Addressing anaemia in pregnancy in rural plains Nepal: A qualitative, formative study

Factors associated with malaria in pregnancy among antenatal care mothers at Gulu Regional Referral Hospital in northern Uganda

BACKGROUND

All pregnant mothers in Uganda are given sulfadoxine-pyrimethamine (SP, Fansidar®) for presumptive treatment of malaria in pregnancy from 14 weeks of gestation, every four weeks, until delivery. However, prenatal mothers still fall sick of malaria. This study aimed to assess the factors associated with malaria in pregnancy among antenatal care mothers at Gulu Regional Referral Hospital.

METHODS

This was a cross-sectional study at Gulu Regional Referral Hospital antenatal clinic from July to August 2023. Consecutive sampling was used. An interviewer-administered questionnaire was used to collect sociodemographic characteristics, physical examination findings and blood samples taken for rapid diagnostic test (RDT) for malaria. A positive RDT was taken as the presence of malaria infection in pregnancy. Data was pre-processed in STATA®15, and logistic regression analysis was done in RStudio 4.2.2. Variables with p < 0.05 were taken as independently associated with malaria in pregnancy and reported as adjusted risk ratios (aRR).

RESULTS

Three hundred fifty (350) pregnant women were recruited; 96% of them slept under mosquito nets daily, while more than half of them (51.7%) had not yet taken SP (IPTp) during their current pregnancy. Prevalence of anaemia (Hb < 11.0 g/dl) was 46.0%. Twenty-four per cent of the mothers were in the first trimester, 56.3% in the second and 19.7% in the third. The prevalence of malaria in pregnancy was 39.7% (95% CI 34.5-45.1%), equally distributed throughout the trimesters. Anaemia (aRR = 4.99, 95%CI 3.10-8.05, p < 0.001) and tertiary level of education (aRR = 0.29, 95% CI 0.14-0.62, p = 0.001) were significantly associated with malaria in pregnancy. Not sleeping under a mosquito net (aRR = 3.79, 95% CI 0.95-15.16, p = 0.059) may be a factor associated with malaria in pregnancy.

CONCLUSION

Four in every ten mothers had malaria infection, with anaemia being a risk factor, while a tertiary level of education was protective against malaria in pregnancy.

Impact of a virtual antenatal intervention for improved diet and iron intake in Kapilvastu district, Nepal - the VALID randomized controlled trial

Introduction

Counseling, together with iron and folic acid supplements, can improve hemoglobin levels in pregnant women, but few interventions have tested a virtual method of delivering counseling. We hypothesized that a virtual counseling intervention delivered via a mobile device (mHealth) would prevent and treat anemia, compared with routine antenatal care (ANC).

Methods

Virtual antenatal intervention for improved diet and iron intake (VALID) was a non-blinded parallel group two-arm, individually randomized superiority trial (1:1 allocation). Participants were pregnant women who were married, aged 13-49 years, able to answer questions, 12-28 weeks' gestation and living in Kapilvastu district, Nepal. Women were randomized to receive routine ANC (control arm), or ANC plus a virtual antenatal intervention of two problem-solving counseling sessions via video call. The primary outcome was iron folic acid (IFA) tablet compliance (consumption on 12 or more days of the previous 14 days). Secondary outcomes were dietary diversity, promoted food consumption, iron bioavailability enhancement, and knowledge of iron-rich foods. Primary logistic regression analysis was by intention-to-treat, adjusting for baseline values.

Results

We enrolled 319 pregnant women (161 control, 158 intervention) from 23 January 2022 to 6 May 2022 and analyzed outcomes in 144 control and 127 intervention women. Compliance with IFA increased in both arms. In the intervention arm, compliance increased by 29.7 percentage points (pp) (49.0-78.7%) and 19.8 pp. in the control arm (53.8-73.6%). Despite the more significant increase in the intervention arm, we found no intervention effect upon IFA compliance (adjusted odds ratio [aOR] 1.33; 95% confidence interval [CI]: 0.75, 2.35; p = 0.334), dietary diversity, or ANC visits. The intervention increased knowledge of iron-rich foods (coefficient 0.96; 95% CI: 0.50, 1.41; p < 0.001), consumption of promoted foods (aOR: 1.81; 95% CI: 1.08, 3.02; p = 0.023), behavior to enhance iron bioavailability (aOR: 4.41; 95% CI: 1.23, 15.83; p = 0.023), and coronavirus disease 2019 (COVID-19) knowledge (aOR: 4.06; 95% CI: 1.56, 10.54; p = 0.004). The total intervention cost was US$35,193, and the cost per pregnant woman receiving two virtual counseling sessions was US$277.

