Dietary Practices and Nutritional Knowledge Among Caregivers of Stunted Under-Five Children in Njombe Region, Tanzania

Dietary Practices and Nutritional Knowledge Among Caregivers of Stunted Under-Five Children in Njombe Region, Tanzania | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Dietary Practices and Nutritional Knowledge Among Caregivers of Stunted Under-Five Children in Njombe Region, Tanzania Victoria Melkion Kilamlya, Justin Edward Lusasi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8763772/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Childhood stunting remains a major public health challenge in Tanzania, including Njombe District, despite various nutrition and health interventions. Understanding the factors associated with caregivers’ dietary practices is essential for informing effective stunting reduction strategies. This study examined dietary practices among caregivers of under-five children with stunted growth and assessed their association with selected socio-demographic characteristics, nutrition knowledge, and exposure to nutrition training. Methods A cross-sectional study was conducted among caregivers of under-five children identified as stunted at health facilities in Njombe District. Data were collected using a structured questionnaire capturing socio-demographic characteristics, nutrition knowledge, nutrition training exposure, and dietary practices. Dietary practice was assessed based on adequacy of protein-rich food consumption. Nutrition knowledge was categorized using Bloom’s taxonomy. Chi-square tests of independence were used to examine associations between variables at a significance level of p < 0.05. Results A total of 151 respondents were included in the analysis. No statistically significant associations were observed between dietary practices and caregiver education level (χ² = 1.80, p = 0.180) or nutrition knowledge (χ² = 0.683, p = 0.409). Similarly, nutrition training was not significantly associated with nutrition knowledge (χ² = 0.099, p = 0.753). In contrast, a strong and statistically significant association was found between nutrition training and dietary practices (χ² = 49.6, p < 0.001). Nearly half (45.9%) of caregivers who had received nutrition training demonstrated appropriate dietary practices compared to only 1.8% among those without training. Conclusion The findings indicate that formal education and general nutrition knowledge alone are insufficient to improve dietary practices among caregivers of stunted children in Njombe District. Practical, structured nutrition training appears to play a critical role in promoting appropriate dietary practices. Strengthening community-based nutrition training in line with Tanzania’s National Nutrition Action Plan may contribute to improved feeding practices and support ongoing efforts to reduce childhood stunting. Childhood stunting dietary practices nutrition training nutrition knowledge Njombe District Tanzania 1. Introduction Stunting, defined as low height-for-age resulting from chronic undernutrition, remains a major public health challenge affecting children under five years of age worldwide. In 2022, an estimated 148 million children under five were stunted globally, representing approximately 22% of all children in this age group [ 1 ]. Stunting reflects prolonged nutritional deprivation during critical periods of growth and development, particularly from conception through early childhood. The consequences of stunting extend beyond impaired physical growth and include irreversible cognitive deficits, reduced school performance, increased susceptibility to infectious diseases, and lower economic productivity later in life [ 2 , 3 ]. Although global stunting prevalence has declined over recent decades, progress has been uneven, with Sub-Saharan Africa continuing to carry a disproportionate burden. Tanzania remains among the countries with high levels of childhood stunting, with nearly one-third of children under five affected nationally [ 4 ]. More concerning are substantial subnational disparities, where certain regions report stunting prevalence far above the national average. Njombe Region, located in the Southern Highlands of Tanzania, exemplifies this challenge. Despite being one of the country’s most agriculturally productive and food-secure regions, Njombe has consistently recorded stunting prevalence exceeding 50% [ 5 ]. This apparent paradox suggests that food availability alone is insufficient to prevent chronic undernutrition and that household-level factors, particularly dietary practices and caregiver nutritional knowledge, play a critical role in shaping child growth outcomes. Adequate nutrition during the first 1,000 days of life is widely recognized as essential for preventing stunting. Exclusive breastfeeding for the first six months, followed by the timely introduction of appropriate, diverse, and nutrient-dense complementary foods while continuing breastfeeding, is strongly recommended to support optimal growth and development [ 6 , 7 ]. However, evidence from low- and middle-income countries shows that inappropriate infant and young child feeding practices persist even in food-producing settings. Diets dominated by starchy staples, low dietary diversity, premature introduction of complementary foods, and inadequate intake of animal-source foods and micronutrients are frequently reported contributors to chronic undernutrition [ 8 , 9 ]. Beyond infancy, children older than two years remain vulnerable to stunting due to continued dietary inadequacies and suboptimal household feeding behaviors. At this stage, children increasingly depend on family diets, which are shaped by caregivers’ food choices, preparation practices, and nutritional understanding. Caregivers with limited nutrition knowledge may prioritize food quantity over quality, relying heavily on carbohydrate-rich staples while neglecting protein- and micronutrient-rich foods essential for linear growth. Such practices can sustain or worsen growth faltering established during early childhood, particularly in rural contexts where access to formal nutrition education is limited [ 10 , 11 ]. The persistence of high stunting prevalence in food-secure regions such as Njombe underscores the importance of examining behavioral and knowledge-related determinants of child nutrition. National nutrition initiatives in Tanzania, including food fortification, growth monitoring services, and health education campaigns, have contributed to improvements in some settings, yet their impact appears uneven across regions. Many existing studies focus on national or regional prevalence estimates or on urban populations, where access to healthcare and nutrition information is relatively higher. Consequently, there is limited empirical evidence linking household dietary practices and caregiver nutritional knowledge directly to stunting outcomes in rural, food-secure, high-burden contexts such as Njombe. This study is informed by the Health Belief Model and Social Cognitive Theory, which together provide a useful framework for understanding caregiver feeding behaviors and child nutrition outcomes. The Health Belief Model posits that caregivers’ feeding practices are influenced by their perceptions of the severity of malnutrition, perceived benefits of appropriate dietary behaviors, and perceived barriers such as limited knowledge, misconceptions, or cultural beliefs [ 12 ]. Social Cognitive Theory complements this perspective by emphasizing the role of observational learning, self-efficacy, and social influences in shaping dietary behaviors within households [ 13 ]. In rural settings like Wanging’ombe District, where caregivers often rely on informal sources of information such as family members and peers, limited exposure to accurate nutrition education may reinforce suboptimal feeding practices. These theoretical perspectives support the study’s focus on caregiver nutritional knowledge and household dietary practices as key determinants of childhood stunting. Wanging’ombe District, within Njombe Region, provides an important context for examining these relationships. Despite routine access to health facilities and adequate food production, children in this district continue to experience high levels of moderate and severe stunting. This situation raises critical questions regarding the adequacy of household dietary practices, caregivers’ understanding of child nutrition and stunting, and the extent to which growth monitoring tools are understood and utilized at the community level. Therefore, this study aimed to investigate household dietary practices and caregivers’ nutritional knowledge as key determinants of stunting among children under five years in Wanging’ombe District, Njombe Region. Specifically, the study aimed to examine dietary practices among caregivers of under-five children with stunted growth in Njombe District and assessed the association between selected socio-demographic characteristics, nutrition knowledge, and exposure to nutrition training with dietary practices. By focusing on a food-secure yet high-burden setting, this study seeks to generate evidence that can inform context-specific nutrition education strategies, strengthen behavior-change interventions, and support more effective policies to reduce childhood stunting in similar rural settings. 2. Methods 2.1. Study Design and Setting A community-based cross-sectional study was conducted in Wanging’ombe District, located in Njombe Region in the Southern Highlands of Tanzania. The district is predominantly rural and agriculturally productive, with most households engaged in small-scale farming. Despite relatively high food availability, the district has persistently reported high levels of childhood stunting. The study was conducted in selected wards with documented high stunting prevalence, namely Makoga and Kipengele, which include several villages served by nearby primary health facilities. 