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Cormick G, Moraa H, Zahroh RI, Allotey J, Rocha T, Peña-Rosas JP, Qureshi ZP, Hofmeyr GJ, Mistry H, Smits L, Vogel JP, Palacios A, Gwako GN, Abalos E, Larbi KK, Carroli G, Riley R, Snell KI, Thorson A, Young T, Betran AP, Thangaratinam S, Bohren MA. Factors affecting the implementation of calcium supplementation strategies during pregnancy to prevent pre-eclampsia: a mixed-methods systematic review. BMJ Open 2023; 13:e070677. [PMID: 38135336 DOI: 10.1136/bmjopen-2022-070677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2023] Open
Abstract
OBJECTIVES Daily calcium supplements are recommended for pregnant women from 20 weeks' gestation to prevent pre-eclampsia in populations with low dietary calcium intake. We aimed to improve understanding of barriers and facilitators for calcium supplement intake during pregnancy to prevent pre-eclampsia. DESIGN Mixed-method systematic review, with confidence assessed using the Grading of Recommendations, Assessment, Development and Evaluations-Confidence in the Evidence from Reviews of Qualitative research approach. DATA SOURCES MEDLINE and EMBASE (via Ovid), CINAHL and Global Health (via EBSCO) and grey literature databases were searched up to 17 September 2022. ELIGIBILITY CRITERIA We included primary qualitative, quantitative and mixed-methods studies reporting implementation or use of calcium supplements during pregnancy, excluding calcium fortification and non-primary studies. No restrictions were imposed on settings, language or publication date. DATA EXTRACTION AND SYNTHESIS Two independent reviewers extracted data and assessed risk of bias. We analysed the qualitative data using thematic synthesis, and quantitative findings were thematically mapped to qualitative findings. We then mapped the results to behavioural change frameworks to identify barriers and facilitators. RESULTS Eighteen reports from nine studies were included in this review. Women reported barriers to consuming calcium supplements included limited knowledge about calcium supplements and pre-eclampsia, fears and experiences of side effects, varying preferences for tablets, dosing, working schedules, being away from home and taking other supplements. Receiving information regarding pre-eclampsia and safety of calcium supplement use from reliable sources, alternative dosing options, supplement reminders, early antenatal care, free supplements and support from families and communities were reported as facilitators. Healthcare providers felt that consistent messaging about benefits and risks of calcium, training, and ensuring adequate staffing and calcium supply is available would be able to help them in promoting calcium. CONCLUSION Relevant stakeholders should consider the identified barriers and facilitators when formulating interventions and policies on calcium supplement use. These review findings can inform implementation to ensure effective and equitable provision and scale-up of calcium interventions. PROSPERO REGISTRATION NUMBER CRD42021239143.
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Affiliation(s)
- Gabriela Cormick
- Centro de Investigaciones en Epidemiología y Salud Pública (Consejo Nacional de Investigaciones Científicas y Técnicas- CONICET), Instituto de Efectividad Clinica y Sanitaria, Buenos Aires, Argentina
- Universidad Nacional de La Matanza, San Justo, Provincia de Buenos Aires, Argentina
| | | | - Rana Islamiah Zahroh
- Gender and Women's Health Unit, Nossal Institute for Global Health, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - John Allotey
- WHO Collaborating Centre for Global Women's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Centre (BRC), University Hospitals Birmingham, Birmingham, UK
| | - Thaís Rocha
- WHO Collaborating Centre for Global Women's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | | | | | - G Justus Hofmeyr
- Effective Care Research Unit, University of the Witwatersrand Faculty of Health Sciences, East London, Eastern Cape, South Africa
- University of Botswana, Gaborone, Botswana
| | - Hema Mistry
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Luc Smits
- Department of Epidemiology, Maastricht University, Maastricht, Netherlands
| | - Joshua Peter Vogel
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Victoria, Australia
| | - Alfredo Palacios
- Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
- Centre for Health Economics, University of York, York, UK
| | | | - Edgardo Abalos
- Centro de Estudios de Estado y Sociedad, Buenos Aires, Argentina
| | | | - Guillermo Carroli
- Centro Rosarino de Estudios Perinatales (CREP), Rosario, Santa Fe, Argentina
| | - Richard Riley
- WHO Collaborating Centre for Global Women's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | | | - Anna Thorson
- Human Reproduction Program/World Health Organization (Geneva), Geneva, Switzerland
| | - Taryn Young
- Centre for Evidence-based Health Care, Division Epidemiology and Biostatistics, Dept. of Global Health, Stellenbosch University, Cape Town, South Africa
| | - Ana Pilar Betran
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneve, Switzerland
| | - Shakila Thangaratinam
- WHO Collaborating Centre for Global Women's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Centre (BRC), University Hospitals Birmingham, Birmingham, UK
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Meghan A Bohren
- Gender and Women's Health Unit, Nossal Institute for Global Health, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
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Ajong AB, Kenfack B, Ali IM, Yakum MN, Ukaogo PO, Mangala FN, Aljerf L, Telefo PB. Calcium supplementation in pregnancy: An analysis of potential determinants in an under-resourced setting. PLoS One 2023; 18:e0292303. [PMID: 37796953 PMCID: PMC10553325 DOI: 10.1371/journal.pone.0292303] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 09/18/2023] [Indexed: 10/07/2023] Open
Abstract
INTRODUCTION Despite the evidence that calcium supplementation in pregnancy improves maternofoetal outcomes, many women still do not take calcium supplements during pregnancy in Cameroon. This study identifies factors that influence calcium supplementation during pregnancy in a low resource setting. METHODS We conducted a cross-sectional hospital-based study (from November 2020 to September 2021) targeting 1074 healthy women in late pregnancy at the maternities of four major health facilities in the Nkongsamba Health District, Cameroon. Data were collected using an interview-administered semi-structured questionnaire and analysed using Epi Info version 7.2.4.0, and the statistical threshold for significance set at p-value = 0.05. RESULTS The mean age of the participants was 28.20±6.08 years, with a range of 15-47 years. The proportion of women who reported taking any calcium supplements in pregnancy was 72.62 [69.85-75.22]%. Only 12% of calcium-supplemented women took calcium supplements throughout pregnancy, while a majority (50%) took calcium supplements just for 4-5 months. Women believe that taking calcium supplements is more for foetal growth and development (37.12%) and prevention of cramps (38.86%), than for the prevention of hypertensive diseases in pregnancy (2.84%). About all pregnant women (97.65%) took iron and folic acid supplements during pregnancy, and 99.24% took these supplements at least once every two days. Upon control for multiple confounders, the onset of antenatal care before 4 months of pregnancy (AOR = 2.64 [1.84-3.78], p-value = 0.000), having had more than 3 antenatal care visits (AOR = 6.01 [3.84-9.34], p-value = 0.000) and support/reminder from a partner on the necessity to take supplements in pregnancy (AOR = 2.00 [1.34-2.99], p-value = 0.001) were significantly associated with higher odds of taking any calcium supplements in pregnancy. CONCLUSION Calcium supplementation practices in pregnancy remain poor in this population and far from WHO recommendations. Early initiation of antenatal care, a high number of antenatal visits and reminders or support from the partner on supplement intake significantly increase the odds of taking any calcium supplements in pregnancy. In line with WHO recommendations, women of childbearing age should be sensitised to initiate antenatal care earlier and attain as many visits as possible. Male involvement in prenatal care might also boost the likelihood of these women taking calcium supplements.
