The results of this study suggest that malnutrition remains a problem within Bagamoyo and surrounding areas. While our results focus on only one district hospital and three surrounding health facilities in Tanzania, they agree with national household surveys that rural populations have higher rates of malnutrition than urban populations within Tanzania. More importantly, though, there is currently a gap in literature on malnutrition in hospital and facility-based populations under-five. The objective of this study was to examine the status of malnutrition among male and female children aged 6–59 months in rural and urban areas of Bagamoyo District, Tanzania, specifically that population presenting to the RCH clinic at BDH and selected surrounding rural facilities.
As malnutrition has been widely documented in resource-poor settings [12–14], it is extremely important given its links to morbidity, mortality and disease. Our study confirmed that malnutrition remains an issue within and surrounding Bagamoyo. Across the axes of gender and geographical location (i.e. urban v. rural), our findings indicate a concerning level of malnutrition as assess by stunting, underweight, and wasting in both groups aged 6–23 months and 24–59 months (see Table 2). Similarly, as Table 2 indicates, our study also confirms a significant difference of malnourishment between urban and rural populations [15–17], even among children with access to hospital and facility services.
Beyond analysing the prevalence and assessing levels of malnutrition along anthropometric criteria, the risk factors and underlying conditions that contribute to malnutrition must be discussed. Among other factors, high birth rates, poverty, lack of education, disease prevalence [18], have a long history of correlation and/or causation to malnutrition levels. Our data substantiated Smith’s [16] claim that urban children have better nutrition due to overall more favourable socioeconomic factors in urban areas to rural such as market for fish and variety of food options.
Similarly, a number of studies have shown a relationship between education and malnutrition [19–22]. Arguably, educational differences contribute to the unequal distribution of malnutrition among urban and rural residents. We suggest, however, that among children presenting to BDH, malnutrition remains an issues even within the hospital-presenting population. Where access and availability of the hospital and its services may demonstrate lower than national averages, this study concluded that malnutrition remains a problem even within hospital-based settings.
Interventions – What was done? What else is needed?
In light of MDG1 and MDG4, malnutrition in resource poor settings has been a major focus of both governmental and non-governmental interventions. Where our study was conducted at just over the halfway point of the MDG timeline (2009), these findings contribution to assessing the current trend of poverty, malnutrition and child health in Tanzania. The National Poverty Eradication Strategy, the Tanzania Development Vision 2025, The Tanzania Mini-Tiger Plan, The Poverty Reduction Strategy Paper, and the National Strategy for Growth and Reduction of Poverty are major strategies focused on drastically reducing poverty and creating high quality livelihoods for Tanzanians. Rooted in neoliberalism, many of these policies focus on reducing poverty as a means to improving quality of life, such as nutritional status.
Our study suggested that malnutrition rates among patients presented to BDH are lower than average for the Pwani Region according to the 2010 Demographic and Household Survey; data collection for the 2010 DHS overlapped with this study. While Bagamoyo may be unique in its urban and rural population distribution, the difference is also do to the population studied. Although those attending BDH resided within Pwani Region, they are not a representative sample of the region whereas the DHS sampling techniques lead to a regionally representative average. According to WHO, the right to health must be available, accessible, acceptable, and of good quality. As an inclusive right, the right to health also demands access to safe and potable water and adequate sanitation, an adequate supply of safe food, nutrition and housing, occupational health, environmental conditions, and access to health-related education and information. Given the more urban setting of BDH compared to the entire Pwani Region, many of these determinants of quality healthcare are present to a much higher degree within the BDH RCH clinic. Thus, the very notion that patients have access to BDH accounts for part of the difference in malnutrition rates in our study population compared to Pwani Region. However, the data also suggested that even with these increased resources, the presenting population remains malnourished.
Implications
Bagamoyo District Hospital encounters a unique population of children under-five from both urban and rural areas. Given the large population of patients that present for both well child checks and immunizations, as well as patients presenting with other pathologies (e.g. malaria, infection, pneumonia, etc.), unique approaches can be taken to curb the malnutrition rates. As stated above, it is imperative to develop a deeper understanding of food, agricultural and fishing changes, and the ways in which these economic changes affect nutritional status of children. In developing a deeper sensibility of poverty’s interaction with malnutrition in Bagamoyo, additional interventions can be targeted to improve both immediate and generational malnutrition rates. Hospital-based nutrition interventions should be considered alongside community-based intervention. Hospital-based interventions can focus on interventions that take advantage of reaching large groups of caregivers and children at one time. Basic nutritional education is currently only provided to at-risk children for weight/age ratio at BDH. The nutritional education comes primarily in the form of verbal instructions to provide the child with a balanced diet. Due to multiple contributing factors to malnutrition, verbal instructions to caregivers about providing a balanced diet are unlikely to be very effective in addressing malnutrition. In addition, because MUAC measurements are not being regularly used, many at-risk children are being missed. However, the large number of caregivers (approximately100 caregivers present five days a week) at RCH at BDH provides a unique opportunity to reach thousands of at-risk children in a centralized location. By providing additional educational workshops on cooking preparation and food preservation demonstrations, breastfeeding support and access to fortified staples at RCH clinics, many at-risk children in high malnutrition areas could be reached with relatively small increases in staff and resources.