2.2. Study Population The study population comprised caregivers of children under five years of age residing in the selected wards. Caregivers were defined as adults primarily responsible for child feeding and daily care, most commonly mothers. Caregivers were eligible to participate if they had at least one child aged 6–59 months and had lived in the study area for at least six months prior to data collection. Caregivers who were severely ill or unable to participate in the survey were excluded. 2.3. Sample Size and Sampling Technique A total of 151 caregivers participated in the study. A multistage sampling approach was employed. First, wards with high reported stunting prevalence were purposively selected. Within these wards, villages were identified, and households with eligible children were listed with the assistance of local leaders and health workers. Simple random sampling was then used to select households from the sampling frame. Where more than one eligible caregiver was present in a household, one was selected using a simple lottery method. 2.4. Data Collection Methods Data were collected using structured interviewer-administered questionnaires and documentary review of child health records. 2.4.1. Questionnaire Data The questionnaire was developed based on existing literature and national infant and young child feeding guidelines. It captured information on: Socio-demographic characteristics of caregivers and children, Household dietary practices, including meal frequency, food types consumed, dietary diversity, and snack quality, Infant and young child feeding practices, including duration of exclusive breastfeeding and timing of complementary feeding, Caregivers’ nutritional knowledge, including understanding of balanced diets, nutrient sources, and stunting, also Growth monitoring practices and caregiver perceptions of child growth. The questionnaire was administered in Swahili language by trained research assistants through face-to-face interviews. 2.4.2. Anthropometric and Documentary Data Anthropometric data (child height and age) were obtained from child health cards and health facility records. Height-for-age Z-scores (HAZ) were used to assess stunting status in accordance with World Health Organization growth standards. Moderate stunting was defined as HAZ between − 2 and − 3 standard deviations, while severe stunting was defined as HAZ below − 3 standard deviations. 2.5. Measurement of Key Variables 2.5.1. Dependent Variable The primary outcome variable was stunting status, categorized as moderate stunting and severe stunting. 2.5.2. Independent Variables Key independent variables included Household dietary practices, assessed using a composite score based on meal frequency, food diversity, and quality of foods consumed, caregiver nutritional knowledge, assessed through structured knowledge questions on balanced diets, child feeding, and stunting, infant feeding practices, including duration of exclusive breastfeeding and type of complementary foods introduced, and growth monitoring practices, including frequency of clinic visits and use of growth charts Dietary practices and nutritional knowledge were categorized into levels (poor/low vs. moderate) using Bloom’s cut-ff points, consistent with previous nutrition studies [ 14 ]. 2.6. Data Analysis Data were coded, entered, and analyzed using Statistical Product and Service Solutions SPSS version 20.0. Descriptive statistics, including frequencies and percentages, were used to summarize socio-demographic characteristics, dietary practices, nutritional knowledge, and stunting prevalence. Inferential analysis was conducted using the Chi-square (χ²) test to examine associations between: Dietary practice level and education of caregivers, Caregiver nutritional knowledge and Infant feeding practices, also caregivers training on infant nutrition and dietary practices. Statistical significance was set at p < 0.05. 2.7. Ethical Considerations Ethical approval to conduct the study was obtained from the Wanging’ombe District and District Health Department. Permission was also sought from ward and village leaders prior to data collection. All participants were informed about the purpose of the study, procedures involved, potential benefits, and their right to withdraw at any time without consequences. Confidentiality and anonymity were strictly maintained by using identification codes instead of personal identifiers. 3. Results 3.1. Characteristics of Study Participants A total of 151 caregivers of children under five years participated in the study. Most caregivers were aged 26–35 years (53.6%), followed by those aged 18–25 years (26.5%) and 36–45 years (19.9%). The majority had attained primary education (68.3%), while 31.1% had secondary education and less than 1% had higher education. Nearly all caregivers were engaged in subsistence farming, reflecting the predominantly rural and agrarian nature of the study area. Table 1 Socio-demographic and nutrition-related characteristics of respondents (N = 151) Variable Category N % Education level Primary education 102 68.9 Secondary/Higher 49 31.1 Nutrition training Yes 37 24 No 114 76 Nutrition knowledge Correct knowledge 26 17.2 Incorrect knowledge 125 82.8 Dietary practice Appropriate 19 12.6 Inappropriate 132 87.4 Most households (88.7%) had one child under five years, while 11.3% had two. Children aged 3–5 years constituted the majority (90.0%), with only 10.0% aged between 2 and 3 years. 3.2. Prevalence of Stunting Anthropometric assessment revealed a very high prevalence of stunting among children under five years in Wanging’ombe District. Of the 151 children assessed, 73.5% (n = 111) were moderately stunted (height-for-age Z-score between − 2 and − 3 SD), while 26.5% (n = 40) were severely stunted (HAZ < − 3 SD). No child fell within the normal height-for-age range, indicating widespread chronic undernutrition in the study population. 3.3. Household Dietary Practices 3.3.1. Meal Frequency and Snack Quality Most caregivers (89.4%) reported providing three main meals per day, while 10.6% provided four meals. Nearly all caregivers (98.0%) reported offering food between meals. However, the nutritional quality of snacks was poor, with 87.2% of children consuming low-nutrient snacks such as refined maize porridge, bread, sugary tea, or commercially processed juices. Only 12.8% of caregivers reported providing nutrient-dense snacks, including milk, fruits, or enriched porridge. 3.3.2. Food Types and Dietary Diversity Children’s diets were dominated by starchy staples, including maize products, Irish potatoes, rice, and legumes, consumed daily by 98.7% of households. Protein-rich foods such as meat, eggs, fish, or liver were consumed once per week by 65.8% of children, while 21.6% consumed protein foods rarely. Only 12.6% consumed protein foods two to three times per week. Consumption of green leafy vegetables was relatively common, with 86.1% of caregivers reporting daily intake. However, 58.3% of caregivers reported not providing mineral-rich foods, citing limited knowledge of their importance. 3.3.3. Infant and Young Child Feeding Practices Exclusive breastfeeding and complementary feeding practices were suboptimal. More than half of caregivers (58.3%) reported introducing complementary foods before six months, contrary to WHO recommendations. First complementary foods were predominantly maize porridge and other starchy foods, reported by 87.2% of caregivers. Only 12.8% introduced fortified or nutrient-rich foods during early complementary feeding. Using composite dietary practice scores, 86.8% of caregivers were classified as having poor dietary practices, while only 13.2% demonstrated moderate practices. 3.4. Caregivers’ Nutritional Knowledge 3.4.1. Understanding of Child Nutrition A large proportion of caregivers (83.4%) perceived nutrition primarily as eating frequently and in large quantities, with the aim of weight gain. Only 16.6% correctly identified nutrition as consumption of a balanced diet containing essential macro- and micronutrients necessary for child growth and disease prevention. 3.4.2. Sources of Nutrition Information Only 24.0% of caregivers reported having attended any formal nutrition education or training. Among those who had not attended training, 92.6% relied on informal sources such as family members or peers for nutrition information, while only 7.4% reported obtaining information from mass media. 3.4.3. Knowledge of Stunting Knowledge of stunting was limited. The majority of caregivers (70.2%) defined stunting as being thin due to inadequate food, while only 18.5% correctly identified it as poor linear growth related to chronic undernutrition. Most caregivers (79.1%) misidentified the signs of stunting as thinness or an enlarged abdomen, rather than short stature for age. Overall, 80.8% of caregivers demonstrated low nutritional knowledge, while 19.2% had moderate knowledge based on composite scores. 3.4.4. Growth Monitoring Practices and Perceptions of Child Growth All caregivers reported having taken their children to a health facility for growth monitoring within the previous six months. However, only 23.2% reported using or understanding growth monitoring charts, while 76.8% reported that they could not interpret them. Most caregivers (75.5%) believed their children were not growing normally. Among these caregivers, 61.4% attributed poor growth to inadequate nutrition, 35.1% to frequent illness, and a small proportion to normal growth variation. 