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Affiliation(s)
- Atem Bethel Ajong
- Department of Mother and Child care, Kekem District Hospital, Kekem, West Region, Cameroon
- Department of Biochemistry, University of Dschang, Dschang, West Region, Cameroon
| | - Bruno Kenfack
- Department of Obstetrics / Gynaecology and Maternal Health, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, West Region, Cameroon
| | - Innocent Mbulli Ali
- Department of Biochemistry, University of Dschang, Dschang, West Region, Cameroon
| | - Martin Ndinakie Yakum
- Department of Epidemiology and Biostatistics, School of Medical and Health Sciences, Kesmonds International University, Bamenda, Cameroon
| | | | - Fulbert Nkwele Mangala
- Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Douala, Cameroon
- Maternity unit, Nkongsamba Regional Hospital, Nkongsamba, Littoral Region, Cameroon
| | - Loai Aljerf
- Faculty of Dentistry, Damascus University, Damascus, Syria
| | - Phelix Bruno Telefo
- Department of Biochemistry, University of Dschang, Dschang, West Region, Cameroon
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Sanghvi TG, Nguyen PH, Forissier T, Ghosh S, Zafimanjaka M, Walissa T, Mahmud Z, Kim S. Comprehensive Approach for Improving Adherence to Prenatal Iron and Folic Acid Supplements Based on Intervention Studies in Bangladesh, Burkina Faso, Ethiopia, and India. Food Nutr Bull 2023; 44:183-194. [PMID: 37309106 DOI: 10.1177/03795721231179570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND The World Health Organization recommends daily iron and folic acid (IFA) supplementation during pregnancy, but consumption remains low, and high prevalence of anemia among pregnant women (PW) persists. OBJECTIVES This study aims to (1) examine factors at the health system, community, and individual levels, which influence adherence to IFA supplements; and (2) describe a comprehensive approach for designing interventions to improve adherence based on lessons learned from 4 country experiences. METHODS We conducted literature search, formative research, and baseline surveys in Bangladesh, Burkina Faso, Ethiopia, and India and applied health systems strengthening and social and behavior change principles to design interventions. The interventions addressed underlying barriers at the individual, community, and health system levels. Interventions were further adapted for integration into existing large-scale antenatal care programs through continuous monitoring. RESULTS Key factors related to low adherence were lack of operational protocols to implement policies, supply chain bottlenecks, low capacity to counsel women, negative social norms, and individual cognitive barriers. We reinforced antenatal care services and linked them with community workers and families to address knowledge, beliefs, self-efficacy, and perceived social norms. Evaluations showed that adherence improved in all countries. Based on implementation lessons, we developed a program pathway and details of interventions for mobilizing health systems and community platforms for improving adherence. CONCLUSION A proven process for designing interventions to address IFA supplement adherence will contribute to achieving global nutrition targets for anemia reduction in PW. This evidence-based comprehensive approach may be applied in other countries with high anemia prevalence and low IFA adherence.
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Affiliation(s)
| | | | | | | | | | | | | | - Sunny Kim
- International Food Policy Research Institute, Washington DC, USA
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4
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Willemse JP, Smits LJ, Braat MM, Meertens LJ, van Montfort P, van Dongen MC, Ellerbrock J, van Dooren IM, Duvekot EJ, Zwaan IM, Spaanderman ME, Scheepers HC. Counseling pregnant women on calcium: effects on calcium intake. J Perinat Med 2023; 51:346-355. [PMID: 35998889 PMCID: PMC10010736 DOI: 10.1515/jpm-2021-0376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 07/29/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To evaluate the effect of incorporating calcium advice into early pregnancy counseling on calcium intake during pregnancy in the Netherlands. METHODS A multicenter prospective before-after cohort study was conducted introducing risk-based care including calculating individual pre-eclampsia risk. Part of the intervention was to incorporate calcium advice into routine counseling. We calculated individual daily calcium intake and adequacy of calcium intake (≥1,000 mg/day) at 16, 24 and 34 weeks of pregnancy. We performed a multiple logistic regression adjusting for covariates to identify any differences in the risk of inadequate calcium intake between RC and CAC. RESULTS In regular care (RC, 2013-2015, n=2,477) 60% had inadequate calcium intake, compared to 49% during calcium advice care (CAC, 2017-2018, n=774) (aOR 0.75, 95% CI 0.64-0.88). Specific calcium supplements were used by 2% and 29% in RC and CAC, respectively (OR 25.1, 95% CI 17.8-36.0). Determinants of an inadequate calcium intake were lower age (aOR per additional year 0.96, 95% CI: 0.94-0.98), nulliparity (aOR 1.22, 95% CI: 1.03-1.45) and non-Caucasian origin (aOR 1.83, 95% CI 1.09-3.09). In CAC, risk of inadequate intake decreased with increasing predicted pre-eclampsia risk, which was a trend reversal compared to RC. CONCLUSIONS Incorporating calcium advice into early pregnancy counseling was shown to lead to a decrease in the risk of inadequate calcium intake during pregnancy, but still inadequate intake in half of the women suggesting the need for further study on improving implementation. Awareness of individual increased PE risk had positive effect on calcium intake.
