Introduction

Adequate nutrition is fundamental to child development [1]. Undernutrition in the 1000 days following conception can cause lasting damage. It can lead to stunting, impaired cognitive development, delayed motor development, poor school performance, and reduced productivity later in life [2]. Stunting in children under 5 is an indicator of chronic, long-term undernutrition. Globally, stunting affects around 22% (149 million) of children under five, but the prevalence is markedly higher in low and middle-income countries (LMIC) [3].

Across Africa, the burden of maternal and child undernutrition remains persistent. For example, in Uganda, 33% of deaths are linked to malnutrition [4], and in Malawi, only 8% of children access the minimum acceptable diet of at least four food groups a day [5]. While in Kenya, despite the adoption of a set of high-impact Infant and Young Child Feeding (IYCF) policies and guidelines, only 39% of all children aged 6–23 months are fed in accordance with the recommendations [6]. Despite the adoption of evidence-based nutrition policies and guidelines, many African countries struggle with implementation due to entrenched gender and social norms that shape household decision-making and caregiving practices and socio-economic burden in most households [7].

In Tanzania, malnutrition, particularly undernutrition, is reflected by stunting, underweight, and wasting among children under five years [2]. In 2015, despite substantial improvement over the previous two decades, Tanzania had one of the world’s highest rates of stunting, with one in three children under the age of five classified as stunted [8]. Malnutrition is directly or indirectly responsible for 35% of all deaths among children under five in the country [2]. Effective maternal and child health practices, such as proper nutrition during pregnancy, appropriate breastfeeding, and complementary feeding, are key to preventing stunting and improving optimal child development. Tanzania has several governmental interventions, guidelines and policies in place which aim to improve maternal and child health and reduce stunting. For example, promoting nutritional behavioural change among families [9] and through strategies to achieve adequate nutritional status for all Tanzanians [10].

Mass media (radio, TV, social media) campaigns have increasingly been used as behaviour change interventions to improve health behaviours [11–14]. Studies have suggested that the ability for mass media campaigns to encourage behaviour change depends on the ability to disseminate well-defined and behaviour-focused messages to a large audience repeatedly [15–17]. The effectiveness of mass media campaigns to cost-effectively change health-related behaviours in low-income settings has previously been evidenced in two cluster randomized controlled trials (RCT) conducted in Burkina Faso [16,17].

The Addressing Stunting in Tanzania Early (ASTUTE) project aimed, over five years, to reduce stunting prevalence among children in the Lake Zone regions of Tanzania, using the Saturation+ approach that was used in effective mass media campaigns in Burkina Faso [18,19]. Four organizations worked together to design, implement, and assess ASTUTE. Interchurch Medical Assistance (IMA) World Health, the lead organization, was responsible for the technical and financial management of the project. Partnership for Nutrition in Tanzania (PANITA) worked with civil society organizations to strengthen their capacity in nutrition counselling via training, mentoring and monitoring. Development Media International (DMI) led the design and implementation of the mass media campaign via radio and television, conducted formative research, and coordinated baseline, midline, and endline quantitative surveys on nutrition and child development practices. Cornell University was responsible for ASTUTE’s operational research, which included TIPs (Trial of Improved Practices) studies designed to shed light on community acceptability of behaviours related to exclusive breastfeeding and complementary feeding [20,21].

In line with recommendations for social behaviour change communication (SBCC) and mass media campaigns, formative research was conducted to explore behavioural practices that contribute to stunting or factors that facilitate beneficial behaviours, and to develop the SBCC strategy. The results highlighted that many of the behaviours affecting outcomes of interest were associated with women’s social position and gender norms [22]. For example, a lack of male support during breastfeeding left women with inadequate time to breastfeed, leading women to give babies younger than 6 months additional fluids and complementary foods, which may contribute to stunting. The importance of engaging men in order to change behaviors associated with child stunting was confirmed in two further qualitative studies conducted in the target regions of Tanzania by ASTUTE partners [20,21]. Male involvement is increasingly recognized as a critical, yet underutilized, component of maternal and child health promotion. A growing body of evidence indicates that increasing men’s engagement with maternal and child health (MCH) can improve outcomes [23–26]. However, approaches to involve men can also have unintended negative effects. Formative research found that the Tanzanian policy of requiring women to attend their first antenatal care visit with their husband [27] hindered antenatal care (ANC) attendance and resulted in delayed initiation of ANC as women had to wait until their husbands agreed to attend [22,28]. Other barriers to positive behaviours associated with child stunting, in Tanzania and elsewhere, include cultural beliefs, stigmatization of men involved in MCH [29–32] and fear of taking HIV tests [28]. Men typically have less direct engagement with MCH services, making it difficult to reach them with important MCH and infant and young child feeding (IYCF) messages, indicating mass media as a potentially effective tool for reaching men.