Conclusion

Virtual counseling can improve antenatal health behaviors, such as the consumption of promoted foods and methods to enhance bioavailability. Improved IFA consumption and ANC attendance may require additional family/community support.

Clinical trial registration

https://www.isrctn.com/ISRCTN17842200, identifier ISRCTN17842200.

Factors influencing the implementation of integrated screening for HIV, syphilis, and hepatitis B for pregnant women in Nepal: A qualitative study

In Nepal, national guidelines recommend free HIV and syphilis screening for pregnant women at their first antenatal visit, using an opt-out approach. However, screening uptake is low and the guidelines do not include hepatitis B screening. It is essential to understand the factors influencing the implementation of integrated screening for HIV, syphilis, and hepatitis B, as recommended by WHO, to improve uptake and prevent vertical transmission. This study explored the knowledge, attitudes, and perceptions of pregnant women, their families, healthcare providers and policymakers on integrated prenatal screening. We conducted 12 in-depth interviews with pregnant women, 10 with their husbands and 4 with mothers-in-law in Kapilvastu and Kathmandu. In addition, we interviewed 7 health workers and 4 decision-makers. These interviews were sufficient to reach saturation. Data were analysed using a thematic content analysis. A combination of the social-ecological model and the WHO building blocks provided a theoretical framework for interpreting data. The analysis showed that antenatal screening in Nepal involved many stakeholders and was influenced by various factors. Implementation issues were found in the building blocks service delivery, health workforce and medical products. Husbands and in-laws play an important role in the acceptance of screening by pregnant women, especially in rural areas. High levels of stigma and discrimination against people with sexually transmitted diseases were reported, and knowledge of hepatitis B and syphilis was low. Access and uptake of screening could be improved through rapid testing, by strengthening the health system and by integrating hepatitis B screening through an opt-out approach like that for HIV and syphilis. Effective community involvement through awareness campaigns and investment in lower-level health facilities is essential to improve screening rates. This study provides information for decision-makers about challenges in implementing integrated screening to guide the design of targeted interventions to reduce vertical transmission.

Development and validation of a tool to assess underlying factors of iron-rich food consumption among pregnant women

Anaemia among pregnant women remains a public health concern globally. One major cause of this persistent problem is iron deficiency, which may be the result of limited iron intake in the diet. Using the extended version of the theory of planned behaviour (eTPB), this study aims to develop and validate a questionnaire assessing psychosocial and environmental factors that could influence the consumption of iron-rich foods (IRFs) among Senegalese pregnant women. A three-step procedure was used. Six focus group discussions (FGDs) were held with 10 pregnant women each from a different region to identify salient beliefs related to each of the four constructs of the eTPB using a structured guide. Information from FGDs was used to develop a questionnaire, which was administered to the first group (n = 200) of pregnant women. Principal component analyses and exploratory factorial analyses were performed on the first set of data to identify latent factors for each construct namely the attitude, subjective norm and perceived behavioural control. A revised and shorter version of the questionnaire was administered to a second sample of pregnant women (n = 226) and confirmatory factorial analyses were conducted using this second set of data. Hancock and Muller's H reliability index was computed on the final model. The final questionnaire included 44 items. Most criteria for fit indices were met and H values were satisfactory. This study proposes a tool that could be used to explore determinants of the consumption of IRF among pregnant women. Further validation is still warranted in other contexts.

How Do Social and Behavioral Change Interventions Respond to Social Norms to Improve Women's Diets in Low- and Middle-Income Countries? A Scoping Review