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Affiliation(s)
- Jessica P.M.M. Willemse
- Department of Epidemiology, CAPHRI Care and Public Health Research Institute, Maastricht UniversityMaastricht, The Netherlands
| | - Luc J.M. Smits
- Department of Epidemiology, CAPHRI Care and Public Health Research Institute, Maastricht UniversityMaastricht, The Netherlands
| | | | - Linda J.E. Meertens
- Department of Epidemiology, CAPHRI Care and Public Health Research Institute, Maastricht UniversityMaastricht, The Netherlands
| | - Pim van Montfort
- Department of Epidemiology, CAPHRI Care and Public Health Research Institute, Maastricht UniversityMaastricht, The Netherlands
| | - Martien C. van Dongen
- Department of Epidemiology, CAPHRI Care and Public Health Research Institute, Maastricht UniversityMaastricht, The Netherlands
| | - Jonas Ellerbrock
- Department of Obstetrics & Gynaecology, Zuyderland Medical CentreHeerlen, The Netherlands
| | - Ivo M.A. van Dooren
- Department of Obstetrics and Gynaecology, Sint Jans Gasthuis WeertWeert, The Netherlands
| | - Ella. J. Duvekot
- Department of Obstetrics and Gynaecology, VieCuri Medical CentreVenlo, The Netherlands
| | - Iris M. Zwaan
- Department of Obstetrics and Gynaecology, Laurentius Medical CentreRoermond, The Netherlands
| | - Marc E.A. Spaanderman
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Hubertina C.J. Scheepers
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Grow, school for oncology and developmental biology, Maastricht University, Maastricht, The Netherlands
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Yap F, Loy SL, Ku CW, Chua MC, Godfrey KM, Chan JKY. A Golden Thread approach to transforming Maternal and Child Health in Singapore. BMC Pregnancy Childbirth 2022; 22:561. [PMID: 35836151 PMCID: PMC9284894 DOI: 10.1186/s12884-022-04893-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 07/04/2022] [Indexed: 11/10/2022] Open
Abstract
Maternal and child health (MCH) in Singapore is entering a new phase, with challenges different to those faced 50 years ago. The advancement of medical technologies and access to MCH resources have led to a dramatic fall in maternal and infant mortality rates. However, there has been a steep rise in the rates of obesity and related metabolic diseases. Alongside this is an emerging mental wellness challenge, with one in ten women experience depression across pre-, during and post-pregnancy. Maternal obesity and mental disorders before and during pregnancy not only increase a woman's risk of pregnancy complications, but also result in increased risks in the offspring of childhood obesity, behavioral disorders and later life metabolic disease, catalyzing vicious cycles of disease. Thus, there is a pressing need to transform the current MCH system to address a burgeoning metabolic and mental health challenge for Singapore. Initiating interventions during preconception and continuing into the postpartum has the potential to confer long-term maternal-child benefits, promoting virtuous cycles of health. However, the current MCH system emphasizes antenatal care and lacks focus on the equally, if not more important, preconception, postpartum and inter-pregnancy stages. We describe a new model-of-care framework that integrates a life-course approach to health across preconception, pregnancy and postpartum phases, with the social-ecological model comprising individual, interpersonal, institutional, community and policy as the major targets for health promotion interventions. This "golden thread" approach is being established at the Singapore KK Women's and Children's Hospital (KKH), to address both metabolic and mental health challenges to achieve the goal of a thriving, healthy nation. This new model-of-care is set up in KKH as a pilot program known as Healthy Early Life Moments in Singapore (HELMS). HELMS will reach out to women planning to conceive through coordinated interventions across preconception, pregnancy and postpartum periods. A mobile health platform is being developed to facilitate interventions and engage participants in the program through a digital, personalized and interactive approach. This new model-of-care is designed to secure a population with healthy life cycles, by influencing each life-course, early-in-life, to provide the best start for generations to come.
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Affiliation(s)
- Fabian Yap
- Department of Pediatrics, KK Women's and Children's Hospital, Singapore, 229899, Singapore
- Duke-NUS Medical School, Singapore, 169857, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, 636921, Singapore
| | - See Ling Loy
- Duke-NUS Medical School, Singapore, 169857, Singapore
- Department of Reproductive Medicine, KK Women's and Children's Hospital, Singapore, 229899, Singapore
| | - Chee Wai Ku
- Duke-NUS Medical School, Singapore, 169857, Singapore.
- Department of Reproductive Medicine, KK Women's and Children's Hospital, Singapore, 229899, Singapore.
| | - Mei Chien Chua
- Duke-NUS Medical School, Singapore, 169857, Singapore
- Department of Neonatology, KK Women's and Children's Hospital, Singapore, 229899, Singapore
| | - Keith M Godfrey
- Medical Research Council Lifecourse Epidemiology Unit, University of Southampton, Southampton, SO16 6YD, UK
- National Institute for Health Research Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton National Health Service Foundation Trust, Southampton, SO16 6YD, UK
| | - Jerry Kok Yen Chan
- Duke-NUS Medical School, Singapore, 169857, Singapore
- Department of Reproductive Medicine, KK Women's and Children's Hospital, Singapore, 229899, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 119228, Singapore
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Gomes F, Ashorn P, Askari S, Belizan JM, Boy E, Cormick G, Dickin KL, Driller‐Colangelo AR, Fawzi W, Hofmeyr GJ, Humphrey J, Khadilkar A, Mandlik R, Neufeld LM, Palacios C, Roth DE, Shlisky J, Sudfeld CR, Weaver C, Bourassa MW. Calcium supplementation for the prevention of hypertensive disorders of pregnancy: current evidence and programmatic considerations. Ann N Y Acad Sci 2022; 1510:52-67. [PMID: 35000200 PMCID: PMC9306576 DOI: 10.1111/nyas.14733] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 10/27/2021] [Accepted: 11/14/2021] [Indexed: 12/13/2022]
Abstract
Most low- and middle-income countries present suboptimal intakes of calcium during pregnancy and high rates of mortality due to maternal hypertensive disorders. Calcium supplementation during pregnancy is known to reduce the risk of these disorders and associated complications, including preeclampsia, maternal morbidity, and preterm birth, and is, therefore, a recommended intervention for pregnant women in populations with low dietary calcium intake (e.g., where ≥25% of individuals in the population have intakes less than 800 mg calcium/day). However, this intervention is not widely implemented in part due to cost and logistical issues related to the large dose and burdensome dosing schedule (three to four 500-mg doses/day). WHO recommends 1.5-2 g/day but limited evidence suggests that less than 1 g/day may be sufficient and ongoing trials with low-dose calcium supplementation (500 mg/day) may point a path toward simplifying supplementation regimens. Calcium carbonate is likely to be the most cost-effective choice, and it is not necessary to counsel women to take calcium supplements separately from iron-containing supplements. In populations at highest risk for preeclampsia, a combination of calcium supplementation and food-based approaches, such as food fortification with calcium, may be required to improve calcium intakes before pregnancy and in early gestation.