In light of these findings, the ASTUTE mass media campaign was designed to create a shift in gender-related social norms relating to MCH. Therefore, a number of the ASTUTE SBCC messages were aimed directly at men (Table 1) with the intention of encouraging them to adopt behaviours supporting the health and well-being of their wives and children. The SBCC campaign used radio and television (TV) to target a range of practices affecting stunting, including promoting maternal health and nutrition during pregnancy, exclusive breastfeeding, complementary feeding, hygiene practices, and the treatment of diarrhoea. 60-second radio spots were broadcast 10 times a day on five regional radio stations and one national radio station; a new spot was aired each week. TV spots were broadcast on two national channels; they were aired twice a day, in the evening during the most-watched programs.

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Table 1. SBCC campaign messages.

https://doi.org/10.1371/journal.pone.0338437.t001

While numerous empirical studies in Tanzania have used quantitative approaches to document maternal and child health (MCH) and nutrition outcomes, limited attention has been paid to the social and cultural determinants of these outcomes, particularly the role of fathers and male caregivers. Over the course of the three-year mass media campaign, we conducted a qualitative process evaluation using focus group discussions (FGDs) to assess the impact of the campaign on knowledge, attitudes, norms and behaviours. A separate quantitative evaluation [31] measured the impact of the campaign through a series of cross-sectional surveys. This paper focuses on the qualitative findings relating to the impact of the campaign on men’s knowledge, attitudes, norms, and behaviours. These findings highlight the importance of integrating males into strategies aiming at improving maternal and child health and nutrition outcomes.

Methods

We conducted a series of fifty-nine (59) FGDs with target audiences across the five Lake Zone regions: Kigoma, Kagera, Geita, Mwanza, and Shinyanga. Each FGD consisted of 8–12 participants. FGDs included different participants in each iteration, and they started on 5^th October 2017, three months after the start of radio broadcasting, and continued until 1^st February 2020. We used the FGDs to explore people’s reactions to the campaign as well as possible mechanisms of behaviour change.

Results

Fifty-nine FGDs were conducted, spread across all 5 campaign regions, involving a total of 553 participants (Table 2). Twenty-two FGDs were conducted with men.

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Table 2. Areas and number of participants in FGDs.

https://doi.org/10.1371/journal.pone.0338437.t002

Discussion

This qualitative study was conducted as part of a mixed-methods evaluation of a three-year mass media campaign targeting behaviors and practices affecting maternal and child health and nutrition. Findings indicate that the inclusion of radio and TV spots targeting men contributed to the success of the campaign across a number of domains. The campaign raised awareness among men about their involvement in the health of pregnant women and their children, making them more willing to accompany their wives to the clinic for ANC. This, in turn, had the benefit of exposing them directly to health information from health care workers. Men were also more willing to support their wives while pregnant and breastfeeding by helping with household chores, and providing nutritious foods for the mother, and for the baby when complementary feeding. Additionally, men played a role in disseminating the campaign information to their wives and other family members, thus increasing the reach of the campaign. Overall, the campaign appears to have helped change men’s perceptions that pregnancy and taking care of children are solely women’s affairs.

The themes emerging from our analysis reflect the multi-level nature of behaviour change as described in the Social Ecological Model [33]. At the individual level, fathers reported improved knowledge and personal motivation to support their partners. At the interpersonal level, changes occurred within the household, including communication between mothers and fathers, support for exclusive breastfeeding, and ANC attendance. At the community level, participants reported a shift in social norms, with men increasingly seen performing tasks considered women’s responsibilities. The organizational level was represented in interactions with ANC providers, where men received praise and further health education. This supports national policies that require male attendance at ANC and the campaign may have helped to normalise compliance with these expectations. Finally, at the societal level, mass media and government policy worked together to promote and normalize male involvement in maternal and child health.