3.5. Socio-demographic and knowledge-related factors associated with dietary practices First, the relationship between nutritional knowledge and dietary practices was assessed. The analysis showed no statistically significant association between nutrition knowledge and diet practice category (χ² = 0.683, df = 1, p = 0.409). Among respondents with correct nutrition knowledge, 7.7% reported appropriate dietary practices compared to 13.6% among those with incorrect knowledge. Overall, appropriate dietary practices were observed in only 12.6% of respondents, indicating generally poor dietary practices irrespective of nutrition knowledge status. Second, the association between education level and dietary practices was examined by categorizing education into primary education versus secondary or higher education. The results indicated no statistically significant association between education level and dietary practices (χ² = 1.80, df = 1, p = 0.180). Respondents with secondary or higher education showed a slightly higher proportion of appropriate dietary practices (17.6%) compared to those with primary education (10.0%), although this difference was not statistically significant. Table 2 Association between Education level and dietary practices (N = 151) Variable Category Inappropriate practice n (%) Appropriate practice n (%) χ² P-value Education level Primary 90 (90.0) 10 (10.0) 1.80 1.180 Secondary or higher 42 (82.4) 9 (17.6) Third, the relationship between nutrition training and nutrition knowledge was analyzed to assess whether exposure to nutrition training translated into improved nutrition knowledge. The findings revealed no statistically significant association between having received nutrition training and nutrition knowledge (χ² = 0.099, df = 1, p = 0.753). Correct nutrition knowledge was observed in 18.9% of respondents who had received nutrition training and 16.7% among those who had not received any training, suggesting minimal differences between the two groups. Table 3 Association between nutrition training and nutrition knowledge (N = 151) Variable Correct knowledge (%) Incorrect knowledge (%) χ² P-value Nutrition training 0.10 0.735 Yes 7 (18.9) 30 (81.1) No 19 (16.7) 95 (83.3) In contrast, a strong and statistically significant association was observed between nutrition training and dietary practices (χ² = 49.6, df = 1, p < 0.001). Nearly half of the respondents who had received nutrition training demonstrated appropriate dietary practices (45.9%), compared to only 1.8% among those who had not received any nutrition training. This finding indicates that exposure to nutrition training was strongly associated with improved dietary practices among the studied households. This suggests that nutrition training plays a more critical role in shaping dietary behavior than socio-demographic characteristics or nutrition knowledge alone. Table 2 Association between nutrition training and dietary practices among caregivers (N = 151) Nutrition training Inappropriate dietary practices n (%) Appropriate dietary practices n (%) Total χ² P-value Yes 20 (54.1) 17 (45.9) 27 No 112 (98.2) 2 (1.8) 114 Total 1132 (87.4) 19 (12.6) 151 49.6 < 0.001 Percentages are calculated within rows. Overall, the analyses indicate that nutrition knowledge and education level were not significantly associated with dietary practices, but nutrition training has shown a significant association with dietary practices in the study population. These findings suggest that factors beyond formal education, training exposure, and basic nutrition knowledge may play a more critical role in shaping dietary behaviors among the studied households. 4. Discussion This study examined the associations between selected socio-demographic and nutrition-related factors and dietary practices among caregivers of under-five children in Njombe District, a region that has persistently recorded high levels of childhood stunting. The findings demonstrate that while caregiver education level and nutrition knowledge were not significantly associated with dietary practices, nutrition training showed a strong and statistically significant association with appropriate dietary practices. These results provide important insights into the drivers of suboptimal child feeding practices in settings characterized by chronic undernutrition. The lack of a statistically significant association between caregiver education level and dietary practices suggests that formal education alone may be insufficient to influence child feeding behaviors. Although caregivers with secondary or higher education exhibited a slightly higher proportion of appropriate dietary practices compared to those with primary education, the difference was not significant. This finding aligns with previous studies conducted in Tanzania and other low- and middle-income countries, which have shown that maternal or caregiver education does not consistently translate into improved child nutrition outcomes when structural and contextual constraints persist [ 15 , 16 ]. In Njombe, where poverty, food seasonality, and limited dietary diversity remain prevalent, formal education may have limited practical influence on daily feeding decisions. Similarly, nutrition knowledge alone was not significantly associated with dietary practices in this study. Caregivers who demonstrated correct nutrition knowledge were not substantially more likely to practice appropriate child feeding than those with incorrect knowledge. This finding highlights a well-documented knowledge–practice gap in nutrition behavior change [ 17 ]. Knowledge may raise awareness, but often fails to overcome barriers such as household food insecurity, cultural feeding norms, limited access to animal-source foods, and competing household priorities. In Njombe, where diets are heavily dominated by starchy staples despite high agricultural production, caregivers may know what constitutes appropriate feeding but remain constrained in their ability to implement such practices. In contrast, nutrition training emerged as a strong and significant predictor of appropriate dietary practices. Caregivers who had received nutrition training were substantially more likely to demonstrate appropriate feeding practices compared to those who had not received training. This finding is consistent with evidence showing that targeted, participatory nutrition education interventions are more effective than general knowledge dissemination in improving infant and young child feeding practices [ 18 , 19 ]. Nutrition training often emphasizes practical skills, locally available foods, counseling, and repeated engagement, which may enhance caregivers’ capacity to translate information into action. The strong association between nutrition training and dietary practices is particularly important in the context of Njombe, a region that paradoxically experiences high levels of stunting despite being a major food-producing area. Previous studies in Southern Highland regions of Tanzania have documented that child stunting in Njombe is driven not only by food availability but also by poor feeding practices, low dietary diversity, delayed introduction of complementary foods, and inadequate caregiver support [ 20 , 21 ]. The findings of the present study reinforce the argument that improving child nutrition in Njombe requires interventions that go beyond food production and caregiver education, focusing instead on behavior change and practical nutrition support. Taken together, these findings suggest that nutrition training represents a critical leverage point for addressing inappropriate dietary practices and, ultimately, reducing childhood stunting in Njombe. Strengthening nutrition training through routine health facility services, community-based programs, and outreach by community health workers may enhance caregivers’ ability to adopt appropriate feeding practices even in resource-constrained settings. Interventions aimed at reducing stunting should therefore prioritize structured nutrition training and counseling, complemented by efforts to improve food access and household resilience. 5. Conclusion This study shows that inappropriate dietary practices among caregivers of under-five children remain common in Njombe District, despite formal education and basic nutrition knowledge. While education level and nutrition knowledge were not significantly associated with dietary practices, exposure to nutrition training demonstrated a strong and significant association with appropriate feeding practices. These findings underscore the importance of practical, skills-based nutrition interventions over information-based approaches alone. In line with Tanzania’s National Nutrition Action Plan, which emphasizes behavior change communication, community-based nutrition education, and strengthened service delivery, the results highlight nutrition training as a critical entry point for stunting reduction in Njombe. Scaling up context-specific nutrition training through health facilities, community health workers, and routine child health services may enhance caregivers’ ability to translate knowledge into practice. Prioritizing such action-oriented interventions is essential for improving dietary practices and contributing to sustained reductions in childhood stunting in high-burden districts. 