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Affiliation(s)
- Filomena Gomes
- Nutrition Science ProgramNew York Academy of SciencesNew York CityNew York
- NOVA Medical SchoolUniversidade NOVA de LisboaLisboaPortugal
| | - Per Ashorn
- Faculty of Medicine and Health TechnologyTampere University and Tampere University HospitalTampereFinland
| | | | - Jose M. Belizan
- Institute for Clinical Effectiveness and Health Policy/CONICETBuenos AiresArgentina
| | - Erick Boy
- International Food Policy Research InstituteWashingtonDistrict of Columbia
| | - Gabriela Cormick
- Institute for Clinical Effectiveness and Health Policy/CONICETBuenos AiresArgentina
| | | | | | - Wafaie Fawzi
- Harvard T.H. Chan School of Public HealthBostonMassachusetts
| | - G. Justus Hofmeyr
- University of BotswanaGaboroneBotswana
- University of the Witwatersrand and Walter Sisulu UniversityMthathaSouth Africa
| | - Jean Humphrey
- Johns Hopkins Bloomberg School of Public HealthBaltimoreMaryland
| | | | - Rubina Mandlik
- Hirabai Cowasji Jehangir Medical Research InstitutePuneIndia
| | | | | | - Daniel E. Roth
- The Hospital for Sick Children and University of TorontoTorontoOntarioCanada
| | - Julie Shlisky
- Nutrition Science ProgramNew York Academy of SciencesNew York CityNew York
| | | | | | - Megan W. Bourassa
- Nutrition Science ProgramNew York Academy of SciencesNew York CityNew York
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Michaud-Létourneau I, Gayard M, Njoroge B, Agabiirwe CN, Luwangula AK, McGough L, Mwangi A, Pelto G, Tumilowicz A, Pelletier DL. Operationalizing Implementation Science in Nutrition: The Implementation Science Initiative in Kenya and Uganda. Curr Dev Nutr 2022; 6:nzab146. [PMID: 35047720 PMCID: PMC8760423 DOI: 10.1093/cdn/nzab146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 11/16/2021] [Accepted: 11/23/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Implementation science (IS) has the potential to improve the implementation and impact of policies, programs, and interventions. Most of the training, guidance, and experience has focused on implementation research, which is only 1 part of the broader field of IS. In 2018, the Society for Implementation Science in Nutrition borrowed concepts from IS in health to develop a broader and more integrated conceptual framework, adapted to the particular case of nutrition and with language and concepts more familiar to the nutrition community: it is called the IS in Nutrition (ISN) framework. OBJECTIVE The purpose of this research was to generate knowledge concerning challenges and strategies in operationalizing the ISN framework in low- and middle-income country (LMIC) settings. METHODS The ISN framework was operationalized in partnership with country teams in Kenya and Uganda over a 3-y period as part of the Implementation Science Initiative. An action research methodology (developmental evaluation) was used to provide timely feedback to the country teams, facilitate adaptations and adjustments, and generate the data presented in this article concerning challenges and strategies. RESULTS Operationalization of the ISN framework proceeded by first articulating a set of guiding principles as touchstones for the country teams and further articulating 6 components of an IS system to facilitate development of work streams. Challenges and strategies in implementing these 6 components were then documented. The knowledge gained through this experience led to the development of an IS system operational model to assist the application of IS in other LMIC settings. CONCLUSIONS Future investments in IS should prioritize a system- and capacity-building approach in order to realize its full potential and become institutionalized at country level. The operational model can guide others to improve the implementation of IS within a broad range of programs.
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Affiliation(s)
- Isabelle Michaud-Létourneau
- The Society for Implementation Science in Nutrition,
NY, USA
- Department of Social and Preventive Medicine, School of Public Health, University of Montréal, Montréal, Québec, Canada
| | - Marion Gayard
- The Society for Implementation Science in Nutrition,
NY, USA
| | | | | | | | | | | | - Gretel Pelto
- The Society for Implementation Science in Nutrition,
NY, USA
- Division of Nutritional Sciences, College of Human Ecology, Cornell University, Ithaca, NY, USA
| | | | - David L Pelletier
- The Society for Implementation Science in Nutrition,
NY, USA
- Division of Nutritional Sciences, College of Human Ecology, Cornell University, Ithaca, NY, USA
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Martin SL, McCann JK, Gascoigne E, Allotey D, Fundira D, Dickin KL. Engaging family members in maternal, infant and young child nutrition activities in low- and middle-income countries: A systematic scoping review. MATERNAL & CHILD NUTRITION 2021; 17 Suppl 1:e13158. [PMID: 34241961 PMCID: PMC8269148 DOI: 10.1111/mcn.13158] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 01/06/2021] [Accepted: 01/12/2021] [Indexed: 12/20/2022]
Abstract
The influence of fathers, grandmothers and other family members on maternal, infant and young child nutrition practices has been well documented for decades, yet many social and behavioural interventions continue to reach only mothers. While recent guidelines recommend involving fathers, grandmothers and other family members in maternal and child nutrition, we lack a comprehensive review of interventions that have engaged them. This scoping review aimed to address this gap by describing social and behavioural interventions to engage family members in maternal and child nutrition in low- and middle-income countries. We systematically searched PubMed, Scopus, Web of Science, Global Health and CINAHL for peer-reviewed studies meeting inclusion criteria. We screened 6,570 abstracts, evaluated 179 full-text articles, and included 87 articles from 63 studies. Studies reported a broad range of approaches to engage fathers, grandmothers and other family members to support maternal nutrition (n = 6); breastfeeding (n = 32); complementary feeding (n = 6) and multiple maternal and child nutrition practices (n = 19). Interventions were facility and community based; included individual and group-based interpersonal communication, community mobilization, mass media and mHealth; and reached mothers and family members together or separately. Most interventions were located within the health sector; rare exceptions included nutrition-sensitive agriculture, social protection, early child development and community development interventions. Few interventions addressed gender norms, decision-making, and family dynamics or described formative research or theories informing intervention design. These diverse studies can shed light on innovative programme approaches to increase family support for maternal and child nutrition.
