children’s health but not support group attendance was often associated with various dietary practices. Almost all measures of access to health services were significantly associated with mothers’ frequency of eating in the previous 24 h. Receiving advice on nutrition during pregnancy and after giving birth and CHW contact were associated with mothers’ dietary diversity in the previous 24 h. Several program exposure variables—especially being counselled about nutrition—were associated with improved dietary practices. Improving service delivery at scale may contribute to improved dietary behaviors in larger populations, given the associations we describe, along with findings from the existing literature.

Background: Achieving gender equality and women’s empowerment is a major global priority. The purpose of this study was to determine whether the Building the Resilience of Vulnerable Communities in Burkina Faso (BRB) project, an agricultural development program, improved women’s empowerment, as measured by the project-level Women’s Empowerment in Agriculture Index (pro-WEAI). Methods: This study used a longitudinal, quasi-experimental study design. Participants included both treatment and comparison groups (total N = 751) comprising female members of savings groups and their husbands or main male household member in Burkina Faso. All participants completed the pro-WEAI questionnaire at both baseline and endline. The treatment group received a comprehensive intervention package consisting of agriculture loans and services, microenterprise loans, and education, nutrition education, and women’s empowerment programs including gender-based discussions designed to facilitate personalized changes in gender relations. Results: The proportion of the treatment group achieving empowerment did not change from baseline for women, but improved substantially for men. Women from the comparison group saw an increase in empowerment at endline while men saw a substantial decrease. Gender parity was high for women in both groups at baseline and increased slightly at endline. Women were more likely to have adequate empowerment in input in productive decisions, group membership, and membership in influential groups than men while men were more likely to have adequate empowerment in attitudes about domestic violence, control over use of income, and work balance than women. Participants from the treatment group reported an increase in the average number of empowerment indicators that they were adequate in while the comparison group saw a decrease in average adequacy over time (p = 0.002) after controlling for age, sex, and level of education. Conclusion: Despite starting at an empowerment disadvantage, the treatment group experienced gains in individual indicators of empowerment while the comparison group men and women experienced mixed results, with the women gaining, and the men losing empowerment. This research suggests that the BRB intervention may have provided some protection for the treatment group when they faced an economic down-turn prior to the endline, indicative of household resilience. Future research should consider and strengthen relationships between resilience and empowerment.

Background: Diarrhea remains a major cause of morbidity and mortality among children in Tanzania. The purpose of this study was to explore associations between diarrheal disease and water, sanitation, and hygiene (WASH) related behaviors and determine care-seeking predictors for diarrheal disease. Methods: Data from 9996 female primary caregivers were collected as part of a larger integrated nutrition program. Logistic regression was used to measure associations between predictor and dependent variables and diarrheal and care-seeking outcomes. Results: Knowledge of the importance of handwashing after assisting a child who has defecated (OR 0.79, CI 0.72–0.87), before preparing food (OR 0.88, CI 0.80–0.97), and before feeding a child (OR 0.89, CI 0.81–0.99) were each associated with not having a child with diarrhea in the past two weeks. Fathers or male caregivers (OR 0.65, CI 0.48–0.89) were less likely to seek medical care for a child with diarrhea. No associations were found between WASH-related knowledge or behavior and seeking medical care for a child with diarrhea. Conclusions: Findings indicate that knowledge of handwashing importance was significant in washing hands after assisting a child who has defecated, before preparing food, and prior to feeding a child. These findings demonstrate the value of parental involvement to lower morbidity and mortality among children.