6. Recommendations Based on the findings of this study, it is recommended that nutrition interventions in Njombe District prioritize structured, practical nutrition training for caregivers of under-five children as a central strategy for reducing childhood stunting. Consistent with Tanzania’s National Nutrition Action Plan, nutrition training should be strengthened within routine maternal and child health services, including growth monitoring clinics, antenatal and postnatal care, and community outreach programs delivered by community health workers. Nutrition training programs should move beyond information dissemination to emphasize behavior change communication, practical demonstrations, and the use of locally available and affordable foods. District health authorities and implementing partners should integrate regular refresher training and supportive supervision to ensure consistency and quality of nutrition counseling. Additionally, stunting reduction strategies in Njombe should align nutrition training with broader food security and social support initiatives to address structural barriers that limit caregivers’ ability to translate knowledge into practice. Declarations Conflict of Interest: The authors declare no conflict of interest. Clinical trial number Not applicable Ethical approval Ethical approval for this study was obtained from the Ruaha Catholic University (RUCU) Research Ethics, through the Directorate of Research and Publications, Ruaha Catholic University, Tanzania. Formal written approval was granted prior to commencement of data collection. The study was conducted in accordance with the ethical principles for research involving human participants and adhered to institutional research guidelines as well as the Declaration of Helsinki. Consent to participate Written informed consent was obtained from all participants prior to participation in the study. Participation was voluntary, and respondents were informed of their right to withdraw at any time without penalty. Confidentiality and anonymity were strictly maintained throughout the study. Consent to publish Not applicable. The manuscript does not contain any identifiable personal data, images, or information requiring individual consent for publication. Author Contribution Both authors conceived the study. VK wrote the introduction, methods, and collected all the data. JL analysed the data, wrote the results section, and drafted the manuscript. Both authors approved the manuscript; hence, they are accountable for its contents. Acknowledgement The authors acknowledge the Ruaha Catholic University for offering a research permit, through which the data for this study were collected. Further, the authors acknowledge to Wanging’ombe District Council and the Wanging’ombe Health department for the cooperation and support they offered during data collection. We send sincere appreciation to all caregivers who participated in the data collection. Their cooperation has made this study possible. Data Availability The raw data supporting the conclusions of this article are available from the corresponding author upon reasonable request. References UNICEF, WHO, World Bank. Levels and trends in child malnutrition: joint child malnutrition estimates. Geneva: World Health Organization; 2023. Victora CG, de Onis M, Hallal PC, Blössner M, Shrimpton R. Worldwide timing of growth faltering: revisiting implications for interventions. 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How countries can reduce child stunting at scale: lessons from exemplar countries. Am J Clin Nutr. 2020;112:S894–904. Dewey KG, Adu-Afarwuah S. Systematic review of complementary feeding interventions. Matern Child Nutr. 2008;4(s1):24–85. Ministry of Health. Community Development, Gender, Elderly and Children (MoHCDGEC) [Tanzania], ICF. Tanzania Demographic and Health Survey and Malaria Indicator Survey (TDHS-MIS) 2015–16. Dar es Salaam and Rockville: MoHCDGEC and ICF; 2016. United Republic of Tanzania (URT). Tanzania National Nutrition Survey 2018. Dodoma: URT Ministry of Health / Tanzania Food and Nutrition Centre; 2018. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8763772","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":612183824,"identity":"228fee65-de1c-4e8a-b820-7251564ed279","order_by":0,"name":"Victoria Melkion Kilamlya","email":"","orcid":"","institution":"Ruaha Catholic University","correspondingAuthor":false,"prefix":"","firstName":"Victoria","middleName":"Melkion","lastName":"Kilamlya","suffix":""},{"id":612183825,"identity":"e7d783cf-b6d4-483b-975d-7fa041abd8ee","order_by":1,"name":"Justin Edward Lusasi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/UlEQVRIiWNgGAWjYBACxgYgkcDAIAPmJVQQp4WxAaiFB6LlDFzCgKBFEC2MbURoYZ6R/vzBwx0MPAbnDz/+8HDevcT+GQmMH34w/LHHacWMHMOGxDNALTfSzCQStxUnzriRwCzZw2DAjEcLY0NiG0gLgxlD4raExA0SCQzSQIex4daS/hCi5fzxzx8S54C1MP8GauHBrSXBEKLlQI6BRGIDWAsbyBYJnFp63hjOSGyT4JG8kVMmkXAswXjGmYdtlj0GxjiDzLA9/cHHn202cnznj2/++KMmQba/PfnwjR8VcjhDzLABTKG4AhRReGJSHrfUKBgFo2AUjAIoAADGr1O6TZzGowAAAABJRU5ErkJggg==","orcid":"","institution":"Ruaha Catholic University","correspondingAuthor":true,"prefix":"","firstName":"Justin","middleName":"Edward","lastName":"Lusasi","suffix":""}],"badges":[],"createdAt":"2026-02-02 10:39:02","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8763772/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8763772/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108007226,"identity":"1c336664-2451-42e0-87c2-2b03e97b22ba","added_by":"auto","created_at":"2026-04-28 12:59:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":249081,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8763772/v1/45e93806-dfe4-4a9f-bd5e-56ed760a33b1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Dietary Practices and Nutritional Knowledge Among Caregivers of Stunted Under-Five Children in Njombe Region, Tanzania","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eStunting, defined as low height-for-age resulting from chronic undernutrition, remains a major public health challenge affecting children under five years of age worldwide. In 2022, an estimated 148\u0026nbsp;million children under five were stunted globally, representing approximately 22% of all children in this age group [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Stunting reflects prolonged nutritional deprivation during critical periods of growth and development, particularly from conception through early childhood. The consequences of stunting extend beyond impaired physical growth and include irreversible cognitive deficits, reduced school performance, increased susceptibility to infectious diseases, and lower economic productivity later in life [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Although global stunting prevalence has declined over recent decades, progress has been uneven, with Sub-Saharan Africa continuing to carry a disproportionate burden.\u003c/p\u003e \u003cp\u003eTanzania remains among the countries with high levels of childhood stunting, with nearly one-third of children under five affected nationally [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. More concerning are substantial subnational disparities, where certain regions report stunting prevalence far above the national average. Njombe Region, located in the Southern Highlands of Tanzania, exemplifies this challenge. Despite being one of the country\u0026rsquo;s most agriculturally productive and food-secure regions, Njombe has consistently recorded stunting prevalence exceeding 50% [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. This apparent paradox suggests that food availability alone is insufficient to prevent chronic undernutrition and that household-level factors, particularly dietary practices and caregiver nutritional knowledge, play a critical role in shaping child growth outcomes.\u003c/p\u003e \u003cp\u003eAdequate nutrition during the first 1,000 days of life is widely recognized as essential for preventing stunting. Exclusive breastfeeding for the first six months, followed by the timely introduction of appropriate, diverse, and nutrient-dense complementary foods while continuing breastfeeding, is strongly recommended to support optimal growth and development [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, evidence from low- and middle-income countries shows that inappropriate infant and young child feeding practices persist even in food-producing settings. Diets dominated by starchy staples, low dietary diversity, premature introduction of complementary foods, and inadequate intake of animal-source foods and micronutrients are frequently reported contributors to chronic undernutrition [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBeyond infancy, children older than two years remain vulnerable to stunting due to continued dietary inadequacies and suboptimal household feeding behaviors. At this stage, children increasingly depend on family diets, which are shaped by caregivers\u0026rsquo; food choices, preparation practices, and nutritional understanding. Caregivers with limited nutrition knowledge may prioritize food quantity over quality, relying heavily on carbohydrate-rich staples while neglecting protein- and micronutrient-rich foods essential for linear growth. Such practices can sustain or worsen growth faltering established during early childhood, particularly in rural contexts where access to formal nutrition education is limited [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe persistence of high stunting prevalence in food-secure regions such as Njombe underscores the importance of examining behavioral and knowledge-related determinants of child nutrition. National nutrition initiatives in Tanzania, including food fortification, growth monitoring services, and health education campaigns, have contributed to improvements in some settings, yet their impact appears uneven across regions. Many existing studies focus on national or regional prevalence estimates or on urban populations, where access to healthcare and nutrition information is relatively higher. Consequently, there is limited empirical evidence linking household dietary practices and caregiver nutritional knowledge directly to stunting outcomes in rural, food-secure, high-burden contexts such as Njombe.\u003c/p\u003e \u003cp\u003eThis study is informed by the Health Belief Model and Social Cognitive Theory, which together provide a useful framework for understanding caregiver feeding behaviors and child nutrition outcomes. The Health Belief Model posits that caregivers\u0026rsquo; feeding practices are influenced by their perceptions of the severity of malnutrition, perceived benefits of appropriate dietary behaviors, and perceived barriers such as limited knowledge, misconceptions, or cultural beliefs [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Social Cognitive Theory complements this perspective by emphasizing the role of observational learning, self-efficacy, and social influences in shaping dietary behaviors within households [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In rural settings like Wanging\u0026rsquo;ombe District, where caregivers often rely on informal sources of information such as family members and peers, limited exposure to accurate nutrition education may reinforce suboptimal feeding practices. These theoretical perspectives support the study\u0026rsquo;s focus on caregiver nutritional knowledge and household dietary practices as key determinants of childhood stunting.