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Affiliation(s)
- Stephanie L. Martin
- Department of Nutrition, Gillings School of Global Public HealthUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
- Carolina Population CenterUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Juliet K. McCann
- Program in International Nutrition, Division of Nutritional SciencesCornell UniversityIthacaNew YorkUSA
| | - Emily Gascoigne
- Department of Nutrition, Gillings School of Global Public HealthUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Diana Allotey
- Department of Nutrition, Gillings School of Global Public HealthUniversity of North Carolina at Chapel HillChapel HillNorth CarolinaUSA
| | - Dadirai Fundira
- Program in International Nutrition, Division of Nutritional SciencesCornell UniversityIthacaNew YorkUSA
| | - Katherine L. Dickin
- Program in International Nutrition, Division of Nutritional SciencesCornell UniversityIthacaNew YorkUSA
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9
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Martin SL, McCann JK, Gascoigne E, Allotey D, Fundira D, Dickin KL. Mixed-Methods Systematic Review of Behavioral Interventions in Low- and Middle-Income Countries to Increase Family Support for Maternal, Infant, and Young Child Nutrition during the First 1000 Days. Curr Dev Nutr 2020; 4:nzaa085. [PMID: 32607463 PMCID: PMC7311193 DOI: 10.1093/cdn/nzaa085] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 05/08/2020] [Accepted: 05/13/2020] [Indexed: 02/06/2023] Open
Abstract
Fathers, grandmothers, and other family members' influence on maternal, infant, and young child nutrition (MIYCN) is widely recognized, yet synthesis of the effectiveness of engaging them to improve nutrition practices during the first 1000 d is lacking. We examined the impact of behavioral interventions to engage family members in MIYCN in low- and middle-income countries through a mixed-methods systematic review. We screened 5733 abstracts and included 35 peer-reviewed articles on 25 studies (16 with quantitative and 13 with qualitative data). Most quantitative studies focused on early breastfeeding, primarily engaging fathers or, less often, grandmothers. Most found positive impacts on exclusive breastfeeding rates and family members' knowledge and support. The few quantitative studies on complementary feeding, maternal nutrition, and multiple outcomes also suggested benefits. Qualitative themes included improved nutrition behaviors, enhanced relationships, and challenges due to social norms. Interventions engaging family members can increase awareness and build support for MIYCN, but more rigorous study designs are needed. This systematic review is registered at PROSPERO as CRD42018090273, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=90273.
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Affiliation(s)
- Stephanie L Martin
- Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Juliet K McCann
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
| | - Emily Gascoigne
- Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Diana Allotey
- Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Dadirai Fundira
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
| | - Katherine L Dickin
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
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Desta M, Kassie B, Chanie H, Mulugeta H, Yirga T, Temesgen H, Leshargie CT, Merkeb Y. Adherence of iron and folic acid supplementation and determinants among pregnant women in Ethiopia: a systematic review and meta-analysis. Reprod Health 2019; 16:182. [PMID: 31864397 PMCID: PMC6925441 DOI: 10.1186/s12978-019-0848-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 12/11/2019] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Iron and folic acid deficiency anaemia are one of the global public health challenges that pose 1.45% of all disability-adjusted life-years. It is recognized as a cause for an unacceptably high proportion of maternal and perinatal morbidity and mortality. Adherence to iron and folic acid supplementation during the antenatal period is paramount to reduce anaemia and its associated morbidities. Although several studies have been conducted across the country, their reports were inconsistent and inconclusive for intervention. Therefore, this systematic review and meta-analysis were aimed to estimate the pooled national level adherence to iron and folic acid supplementation and its determinants among pregnant women in Ethiopia. METHODS This systematic review and meta-analysis were pursued the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2009 guideline. An extensive search of databases including, PubMed, Google Scholar, and African Journals Online were conducted to access articles. The Newcastle- Ottawa quality assessment tool was used to assess the quality of each study and meta-analysis was conducted using a random-effects model. I2 test and Egger's test were used to assess the heterogeneity and publication bias respectively. The meta-analysis of estimating national level adherence were done using STATA version 11 with 95% CI. RESULTS Twenty studies with a total of 16,818 pregnant women were included in this meta-analysis. The pooled national level iron and folic acid supplementation's adherence were 46.15% (95%CI:34.75,57.55). The highest adherence was observed in Addis Abeba, 60% (95%CI: 55.93, 64.07) followed by Tigray, 58.9% (95% CI: 33.86, 84.03). Women who received supplemental information [OR = 2.34, 95%CI: 1.05, 5.24], who had good knowledge [OR = 2.2, 95%CI: 1.05, 5.24], began the ANC visit before 16 weeks [OR = 2.41, 95%CI: 1.76, 3.29], and had ≥4 ANC visits [OR = 2.59, 95% CI: 1.09, 6.15] were more likely adhere to the supplementation. Fear of side effects (46.4, 95% CI: 30.9 61.8) and forgetfulness (30.7, 95% CI: 17.6, 43.8) were the major barriers of adherence of the supplementations. CONCLUSIONS More than four of nine pregnant women have adhered to the iron and folic acid supplementation. This meta-analysis revealed that receiving supplemental counselling, knowledge of the supplement; early registration and frequent ANC visit were significantly associated with the adherence of the iron and folic acid supplementation. Therefore, provision of strengthened supplemental counselling service, antenatal care services, and improving the knowledge of the supplementation is a crucial strategy to increase the adherence among pregnant women in Ethiopia. Besides, addressing the barriers of the adherence of the supplement mainly counseling or managing of side effects and reducing of forgetfulness to take the tablet through getting family support or male involvement during visit is mandatory.
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Affiliation(s)
- Melaku Desta
- Department of Midwifery, College of Health Science, Debre Markos University, PO. Box: 269, Debre Markos, Ethiopia.
| | - Bekalu Kassie
- Department of Midwifery, College of Health Science, Debre Markos University, PO. Box: 269, Debre Markos, Ethiopia
| | - Habtamu Chanie
- Department of Midwifery, College of Health Science, Debre Markos University, PO. Box: 269, Debre Markos, Ethiopia
| | - Henok Mulugeta
- Department of Nursing, College of Health Science, Debre Markos University, Debre Markos, Ethiopia
| | - Tadesse Yirga
- Department of Nursing, College of Health Science, Debre Markos University, Debre Markos, Ethiopia
| | - Habtamu Temesgen
- Department of Nutrition and Food Science, College of Health Science, Debre Markos University, Debre Markos, Ethiopia
| | - Cheru Tesema Leshargie
- Department of Public Health, College of Health Science, Debre Markos University, Debre Markos, Ethiopia
| | - Yoseph Merkeb
- Department of Biomedical Science, College of Health Science, Debre Markos University, Debre Markos, Ethiopia
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Nguyen PH, Kachwaha S, Avula R, Young M, Tran LM, Ghosh S, Agrawal R, Escobar-Alegria J, Patil S, Menon P. Maternal nutrition practices in Uttar Pradesh, India: Role of key influential demand and supply factors. MATERNAL AND CHILD NUTRITION 2019; 15:e12839. [PMID: 31066195 PMCID: PMC6852235 DOI: 10.1111/mcn.12839] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 04/08/2019] [Accepted: 04/23/2019] [Indexed: 01/29/2023]
Abstract
Despite strong policy and program commitment, essential maternal nutrition services are not reaching enough women in many countries. This paper examined multifactorial determinants (personal, family, community, and health services) associated with maternal nutrition practices in Uttar Pradesh, India. Data were from a household survey of pregnant (n = 667) and recently delivered women (n = 1,835). Multivariable regression analyses were conducted to examine the determinants of four outcomes: consumption of diverse diets, consumption of iron folic acid (IFA) and calcium tablets, and weight monitoring during pregnancy. Population attributable risk analysis was used to estimate how much the outcomes can be improved under optimal program implementation. During pregnancy, women consumed 28 IFA and 8 calcium tablets, 18% consumed diverse diet, and 17% were weighed ≥3 times. Nutrition knowledge was associated with consumption of diverse diet (odds ratio [OR] = 2.2 times), IFA (2.3 times), calcium (11.7 times), and weight monitoring (1.3 times). Beliefs and self‐efficacy were associated with IFA (OR = 2.0) and calcium consumption (OR = 4.6). Family support and adequate health services were also associated with better nutrition practices. Under optimal program implementation, we estimate that 51% of women would have adequate diet diversity, an average consumption of 98 IFA, and 106 calcium tablets, and women would be weighed 4.9 times during pregnancy. Strengthening existing program operations and increasing demand for services has the potential to result in large improvements in maternal nutrition practices from current baseline levels but may not be sufficient to meet World Health Organization‐recommended levels without creating an enabling environment including improvements in education and income levels to support behaviour change.