Healthy dietary practices are highly influenced by social norms, the widely-held expectations about the behaviors that are appropriate or typical within a given group. However, many nutrition programs designed to reduce women's undernutrition in low- and middle-income countries do not address the influence of social and gender norms in their interventions, and therefore, there is limited information about how norms-responsive interventions have been designed and implemented. The objective of this scoping review was to identify and describe social and behavioral change interventions designed to improve women's dietary practices and nutritional intake that integrate the influence of social and gender norms. We systematically searched 4 databases (Scopus, Web of Science, PubMed, and CINAHL) for peer-reviewed articles describing design, implementation, and/or assessment of nutrition interventions in low- or middle-income countries. Results are reported following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Our review identified 27 articles from 25 projects or research studies that addressed social or gender norms related to women's dietary practices. The majority focused on the pregnancy and lactation periods, and a few aimed to reach all women of reproductive age. Interventions most often endeavored to shift norms through multiple activities, channels, and platforms, aiming to reach not only the primary participants but also influencers and reference groups. Intervention approaches ranged from home visits and support groups to engage influential family members to community-level outreach with opinion leaders such as religious leaders, health care workers, and peer change agents. Most interventions were delivered through the health sector or were community-based, with some nutrition-sensitive agriculture interventions. There is increasing, although still limited, integration of social and gender norms perspectives in the design, implementation, and assessment of interventions to improve women's diets. This comprehensive review summarizes influential norms and intervention approaches, an important step toward enhancing the effectiveness of social and behavioral change interventions by addressing nutrition-relevant norms. This study was registered at Open Science Framework as JSBF7.

"Can't live willingly": A thematic synthesis of qualitative evidence exploring how early marriage and early pregnancy affect experiences of pregnancy in South Asia

In South Asia, early marriage has been associated with a range of adverse outcomes during pregnancy and infancy. This may partly be explained by early marriage leading to a younger maternal age, however it remains unclear which other factors are involved. This review aimed to synthesise the qualitative evidence on experiences of pregnancy following early marriage or early pregnancy in South Asia, to inform our understanding of the mechanisms between early marriage and adverse pregnancy outcomes. We searched MEDLINE, EMBASE, Scopus, Global Index Medicus, CINAHL, PsycINFO, Web of Science, and grey literature on 29/11/2022 to identify papers on experiences of pregnancy among those who married or became pregnant early in South Asia (PROSPERO registration number: CRD42022304336, funded by an MRC doctoral training grant). Seventy-nine papers from six countries were included after screening. We appraised study quality using an adapted version of the Critical Appraisal Skills Programme tool for qualitative research. Reporting of reflexivity and theoretical underpinnings was poor. We synthesised findings thematically, presenting themes alongside illustrative quotes. We categorised poor pregnancy experiences into: care-seeking challenges, mental health difficulties, and poor nutritional status. We identified eight inter-connected themes: restrictive social hierarchies within households, earning social position, disrupted education, social isolation, increased likelihood of and vulnerability to abuse, shaming of pregnant women, normalisation of risk among younger women, and burdensome workloads. Socioeconomic position and caste/ethnic group also intersected with early marriage to shape experiences during pregnancy. While we found differences between regions, the heterogeneity of the included studies limits our ability to draw conclusions across regions. Pregnancy experiences are largely determined by social hierarchies and the quality of relationships within and outside of the household. These factors limit the potential for individual factors, such as education and empowerment, to improve experiences of pregnancy for girls married early.

Eating for honour: A cultural-ecological analysis of food behaviours among adolescent girls in the southern plains of Nepal

Access to adequate and nutritious food is important for the current and future health of adolescent girls. Interventions often focus on the individual as responsible for their own health ignoring the complex structural issues that underlie optimal nutrition. In South Asia gender inequalities have been noted as an important determinant of poor nutrition among women and their young children, but analysis of adolescent girls' diets and what influences these are rarely undertaken. Therefore, we sought to analyse the factors affecting what and where girls' eat and what affects their behaviour in the plains of Nepal, using a cultural-ecological approach. We analysed a secondary qualitative dataset of focus group discussions with adolescent girls aged 12-19 years old, young mothers, mothers-in-law, and older female key informants. Eating was heavily influenced by patriarchal norms. Boys had preferential access to food, money, and freedom of movement to appreciate their future role in providing for the family. Food was an investment, and boys were perceived to have more nutritional need than girls. Girls were not perceived to be a good return on investment of food, and eating practices sought to prepare them for life as a subservient daughter-in-law and wife. Obedience and sacrifice were valued in girls, and they were expected to eat less and do more housework than boys. Girls' eating and behaviour was constrained to maintain self and family honour. Interventions should acknowledge cultural influences on eating and engage multiple actors in addressing harmful gender norms which limit eating and prevent girls from reaching their potential.