\u003c/p\u003e \u003cp\u003eWanging\u0026rsquo;ombe District, within Njombe Region, provides an important context for examining these relationships. Despite routine access to health facilities and adequate food production, children in this district continue to experience high levels of moderate and severe stunting. This situation raises critical questions regarding the adequacy of household dietary practices, caregivers\u0026rsquo; understanding of child nutrition and stunting, and the extent to which growth monitoring tools are understood and utilized at the community level.\u003c/p\u003e \u003cp\u003eTherefore, this study aimed to investigate household dietary practices and caregivers\u0026rsquo; nutritional knowledge as key determinants of stunting among children under five years in Wanging\u0026rsquo;ombe District, Njombe Region. Specifically, the study aimed to examine dietary practices among caregivers of under-five children with stunted growth in Njombe District and assessed the association between selected socio-demographic characteristics, nutrition knowledge, and exposure to nutrition training with dietary practices. By focusing on a food-secure yet high-burden setting, this study seeks to generate evidence that can inform context-specific nutrition education strategies, strengthen behavior-change interventions, and support more effective policies to reduce childhood stunting in similar rural settings.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n\u003ch2\u003e2.1. Study Design and Setting\u003c/h2\u003e\n\u003cp\u003eA community-based cross-sectional study was conducted in Wanging\u0026rsquo;ombe District, located in Njombe Region in the Southern Highlands of Tanzania. The district is predominantly rural and agriculturally productive, with most households engaged in small-scale farming. Despite relatively high food availability, the district has persistently reported high levels of childhood stunting. The study was conducted in selected wards with documented high stunting prevalence, namely Makoga and Kipengele, which include several villages served by nearby primary health facilities.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n\u003ch2\u003e2.2. Study Population\u003c/h2\u003e\n\u003cp\u003eThe study population comprised caregivers of children under five years of age residing in the selected wards. Caregivers were defined as adults primarily responsible for child feeding and daily care, most commonly mothers. Caregivers were eligible to participate if they had at least one child aged 6\u0026ndash;59 months and had lived in the study area for at least six months prior to data collection. Caregivers who were severely ill or unable to participate in the survey were excluded.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n\u003ch2\u003e2.3. Sample Size and Sampling Technique\u003c/h2\u003e\n\u003cp\u003eA total of 151 caregivers participated in the study. A multistage sampling approach was employed. First, wards with high reported stunting prevalence were purposively selected. Within these wards, villages were identified, and households with eligible children were listed with the assistance of local leaders and health workers. Simple random sampling was then used to select households from the sampling frame. Where more than one eligible caregiver was present in a household, one was selected using a simple lottery method.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n\u003ch2\u003e2.4. Data Collection Methods\u003c/h2\u003e\n\u003cp\u003eData were collected using structured interviewer-administered questionnaires and documentary review of child health records.\u003c/p\u003e\n\u003cdiv id=\"Sec7\" class=\"Section3\"\u003e\n\u003ch2\u003e2.4.1. Questionnaire Data\u003c/h2\u003e\n\u003cp\u003eThe questionnaire was developed based on existing literature and national infant and young child feeding guidelines. It captured information on: Socio-demographic characteristics of caregivers and children, Household dietary practices, including meal frequency, food types consumed, dietary diversity, and snack quality, Infant and young child feeding practices, including duration of exclusive breastfeeding and timing of complementary feeding, Caregivers\u0026rsquo; nutritional knowledge, including understanding of balanced diets, nutrient sources, and stunting, also Growth monitoring practices and caregiver perceptions of child growth. The questionnaire was administered in Swahili language by trained research assistants through face-to-face interviews.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section3\"\u003e\n\u003ch2\u003e2.4.2. Anthropometric and Documentary Data\u003c/h2\u003e\n\u003cp\u003eAnthropometric data (child height and age) were obtained from child health cards and health facility records. Height-for-age Z-scores (HAZ) were used to assess stunting status in accordance with World Health Organization growth standards. Moderate stunting was defined as HAZ between \u0026minus;\u0026thinsp;2 and \u0026minus;\u0026thinsp;3 standard deviations, while severe stunting was defined as HAZ below \u0026minus;\u0026thinsp;3 standard deviations.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n\u003ch2\u003e2.5. Measurement of Key Variables\u003c/h2\u003e\n\u003cdiv id=\"Sec10\" class=\"Section3\"\u003e\n\u003ch2\u003e2.5.1. Dependent Variable\u003c/h2\u003e\n\u003cp\u003eThe primary outcome variable was stunting status, categorized as moderate stunting and severe stunting.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section3\"\u003e\n\u003ch2\u003e2.5.2. Independent Variables\u003c/h2\u003e\n\u003cp\u003eKey independent variables included Household dietary practices, assessed using a composite score based on meal frequency, food diversity, and quality of foods consumed, caregiver nutritional knowledge, assessed through structured knowledge questions on balanced diets, child feeding, and stunting, infant feeding practices, including duration of exclusive breastfeeding and type of complementary foods introduced, and growth monitoring practices, including frequency of clinic visits and use of growth charts\u003c/p\u003e\n\u003cp\u003eDietary practices and nutritional knowledge were categorized into levels (poor/low vs. moderate) using Bloom\u0026rsquo;s cut-ff points, consistent with previous nutrition studies [\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n\u003ch2\u003e2.6. Data Analysis\u003c/h2\u003e\n\u003cp\u003eData were coded, entered, and analyzed using Statistical Product and Service Solutions SPSS version 20.0. Descriptive statistics, including frequencies and percentages, were used to summarize socio-demographic characteristics, dietary practices, nutritional knowledge, and stunting prevalence.\u003c/p\u003e\n\u003cp\u003eInferential analysis was conducted using the Chi-square (\u0026chi;\u0026sup2;) test to examine associations between: Dietary practice level and education of caregivers, Caregiver nutritional knowledge and Infant feeding practices, also caregivers training on infant nutrition and dietary practices. Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n\u003ch2\u003e2.7. Ethical Considerations\u003c/h2\u003e\n\u003cp\u003eEthical approval\u0026nbsp;to conduct the study was obtained from the Wanging\u0026rsquo;ombe District and District Health Department. Permission was also sought from ward and village leaders prior to data collection. All participants were informed about the purpose of the study, procedures involved, potential benefits, and their right to withdraw at any time without consequences. Confidentiality and anonymity were strictly maintained by using identification codes instead of personal identifiers.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n \u003ch2\u003e3.1. Characteristics of Study Participants\u003c/h2\u003e\n \u003cp\u003eA total of 151 caregivers of children under five years participated in the study. Most caregivers were aged 26\u0026ndash;35 years (53.6%), followed by those aged 18\u0026ndash;25 years (26.5%) and 36\u0026ndash;45 years (19.9%). The majority had attained primary education (68.3%), while 31.1% had secondary education and less than 1% had higher education. Nearly all caregivers were engaged in subsistence farming, reflecting the predominantly rural and agrarian nature of the study area.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eSocio-demographic and nutrition-related characteristics of respondents (N\u0026thinsp;=\u0026thinsp;151)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCategory\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eEducation level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrimary education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e102\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e68.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSecondary/Higher\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eNutrition training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e114\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e76\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eNutrition knowledge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCorrect knowledge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIncorrect knowledge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e125\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e82.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eDietary practice\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAppropriate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInappropriate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e132\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e87.