Our findings indicate that the mass media campaign increased men’s willingness to attend ANC early with their wives and that this contributed to women’s increased ANC attendance. This is important because government policies [27] require men to attend ANC (especially the first ANC visit) with their wives, and studies in Tanzania and other African countries have reported delays in women initiating ANC due to male refusal to attend ANC with their wives [22,28]. These findings were confirmed in our quantitative evaluation of the campaign, which found that exposure to the campaign significantly increased women’s attendance for ANC by 10 percentage points, compared with those not exposed [31].

More generally, our findings support the benefits of men attending ANC with their wives and suggest some of the mechanisms through which men’s attendance may positively influence a range of maternal and child outcomes. In particular, men’s attendance resulted in direct exposure to health counselling by health workers, which had positive effects: men were more likely to perform health-related behavior when told by health workers and reluctant to act when they were told by their wives, as has been reported in another study in central Tanzania [35].

The campaign appears to have successfully mitigated some of the barriers arising from gender norms and women’s social position. For example, in response to the campaign, some fathers reported that they were now helping their wives with household activities so that wives had time to breastfeed or maintain their health during pregnancy. These findings were confirmed in the quantitative evaluation of the campaign, which found that men exposed to the campaign were significantly more likely to have helped with chores during their partner’s last pregnancy [31]. However, while the ASTUTE campaign directly targeted messages at men, encouraging them to assist their wives with household activities, the campaign’s impact on men’s behavior seems likely to have extended beyond the specific behaviors targeted in the campaign. Getting men more involved in maternal and child health may have contributed to broader shifts in gender roles, as has been found elsewhere [30]. However, despite the bulk of evidence from the FGDs and quantitative evaluation [31], indicating that the campaign had successfully mitigated some barriers arising from gender norms, it was also evident that gender and patriarchal norms continue to exert an influence on behaviours that negatively affect child nutrition, which may require long-term, multi-level interventions beyond media exposure.

The findings confirm that the campaign increased men’s knowledge about the importance of breastfeeding. Fathers reported encouraging women to breastfeed and applying pressure for exclusive breastfeeding for the first six months. The significance of breastfeeding for both the child and the mother has been highlighted, including increasing maternal attachment [36], delaying a new pregnancy, helping the uterus to return to its previous size, and protecting the baby against many infections [2].

Our findings indicate that the ASTUTE campaign successfully generated information diffusion within the target communities. Evidence from other campaigns [37–40] indicates that ‘social diffusion’ – information sharing and discussion within social networks- is an important part of the process through which social norms are shaped, and information is translated into practice [40]. It seems likely that the information diffusion generated by ASTUTE will have contributed to the underlying shift in gender-related social norms that appears to have occurred during the campaign. Researchers might consider capturing data on information diffusion when designing future campaign monitoring and evaluating activities.

Conclusion

Overall, our findings add to the evidence that interventions that target men’s behaviour can have beneficial effects on maternal and child health and add further insights into the ways that mass media campaigns can bring about behaviour change. In particular, radio and TV messages targeting men appear to be able to mitigate some barriers arising from gender norms and women’s social position. The ability of campaigns to generate ‘social diffusion’ of messages may well be important for campaigns aiming to shift social norms.

Existing evidence on the impact of interventions targeting maternal and child health predominantly relates to outcomes in women and children, even when the intervention incorporates components targeting men or couples. Given the importance of changes in men’s behaviour, increased reporting on male behaviour changes in future evaluation studies would be beneficial. Creating gender-sensitive mass media campaigns that specifically target men can help challenge harmful gender norms and encourage men’s participation in caregiving, which would subsequently increase the utilization of maternal and child health services.

Supporting information

Acknowledgments

We acknowledge the contribution of regional, district, and village leaders and community health worker for their support during field work activities as well as community members who participated in the discussions. We thank Kate Nelson for her input during the early drafting stages of this manuscript.

Stunting affects one in three children under five in Tanzania. Mass media have been used as one of the intervention methods to promote healthy behavior. We designed a mass media campaign to reduce stunting among children in the lake zones of Tanzania. This paper focuses on the impact of the campaign on men’s behavior. The findings of this study provide evidence that Interventions that target men can have a beneficial impact on maternal and child health.