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Affiliation(s)
- Phuong Hong Nguyen
- Poverty, Health and Nutrition Division, International Food Policy Research Institute (IFPRI), Washington, DC, USA
| | - Shivani Kachwaha
- Poverty, Health and Nutrition Division, International Food Policy Research Institute (IFPRI), Washington, DC, USA
| | - Rasmi Avula
- Poverty, Health and Nutrition Division, International Food Policy Research Institute (IFPRI), Washington, DC, USA
| | | | | | | | | | | | - Sumeet Patil
- Network for Engineering, Economics, Research and Management (NEERMAN), Mumbai, India
| | - Purnima Menon
- Poverty, Health and Nutrition Division, International Food Policy Research Institute (IFPRI), Washington, DC, USA
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Martin SL, Wawire V, Ombunda H, Li T, Sklar K, Tzehaie H, Wong A, Pelto GH, Omotayo MO, Chapleau GM, Stoltzfus RJ, Dickin KL. Integrating Calcium Supplementation into Facility-Based Antenatal Care Services in Western Kenya: A Qualitative Process Evaluation to Identify Implementation Barriers and Facilitators. Curr Dev Nutr 2018; 2:nzy068. [PMID: 30402593 PMCID: PMC6215767 DOI: 10.1093/cdn/nzy068] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 07/11/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND In countries with low calcium intake, the WHO recommends integrating calcium supplementation into antenatal care (ANC) to reduce the risk of preeclampsia, a leading cause of maternal mortality. Current WHO guidelines recommend women take 3-4 calcium supplements plus 1 iron-folic acid supplement at separate times daily. There is limited evidence about implementing these guidelines through routine ANC. Through the Micronutrient Initiative-Cornell University Calcium (MICa) trial, we examined the effect of regimen on supplement consumption among ANC clients in western Kenya. A nested process evaluation examined factors that influence calcium supplementation delivery and uptake. OBJECTIVES This process evaluation assessed ANC providers', pregnant women's, and family members' experiences with calcium supplementation, and investigated the feasibility and acceptability of engaging family members to support adherence. METHODS We conducted semistructured interviews with 7 ANC providers, 32 pregnant women, and 20 adherence partners (family members who provide reminders and support), and 200 observations of ANC consultations. Interviews were transcribed, translated, and analyzed thematically. Observational data were summarized. RESULTS ANC providers reported positive feelings about calcium supplementation, the training received, and counseling materials, but reported increased workloads. Women reported that providers counseled them on supplement benefits and managing side effects, offered reminder strategies, and provided supplements and behavior change materials. Women explained that reminder materials and adherence partners improved adherence. Most adherence partners reported providing reminders and other instrumental support to help with pill taking, which women confirmed and appreciated. Some women reported that comorbidities, concerns about being perceived as HIV positive, pill burden, unfavorable organoleptic properties, and lack of food were adherence barriers. CONCLUSIONS Although integrating calcium into antenatal iron-folic acid supplementation was generally acceptable to ANC providers, pregnant women, and their families, calcium supplementation presents unique challenges that must be considered to successfully implement these guidelines.This trial was registered at clinicaltrials.gov as NCT02238704.
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Affiliation(s)
- Stephanie L Martin
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Violet Wawire
- Department of Education Foundation, Kenyatta University, Nairobi, Kenya
| | - Hedwig Ombunda
- Faculty of Education and Arts, KCA University, Nairobi, Kenya
| | - Terry Li
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY
| | - Kelsey Sklar
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY
| | - Hiwet Tzehaie
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY
| | - Athena Wong
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY
| | - Gretel H Pelto
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY
| | - Moshood O Omotayo
- Department of Epidemiology and Environmental Health, University at Buffalo, Buffalo, NY
| | - Gina M Chapleau
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY
| | - Rebecca J Stoltzfus
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY
| | - Katherine L Dickin
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY
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Nguyen PH, Frongillo EA, Sanghvi T, Wable G, Mahmud Z, Tran LM, Aktar B, Afsana K, Alayon S, Ruel MT, Menon P. Engagement of Husbands in a Maternal Nutrition Program Substantially Contributed to Greater Intake of Micronutrient Supplements and Dietary Diversity during Pregnancy: Results of a Cluster-Randomized Program Evaluation in Bangladesh. J Nutr 2018; 148:1352-1363. [PMID: 29931108 PMCID: PMC6075465 DOI: 10.1093/jn/nxy090] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 03/26/2018] [Indexed: 11/12/2022] Open
Abstract
Background Although husbands may provide support during pregnancy, limited evidence exists on how to promote husbands' engagement and what impact it has. Alive & Thrive integrated nutrition-focused interventions, targeting both wives and husbands, through an existing Maternal, Neonatal, and Child Health (MNCH) platform in Bangladesh. Objectives We evaluated 1) the impact of a nutrition-focused MNCH program, compared with the standard MNCH program, on husbands' behavioral determinants (i.e., awareness, knowledge, self-efficacy) and support to wives to adopt optimal nutrition practices and 2) how much of the previously documented impact on women's supplement intake and dietary diversity was explained by husbands' behavioral determinants and support. Methods We used a cluster-randomized design with cross-sectional surveys at baseline (2015) and endline (2016) (n = ∼1000 women and ∼700 husbands/survey). We used mixed linear regression accounting for clustering to estimate difference-in-differences (DIDs) for impact on husbands' behavioral determinants and path analysis to examine how much these determinants explained the impact on women's nutrition behaviors. Results Of husbands in the nutrition-focused MNCH group, 62% were counseled by health workers, 66% attended a husbands' forum, and 34% saw video shows. The nutrition-focused MNCH, compared with the standard MNCH group, resulted in greater husbands' awareness (DID: 2.74 of 10 points), knowledge (DID: 1.31), self-efficacy and social norms with regard to optimal nutrition practices (difference: 1.08), and support to their wives (DID: 1.86). Husbands' behavioral determinants and support explained nearly half of the program impact for maternal supplement intake and one-quarter for dietary diversity. Conclusions A nutrition-focused MNCH program that promoted and facilitated husbands' engagement during their wives' pregnancies significantly improved husbands' awareness, knowledge, self-efficacy, and support. These improvements substantially explained the program's impact on women's intake of micronutrient supplements and dietary diversity. Targeting wives and husbands and designing activities to engage men in maternal nutrition programs are important to maximize impact. This trial was registered at www.clinicaltrials.gov as NCT02745249.