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eMost households (88.7%) had one child under five years, while 11.3% had two. Children aged 3\u0026ndash;5 years constituted the majority (90.0%), with only 10.0% aged between 2 and 3 years.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\n \u003ch2\u003e3.2. Prevalence of Stunting\u003c/h2\u003e\n \u003cp\u003eAnthropometric assessment revealed a very high prevalence of stunting among children under five years in Wanging\u0026rsquo;ombe District. Of the 151 children assessed, 73.5% (n\u0026thinsp;=\u0026thinsp;111) were moderately stunted (height-for-age Z-score between \u0026minus;\u0026thinsp;2 and \u0026minus;\u0026thinsp;3 SD), while 26.5% (n\u0026thinsp;=\u0026thinsp;40) were severely stunted (HAZ\u0026thinsp;\u0026lt;\u0026thinsp;\u0026minus;\u0026thinsp;3 SD). No child fell within the normal height-for-age range, indicating widespread chronic undernutrition in the study population.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\n \u003ch2\u003e3.3. Household Dietary Practices\u003c/h2\u003e\n \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e\n \u003ch2\u003e3.3.1. Meal Frequency and Snack Quality\u003c/h2\u003e\n \u003cp\u003eMost caregivers (89.4%) reported providing three main meals per day, while 10.6% provided four meals. Nearly all caregivers (98.0%) reported offering food between meals. However, the nutritional quality of snacks was poor, with 87.2% of children consuming low-nutrient snacks such as refined maize porridge, bread, sugary tea, or commercially processed juices. Only 12.8% of caregivers reported providing nutrient-dense snacks, including milk, fruits, or enriched porridge.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec19\" class=\"Section3\"\u003e\n \u003ch2\u003e3.3.2. Food Types and Dietary Diversity\u003c/h2\u003e\n \u003cp\u003eChildren\u0026rsquo;s diets were dominated by starchy staples, including maize products, Irish potatoes, rice, and legumes, consumed daily by 98.7% of households. Protein-rich foods such as meat, eggs, fish, or liver were consumed once per week by 65.8% of children, while 21.6% consumed protein foods rarely. Only 12.6% consumed protein foods two to three times per week.\u003c/p\u003e\n \u003cp\u003eConsumption of green leafy vegetables was relatively common, with 86.1% of caregivers reporting daily intake. However, 58.3% of caregivers reported not providing mineral-rich foods, citing limited knowledge of their importance.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec20\" class=\"Section3\"\u003e\n \u003ch2\u003e3.3.3. Infant and Young Child Feeding Practices\u003c/h2\u003e\n \u003cp\u003eExclusive breastfeeding and complementary feeding practices were suboptimal. More than half of caregivers (58.3%) reported introducing complementary foods before six months, contrary to WHO recommendations. First complementary foods were predominantly maize porridge and other starchy foods, reported by 87.2% of caregivers. Only 12.8% introduced fortified or nutrient-rich foods during early complementary feeding. Using composite dietary practice scores, 86.8% of caregivers were classified as having poor dietary practices, while only 13.2% demonstrated moderate practices.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\n \u003ch2\u003e3.4. Caregivers\u0026rsquo; Nutritional Knowledge\u003c/h2\u003e\n \u003cdiv id=\"Sec22\" class=\"Section3\"\u003e\n \u003ch2\u003e3.4.1. Understanding of Child Nutrition\u003c/h2\u003e\n \u003cp\u003eA large proportion of caregivers (83.4%) perceived nutrition primarily as eating frequently and in large quantities, with the aim of weight gain. Only 16.6% correctly identified nutrition as consumption of a balanced diet containing essential macro- and micronutrients necessary for child growth and disease prevention.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\n \u003ch2\u003e3.4.2. Sources of Nutrition Information\u003c/h2\u003e\n \u003cp\u003eOnly 24.0% of caregivers reported having attended any formal nutrition education or training. Among those who had not attended training, 92.6% relied on informal sources such as family members or peers for nutrition information, while only 7.4% reported obtaining information from mass media.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec24\" class=\"Section3\"\u003e\n \u003ch2\u003e3.4.3. Knowledge of Stunting\u003c/h2\u003e\n \u003cp\u003eKnowledge of stunting was limited. The majority of caregivers (70.2%) defined stunting as being thin due to inadequate food, while only 18.5% correctly identified it as poor linear growth related to chronic undernutrition. Most caregivers (79.1%) misidentified the signs of stunting as thinness or an enlarged abdomen, rather than short stature for age.\u003c/p\u003e\n \u003cp\u003eOverall, 80.8% of caregivers demonstrated low nutritional knowledge, while 19.2% had moderate knowledge based on composite scores.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\n \u003ch2\u003e3.4.4. Growth Monitoring Practices and Perceptions of Child Growth\u003c/h2\u003e\n \u003cp\u003eAll caregivers reported having taken their children to a health facility for growth monitoring within the previous six months. However, only 23.2% reported using or understanding growth monitoring charts, while 76.8% reported that they could not interpret them.\u003c/p\u003e\n \u003cp\u003eMost caregivers (75.5%) believed their children were not growing normally. Among these caregivers, 61.4% attributed poor growth to inadequate nutrition, 35.1% to frequent illness, and a small proportion to normal growth variation.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec26\" class=\"Section2\"\u003e\n \u003ch2\u003e3.5. Socio-demographic and knowledge-related factors associated with dietary practices\u003c/h2\u003e\n \u003cp\u003eFirst, the relationship between nutritional knowledge and dietary practices was assessed. The analysis showed no statistically significant association between nutrition knowledge and diet practice category (\u0026chi;\u0026sup2; = 0.683, df\u0026thinsp;=\u0026thinsp;1, p\u0026thinsp;=\u0026thinsp;0.409). Among respondents with correct nutrition knowledge, 7.7% reported appropriate dietary practices compared to 13.6% among those with incorrect knowledge. Overall, appropriate dietary practices were observed in only 12.6% of respondents, indicating generally poor dietary practices irrespective of nutrition knowledge status.\u003c/p\u003e\n \u003cp\u003eSecond, the association between education level and dietary practices was examined by categorizing education into primary education versus secondary or higher education. The results indicated no statistically significant association between education level and dietary practices (\u0026chi;\u0026sup2; = 1.80, df\u0026thinsp;=\u0026thinsp;1, p\u0026thinsp;=\u0026thinsp;0.180). Respondents with secondary or higher education showed a slightly higher proportion of appropriate dietary practices (17.6%) compared to those with primary education (10.0%), although this difference was not statistically significant.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eAssociation between Education level and dietary practices (N\u0026thinsp;=\u0026thinsp;151)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCategory\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eInappropriate practice n (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAppropriate practice n (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u0026chi;\u0026sup2;\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eEducation level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrimary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e90 (90.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e10 (10.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e1.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e1.180\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSecondary or higher\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e42 (82.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e9 (17.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eThird, the relationship between nutrition training and nutrition knowledge was analyzed to assess whether exposure to nutrition training translated into improved nutrition knowledge. The findings revealed no statistically significant association between having received nutrition training and nutrition knowledge (\u0026chi;\u0026sup2; = 0.099, df\u0026thinsp;=\u0026thinsp;1, p\u0026thinsp;=\u0026thinsp;0.753). Correct nutrition knowledge was observed in 18.9% of respondents who had received nutrition training and 16.7% among those who had not received any training, suggesting minimal differences between the two groups.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003cdiv class=\"colspec\" align=\"char\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eAssociation between nutrition training and nutrition knowledge (N\u0026thinsp;=\u0026thinsp;151)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCorrect knowledge (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eIncorrect knowledge (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u0026chi;\u0026sup2;\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNutrition training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e0.735\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e7 (18.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e30 (81.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e19 (16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e95 (83.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eIn contrast, a strong and statistically significant association was observed between nutrition training and dietary practices (\u0026chi;\u0026sup2; = 49.6, df\u0026thinsp;=\u0026thinsp;1, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Nearly half of the respondents who had received nutrition training demonstrated appropriate dietary practices (45.9%), compared to only 1.8% among those who had not received any nutrition training. This finding indicates that exposure to nutrition training was strongly associated with improved dietary practices among the studied households. This suggests that nutrition training plays a more critical role in shaping dietary behavior than socio-demographic characteristics or nutrition knowledge alone.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n \u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eAssociation between nutrition training and dietary practices among caregivers (N\u0026thinsp;=\u0026thinsp;151)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNutrition training\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eInappropriate dietary practices n (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAppropriate dietary practices n (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u0026chi;\u0026sup2;\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003eP-value\n \u003c/div\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e20 (54.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e17 (45.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e112 (98.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e2 (1.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e114\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e1132 (87.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e19 (12.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e151\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e49.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cem\u003ePercentages are calculated within rows.\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eOverall, the analyses indicate that nutrition knowledge and education level were not significantly associated with dietary practices, but nutrition training has shown a significant association with dietary practices in the study population. These findings suggest that factors beyond formal education, training exposure, and basic nutrition knowledge may play a more critical role in shaping dietary behaviors among the studied households.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis study examined the associations between selected socio-demographic and nutrition-related factors and dietary practices among caregivers of under-five children in Njombe District, a region that has persistently recorded high levels of childhood stunting. The findings demonstrate that while caregiver education level and nutrition knowledge were not significantly associated with dietary practices, nutrition training showed a strong and statistically significant association with appropriate dietary practices. These results provide important insights into the drivers of suboptimal child feeding practices in settings characterized by chronic undernutrition.\u003c/p\u003e \u003cp\u003eThe lack of a statistically significant association between caregiver education level and dietary practices suggests that formal education alone may be insufficient to influence child feeding behaviors. Although caregivers with secondary or higher education exhibited a slightly higher proportion of appropriate dietary practices compared to those with primary education, the difference was not significant. This finding aligns with previous studies conducted in Tanzania and other low- and middle-income countries, which have shown that maternal or caregiver education does not consistently translate into improved child nutrition outcomes when structural and contextual constraints persist [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In Njombe, where poverty, food seasonality, and limited dietary diversity remain prevalent, formal education may have limited practical influence on daily feeding decisions.\u003c/p\u003e \u003cp\u003eSimilarly, nutrition knowledge alone was not significantly associated with dietary practices in this study. Caregivers who demonstrated correct nutrition knowledge were not substantially more likely to practice appropriate child feeding than those with incorrect knowledge. This finding highlights a well-documented knowledge\u0026ndash;practice gap in nutrition behavior change [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Knowledge may raise awareness, but often fails to overcome barriers such as household food insecurity, cultural feeding norms, limited access to animal-source foods, and competing household priorities. In Njombe, where diets are heavily dominated by starchy staples despite high agricultural production, caregivers may know what constitutes appropriate feeding but remain constrained in their ability to implement such practices.\u003c/p\u003e \u003cp\u003eIn contrast, nutrition training emerged as a strong and significant predictor of appropriate dietary practices. Caregivers who had received nutrition training were substantially more likely to demonstrate appropriate feeding practices compared to those who had not received training. This finding is consistent with evidence showing that targeted, participatory nutrition education interventions are more effective than general knowledge dissemination in improving infant and young child feeding practices [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Nutrition training often emphasizes practical skills, locally available foods, counseling, and repeated engagement, which may enhance caregivers\u0026rsquo; capacity to translate information into action.\u003c/p\u003e \u003cp\u003eThe strong association between nutrition training and dietary practices is particularly important in the context of Njombe, a region that paradoxically experiences high levels of stunting despite being a major food-producing area. Previous studies in Southern Highland regions of Tanzania have documented that child stunting in Njombe is driven not only by food availability but also by poor feeding practices, low dietary diversity, delayed introduction of complementary foods, and inadequate caregiver support [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The findings of the present study reinforce the argument that improving child nutrition in Njombe requires interventions that go beyond food production and caregiver education, focusing instead on behavior change and practical nutrition support.\u003c/p\u003e \u003cp\u003eTaken together, these findings suggest that nutrition training represents a critical leverage point for addressing inappropriate dietary practices and, ultimately, reducing childhood stunting in Njombe. Strengthening nutrition training through routine health facility services, community-based programs, and outreach by community health workers may enhance caregivers\u0026rsquo; ability to adopt appropriate feeding practices even in resource-constrained settings. Interventions aimed at reducing stunting should therefore prioritize structured nutrition training and counseling, complemented by efforts to improve food access and household resilience.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThis study shows that inappropriate dietary practices among caregivers of under-five children remain common in Njombe District, despite formal education and basic nutrition knowledge. While education level and nutrition knowledge were not significantly associated with dietary practices, exposure to nutrition training demonstrated a strong and significant association with appropriate feeding practices. These findings underscore the importance of practical, skills-based nutrition interventions over information-based approaches alone.\u003c/p\u003e \u003cp\u003eIn line with Tanzania\u0026rsquo;s National Nutrition Action Plan, which emphasizes behavior change communication, community-based nutrition education, and strengthened service delivery, the results highlight nutrition training as a critical entry point for stunting reduction in Njombe. Scaling up context-specific nutrition training through health facilities, community health workers, and routine child health services may enhance caregivers\u0026rsquo; ability to translate knowledge into practice. Prioritizing such action-oriented interventions is essential for improving dietary practices and contributing to sustained reductions in childhood stunting in high-burden districts.\u003c/p\u003e"},{"header":"6. Recommendations","content":"\u003cp\u003eBased on the findings of this study, it is recommended that nutrition interventions in Njombe District prioritize structured, practical nutrition training for caregivers of under-five children as a central strategy for reducing childhood stunting. Consistent with Tanzania\u0026rsquo;s National Nutrition Action Plan, nutrition training should be strengthened within routine maternal and child health services, including growth monitoring clinics, antenatal and postnatal care, and community outreach programs delivered by community health workers.\u003c/p\u003e \u003cp\u003eNutrition training programs should move beyond information dissemination to emphasize behavior change communication, practical demonstrations, and the use of locally available and affordable foods. District health authorities and implementing partners should integrate regular refresher training and supportive supervision to ensure consistency and quality of nutrition counseling. Additionally, stunting reduction strategies in Njombe should align nutrition training with broader food security and social support initiatives to address structural barriers that limit caregivers\u0026rsquo; ability to translate knowledge into practice.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eConflict of Interest:\u003c/h2\u003e\n\u003cp\u003eThe authors declare no conflict of interest.