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Affiliation(s)
- Phuong Hong Nguyen
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC,Address correspondence to PHN (e-mail: )
| | | | | | - Gargi Wable
- Division of Nutritional Sciences, Cornell University, Ithaca, NY
| | | | | | - Bachera Aktar
- James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh
| | | | | | - Marie T Ruel
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC
| | - Purnima Menon
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC
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Omotayo MO, Martin SL, Stoltzfus RJ, Ortolano SE, Mwanga E, Dickin KL. With adaptation, the WHO guidelines on calcium supplementation for prevention of pre-eclampsia are adopted by pregnant women. MATERNAL & CHILD NUTRITION 2018; 14:e12521. [PMID: 29193667 PMCID: PMC6865867 DOI: 10.1111/mcn.12521] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 08/14/2017] [Accepted: 08/24/2017] [Indexed: 01/08/2023]
Abstract
The World Health Organization (WHO) recommends calcium supplementation for prevention of pre-eclampsia, but factors affecting adoption and acceptability of the recommendations among pregnant women have not been examined. We explored adoption of the WHO guidelines in Kenya, using the trials of improved practices. We recruited 38 pregnant women and assigned participants to three regimens representing potential trade-offs among daily dose, bioavailability, and acceptability. Participants were provided with supplements, requested to select preferred product type, counselled on how to take them, and interviewed 4 times over 6 weeks to assess their experiences. We tracked bottle opening with electronic monitors, as proxy for supplement consumption. We analysed interview transcripts thematically. All participants were willing to try the supplements. Average daily consumption ranged from 77 to 1,577 mg/d. Most participants (74%) chose the chewable product. Participants preferred its "sweet taste" and liked the ability to consume it without water. Women in the 2-dose regimen were least likely to switch; however, women assigned to the 3-dose regimen, or who switched to the 3-dose regimen, consumed the most calcium per day. Difficulties with the 4-dose regimen included afternoon doses when women were likely to forget and having to wait hours after supper for last dose. Use of an illustrated calendar, keeping supplements in conspicuous locations and requesting support from relatives were strategies that supported adherence. Pregnant women are likely to adopt Ca supplementation, with appropriate programmatic adaptations. Careful attention to product attributes, regimen complexity, and strategies for reassuring and reminding women are needed to adapt the WHO guidelines.
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Affiliation(s)
- Moshood O. Omotayo
- Program in International NutritionCornell UniversityIthacaNew YorkUSA
- Department of Epidemiology and Environmental HealthUniversity at BuffaloBuffaloNew YorkUSA
| | | | | | | | - Erick Mwanga
- Malava Sub‐County Health Management TeamKakamegaKenya
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Siekmans K, Roche M, Kung'u JK, Desrochers RE, De-Regil LM. Barriers and enablers for iron folic acid (IFA) supplementation in pregnant women. MATERNAL AND CHILD NUTRITION 2017; 14 Suppl 5:e12532. [PMID: 29271115 PMCID: PMC6865983 DOI: 10.1111/mcn.12532] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 07/12/2017] [Accepted: 08/30/2017] [Indexed: 01/28/2023]
Abstract
In order to inform large scale supplementation programme design, we review and summarize the barriers and enablers for improved coverage and utilization of iron and folic acid (IFA) supplements by pregnant women in 7 countries in Africa and Asia. Mixed methods were used to analyse IFA supplementation programmes in Afghanistan, Bangladesh, Indonesia, Ethiopia, Kenya, Nigeria, and Senegal based on formative research conducted in 2012–2013. Qualitative data from focus‐group discussions and interviews with women and service providers were used for content analysis to elicit common themes on barriers and enablers at internal, external, and relational levels. Anaemia symptoms in pregnancy are well known among women and health care providers in all countries, yet many women do not feel personally at risk. Broad awareness and increased coverage of facility‐based antenatal care (ANC) make it an efficient delivery channel for IFA; however, first trimester access to IFA is hindered by beliefs about when to first attend ANC and preferences for disclosing pregnancy status. Variable access and poor quality ANC services, including insufficient IFA supplies and inadequate counselling to encourage consumption, are barriers to both coverage and adherence. Community‐based delivery of IFA and referral to ANC provides earlier and more frequent access and opportunities for follow‐up. Improving ANC access and quality is needed to facilitate IFA supplementation during pregnancy. Community‐based delivery and counselling can address problems of timely and continuous access to supplements. Renewed investment in training for service providers and effective behaviour change designs are urgently needed to achieve the desired impact.