\u003c/p\u003e\n\u003ch2\u003eClinical trial number\u003c/h2\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cdiv class=\"Heading\"\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/div\u003e\n\u003cp\u003eEthical approval for this study was obtained from the Ruaha Catholic University (RUCU) Research Ethics, through the Directorate of Research and Publications, Ruaha Catholic University, Tanzania. Formal written approval was granted prior to commencement of data collection. The study was conducted in accordance with the ethical principles for research involving human participants and adhered to institutional research guidelines as well as the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from all participants prior to participation in the study. Participation was voluntary, and respondents were informed of their right to withdraw at any time without penalty. Confidentiality and anonymity were strictly maintained throughout the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. The manuscript does not contain any identifiable personal data, images, or information requiring individual consent for publication.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eBoth authors conceived the study. VK wrote the introduction, methods, and collected all the data. JL analysed the data, wrote the results section, and drafted the manuscript. Both authors approved the manuscript; hence, they are accountable for its contents.\u003c/p\u003e\n\u003ch2\u003eAcknowledgement\u003c/h2\u003e\n\u003cp\u003eThe authors acknowledge the Ruaha Catholic University for offering a research permit, through which the data for this study were collected. Further, the authors acknowledge to Wanging\u0026rsquo;ombe District Council and the Wanging\u0026rsquo;ombe Health department for the cooperation and support they offered during data collection. We send sincere appreciation to all caregivers who participated in the data collection. Their cooperation has made this study possible.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eThe raw data supporting the conclusions of this article are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eUNICEF, WHO, World Bank. Levels and trends in child malnutrition: joint child malnutrition estimates. Geneva: World Health Organization; 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVictora CG, de Onis M, Hallal PC, Bl\u0026ouml;ssner M, Shrimpton R. Worldwide timing of growth faltering: revisiting implications for interventions. Pediatrics. 2010;125(3):e473\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSoliman A, De Sanctis V, Alaaraj N, Ahmed S, Alyafei F, Hamed N, et al. Early and long-term consequences of nutritional stunting: from childhood to adulthood. Acta Biomed. 2021;92(1):e2021168.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinistry of Health (MoH). [Tanzania], National Bureau of Statistics (NBS), ICF. Tanzania Demographic and Health Survey and Malaria Indicator Survey 2022 Final Report. Dar es Salaam and Rockville. MoH, NBS, and ICF; 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUNICEF. Nutrition for every child: UNICEF nutrition strategy 2020\u0026ndash;2030. New York: UNICEF; 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Essential nutrition actions: improving maternal, newborn, infant, and young child health and nutrition. Geneva: WHO; 2013.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlack MM, Trude ACB, Lutter CK. All children thrive: integration of nutrition and early childhood development. Annu Rev Nutr. 2020;40:375\u0026ndash;406.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBhutta ZA, Das JK, Rizvi A, Gaffey MF, Walker N, Horton S, et al. Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? Lancet. 2013;382(9890):452\u0026ndash;77.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDewey KG, Adu-Afarwuah S. Systematic review of the efficacy and effectiveness of complementary feeding interventions in developing countries. Matern Child Nutr. 2019;15(S1):e12754.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRussell AL, Hentschel E, Fulcher I, Rav\u0026agrave; MS, Abdulkarim G, Abdalla O, et al. Caregiver parenting practices, dietary diversity knowledge, and association with early childhood development outcomes among children aged 18\u0026ndash;29 months in Zanzibar, Tanzania: a cross-sectional survey. BMC Public Health. 2022;22(1):1640.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFrumence G, Jin Y, Kasangala AA, Mang'enya MA, Bakar S, Ochieng B. A qualitative study on community perceptions of stunting and preventive interventions in rural Tanzania. Int J Public Health. 2023;68:1605294.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBecker MH. The Health Belief Model and personal health behavior. Health Educ Monogr. 1974;2(4):324\u0026ndash;473.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBandura A. Social foundations of thought and action: a social cognitive theory. Englewood Cliffs: Prentice-Hall; 1986.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBloom BS, Engelhart MD, Furst EJ, Hill WH, Krathwohl DR. Taxonomy of educational objectives: the classification of educational goals. Handbook I: Cognitive domain. New York: Longmans, Green; 1956.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFrost MB, Forste R, Haas DW. Maternal education and child nutritional status in Bolivia: finding the links. Soc Sci Med. 2005;60(2):395\u0026ndash;407.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmith LC, Ramakrishnan U, Ndiaye A, Haddad LJ, Martorell R. The importance of women\u0026rsquo;s status for child nutrition in developing countries. Research Report 131. Washington, DC: International Food Policy Research Institute; 2003.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRuel MT, Alderman H. Nutrition-sensitive interventions and programmes: how can they help to accelerate progress in improving maternal and child nutrition? Lancet. 2013;382(9890):536\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBhutta ZA, Akseer N, Keats EC, Vaivada T, Baker S, Horton SE, et al. How countries can reduce child stunting at scale: lessons from exemplar countries. Am J Clin Nutr. 2020;112:S894\u0026ndash;904.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDewey KG, Adu-Afarwuah S. Systematic review of complementary feeding interventions. Matern Child Nutr. 2008;4(s1):24\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinistry of Health. Community Development, Gender, Elderly and Children (MoHCDGEC) [Tanzania], ICF. Tanzania Demographic and Health Survey and Malaria Indicator Survey (TDHS-MIS) 2015\u0026ndash;16. Dar es Salaam and Rockville: MoHCDGEC and ICF; 2016.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUnited Republic of Tanzania (URT). Tanzania National Nutrition Survey 2018. Dodoma: URT Ministry of Health / Tanzania Food and Nutrition Centre; 2018.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Childhood stunting, dietary practices, nutrition training, nutrition knowledge, Njombe District, Tanzania","lastPublishedDoi":"10.21203/rs.3.rs-8763772/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8763772/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eChildhood stunting remains a major public health challenge in Tanzania, including Njombe District, despite various nutrition and health interventions. Understanding the factors associated with caregivers\u0026rsquo; dietary practices is essential for informing effective stunting reduction strategies. This study examined dietary practices among caregivers of under-five children with stunted growth and assessed their association with selected socio-demographic characteristics, nutrition knowledge, and exposure to nutrition training.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA cross-sectional study was conducted among caregivers of under-five children identified as stunted at health facilities in Njombe District. Data were collected using a structured questionnaire capturing socio-demographic characteristics, nutrition knowledge, nutrition training exposure, and dietary practices. Dietary practice was assessed based on adequacy of protein-rich food consumption. Nutrition knowledge was categorized using Bloom\u0026rsquo;s taxonomy. Chi-square tests of independence were used to examine associations between variables at a significance level of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 151 respondents were included in the analysis. No statistically significant associations were observed between dietary practices and caregiver education level (χ\u0026sup2; = 1.80, p\u0026thinsp;=\u0026thinsp;0.180) or nutrition knowledge (χ\u0026sup2; = 0.683, p\u0026thinsp;=\u0026thinsp;0.409). Similarly, nutrition training was not significantly associated with nutrition knowledge (χ\u0026sup2; = 0.099, p\u0026thinsp;=\u0026thinsp;0.753). In contrast, a strong and statistically significant association was found between nutrition training and dietary practices (χ\u0026sup2; = 49.6, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Nearly half (45.9%) of caregivers who had received nutrition training demonstrated appropriate dietary practices compared to only 1.8% among those without training.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe findings indicate that formal education and general nutrition knowledge alone are insufficient to improve dietary practices among caregivers of stunted children in Njombe District. Practical, structured nutrition training appears to play a critical role in promoting appropriate dietary practices. Strengthening community-based nutrition training in line with Tanzania\u0026rsquo;s National Nutrition Action Plan may contribute to improved feeding practices and support ongoing efforts to reduce childhood stunting.\u003c/p\u003e","manuscriptTitle":"Dietary Practices and Nutritional Knowledge Among Caregivers of Stunted Under-Five Children in Njombe Region, Tanzania","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-27 07:34:11","doi":"10.21203/rs.3.rs-8763772/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"00e8167a-0813-4ecb-9c2c-b392c7d5375f","owner":[],"postedDate":"March 27th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-27T19:10:12+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-27 07:34:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8763772","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8763772","identity":"rs-8763772","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}