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Affiliation(s)
| | - Marion Roche
- Nutrition International, Ottawa, Ontario, Canada
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Tumilowicz A, Schnefke CH, Neufeld LM, Pelto GH. Toward a Better Understanding of Adherence to Micronutrient Powders: Generating Theories to Guide Program Design and Evaluation Based on a Review of Published Results. Curr Dev Nutr 2017; 1:e001123. [PMID: 29955708 PMCID: PMC5998355 DOI: 10.3945/cdn.117.001123] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 05/22/2017] [Accepted: 06/05/2017] [Indexed: 11/19/2022] Open
Abstract
Background: The Global Alliance for Improved Nutrition is conducting theory-driven process evaluations of micronutrient powder (MNP) programs. Objective: The aim was to generate preliminary theories about factors affecting adherence to recommendations with regard to point-of-use fortification of foods with MNPs. Methods: A literature search was conducted to identify documents with content related to adherence to MNPs as an intervention provided at home to children 6-59 mo of age. Thirty-five studies and 6 program descriptions were identified. We used thematic analyses to generate a comprehensive list of factors that could influence adherence, followed by content analysis to quantify the results. We developed a Program Impact Pathway to concretize the points at which the factors identified affect the process of adherence. Results: In the set of documents reviewed (n = 41), the most influential factors, measured by number of documents reporting the factor having effect, were 1) caregivers' perception of positive changes as a result of MNP use (n = 14), 2) caregivers' perceived child acceptance of food with MNPs (n = 12), and 3) caregivers' forgetfulness (n = 11). Behavior change communication channels (n = 13) and messages (n = 12) were the most frequently reported program design features influencing caregiver knowledge and subsequent adherence. Administration regimen (n = 10), which may be related to caregivers' capacity to remember to give MNPs, was also a frequently cited program design feature affecting adherence. Conclusions: The preponderance of knowledge and perception factors may reflect an underlying theoretical bias among researchers as to what they measure. To achieve programs that support greater adherence, we need to adopt a cultural-ecological perspective to inform program design in order to address a broader set of determinants. Studies that assess progress across the impact pathway, particularly from adherence to biological outcomes, would also provide guidance for evaluation studies, particularly when time or other constraints limit the potential to measure biological outcomes.
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Affiliation(s)
| | | | | | - Gretel H Pelto
- Division of Nutritional Sciences, Cornell University, Ithaca, NY
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Martin SL, Omotayo MO, Pelto GH, Chapleau GM, Stoltzfus RJ, Dickin KL. Adherence-Specific Social Support Enhances Adherence to Calcium Supplementation Regimens among Pregnant Women. J Nutr 2017; 147:688-696. [PMID: 28250195 DOI: 10.3945/jn.116.242503] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 11/11/2016] [Accepted: 01/31/2017] [Indexed: 11/14/2022] Open
Abstract
Background: WHO guidelines recommend integrating calcium supplementation into antenatal care (ANC) alongside iron and folic acid (IFA) to reduce maternal mortality. However, supplementation programs face multiple barriers, and strategies to improve adherence are needed. An adherence partner is someone whom pregnant women ask to support adherence at home.Objectives: This study 1) assessed adherence partner acceptability, feasibility, and associations with calcium and IFA supplement adherence and 2) examined relations between social support and adherence.Methods: This secondary analysis is from a trial integrating calcium supplementation into ANC in Kenya. ANC providers were trained on calcium and IFA supplementation and counseling, provided with behavior change materials, and given adequate supplement supplies. Pregnant women from 16 government health facilities were recruited (n = 1036); sociodemographic and adherence data were collected at baseline and at 4- to 6-wk follow-up visits. Adherence was measured with pill counts and self-reports. Culturally adapted scales measured social support in general and specific to adherence. Mixed-effects regression analyses were used to examine factors associated with adherence partners, social support, and adherence.Results: Most participants received information about adherence partners (91%) and had a partner at follow-up (89%). Participants with adherence partners reported higher adherence support (OR: 2.10; 95% CI: 1.32, 3.34). Mean ± SD adherence was high for calcium (88.3% ± 20.7%) and IFA (86.1% ± 20.9%). Adherence support was positively associated with calcium adherence at follow-up by using pill counts (OR: 2.2; 95% CI: 1.1, 2.6) and self-report data (OR: 1.9; 95% CI: 1.2, 2.9), but there was not a direct relation between adherence partners and adherence.Conclusions: Adherence support enhanced adherence to calcium supplements. The adherence partner strategy was highly acceptable and feasible but warrants further study. This research demonstrates the importance of adherence support and suggests that interventions to increase household-level support for antenatal micronutrient supplementation may be needed to implement the WHO guidelines. This trial was registered at clinicaltrials.gov as NCT02238704.
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Affiliation(s)
- Stephanie L Martin
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY
| | - Moshood O Omotayo
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY
| | - Gretel H Pelto
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY
| | - Gina M Chapleau
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY
| | - Rebecca J Stoltzfus
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY
| | - Katherine L Dickin
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY
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Martin SL, Omotayo MO, Chapleau GM, Stoltzfus RJ, Birhanu Z, Ortolano SE, Pelto GH, Dickin KL. Adherence partners are an acceptable behaviour change strategy to support calcium and iron-folic acid supplementation among pregnant women in Ethiopia and Kenya. MATERNAL AND CHILD NUTRITION 2016; 13. [PMID: 27507135 DOI: 10.1111/mcn.12331] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 03/30/2016] [Accepted: 03/31/2016] [Indexed: 01/27/2023]
Abstract
Antenatal calcium and iron-folic acid (IFA) supplementation can reduce maternal mortality and morbidity. Yet, even when pregnant women have a stable supply of supplements, forgetting is often a barrier to adherence. We assessed the acceptability of adherence partners to support calcium and IFA supplementation among pregnant women in Kenya and Ethiopia. Adherence partners are a behaviour change strategy to improve adherence, where pregnant women are counselled to select a partner (e.g. spouse, relative) to remind them to take their supplements. We conducted trials of improved practices, a formative research method that follows participants over time as they try a new behaviour. We provided pregnant women in Ethiopia (n = 50) and Kenya (n = 35) with calcium and IFA supplements and counselling, and suggested selecting an adherence partner. For each participant, we conducted semi-structured interviews about acceptability and adherence during four interviews over six weeks. We analysed interview transcripts thematically and tallied numerical data. In Kenya, 28 of 35 women agreed to try an adherence partner; almost all selected their husbands. In Ethiopia, 42 of 50 women agreed to try an adherence partner; half asked their husbands, others asked children or relatives. Most women who did not select adherence partners reported not needing help or not having anyone to ask. Participants reported adherence partners reminded and encouraged them, brought supplements, provided food and helped address side-effects. Almost all women with adherence partners would recommend this strategy to others. Adherence partners are an acceptable, low-cost strategy with the potential to support antenatal micronutrient supplementation adherence.
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Affiliation(s)
- Stephanie L Martin
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, New York, USA
| | - Moshood O Omotayo
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, New York, USA
| | - Gina M Chapleau
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, New York, USA
| | - Rebecca J Stoltzfus
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, New York, USA
| | - Zewdie Birhanu
- Department of Health Education and Behavioral Sciences, College of Health Sciences, Jimma University, Jimma, Ethiopia
| | - Stephanie E Ortolano
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, New York, USA
| | - Gretel H Pelto
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, New York, USA
| | - Katherine L Dickin
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, New York, USA
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