Assessing food-based strategies to address anaemia in pregnancy in rural plains Nepal: a mixed methods study

Anaemia in pregnancy is a persistent health problem in Nepal and could be reduced through nutrition counselling and strengthened iron folic acid supplementation programmes. We analysed 24-hour diet recall data from 846 pregnant women in rural plains Nepal, using linear programming to identify the potential for optimised food-based strategies to increase iron adequacy. We then conducted qualitative research to analyse how anaemia was defined and recognised, how families used food-based strategies to address anaemia, and the acceptability of optimised food-based strategies. We did 16 interviews of recently pregnant mothers, three focus group discussions with fathers, three focus group discussions with mothers-in-law and four interviews with key informants. Dietary analyses showed optimised diets did not achieve 100 % of recommended iron intakes, but iron intakes could be doubled by increasing intakes of green leaves, egg and meat. Families sought to address anaemia through food-based strategies but were often unable to because of the perceived expense of providing an 'energy-giving' diet. Some foods were avoided because of religious or cultural taboos, or because they were low status and could evoke social consequences if eaten. There is a need for counselling to offer affordable ways for families to optimise iron adequacy. The participation of communities in tailoring advice to ensure cultural relevance and alignment with local norms is necessary to enable its effectiveness.

Dietary Behaviour and Sociocultural Determinants of Dietary Diversity among Rural Women of Reproductive Age: A Case of Amhara Region, Ethiopia

Women of reproductive age have specific nutritional requirements due to pregnancy and lactation. Little is known about the sociocultural determinants of dietary diversity among women of reproductive age. This study assesses trends of dietary behaviour and associated determinants of dietary diversity of women of reproductive age. A community-based cross-sectional study was conducted in the Amhara region of Ethiopia in 2019. Using multistage systematic random sampling, the dietary diversity of n = 421 women of reproductive age was assessed by a qualitative 24 h dietary recall. Descriptive analysis revealed characteristics of dietary behaviour and a chi-square test enabled the identification of associated determinants of women's dietary diversity. Only about a quarter (26.8%) of the women consumed five or more food groups per day and met the minimum dietary diversity score (MDD-W). Drawing on the socioecological framework, at an intrapersonal/individual level, women's education, age, perception of nutritious diet, and frequency of consumption of animal-sourced foods, vegetables, and fruit were significantly associated with MDD-W. At an interpersonal/household level, the husbands' education, women's decision-making regarding food purchase/consumption, the family's actual eating occasion, and women's engagement in domestic and farming tasks were significantly associated with MDD-W. At a community level, access to clean water and especially cultural beliefs were significant determinants of MDD-W. Amharic proverbs and sayings prioritise men and pose severe restrictions on women regarding food allocation. The majority (76.7%) of women of reproductive age practise frequent religious fasting, relating to the institutional/national level. This undermines efforts to support healthy dietary behaviour of women of reproductive age. Indepth studies on religious and cultural practices are needed, to assess not only their negative effects on the dietary diversity of women of reproductive age but also on women's lives.

Contextual factors affecting the implementation of an anemia focused virtual counseling intervention for pregnant women in plains Nepal: a mixed methods process evaluation

BACKGROUND

Anemia is estimated to cause 115,000 maternal deaths each year. In Nepal, 46% of pregnant women have anemia. As part of an integrated anemia-prevention strategy, family engagement and counseling of pregnant women can increase compliance to iron folic acid tablets, but marginalized women often have lower access to these interventions. We implemented the VALID (Virtual antenatal intervention for improved diet and iron intake) randomized controlled trial to test a family-focused virtual counseling mHealth intervention designed to inclusively increase iron folic acid compliance in rural Nepal; here we report findings from our process evaluation research.

METHODS

We conducted semi structured interviews with 20 pregnant women who had received the intervention, eight husbands, seven mothers-in-laws and four health workers. We did four focus groups discussions with intervention implementers, 39 observations of counseling, and used routine monitoring data in our evaluation. We used inductive and deductive analysis of qualitative data, and descriptive statistics of monitoring data.

RESULTS

We were able to implement the intervention largely as planned and all participants liked the dialogical counseling approach and use of story-telling to trigger conversation. However, an unreliable and inaccessible mobile network impeded training families about how to use the mobile device, arrange the counseling time, and conduct the counseling. Women were not equally confident using mobile devices, and the need to frequently visit households to troubleshoot negated the virtual nature of the intervention for some. Women's lack of agency restricted both their ability to speak freely and their mobility, which meant that some women were unable to move to areas with better mobile reception. It was difficult for some women to schedule the counseling, as there were competing demands on their time. Family members were difficult to engage because they were often working outside the home; the small screen made it difficult to interact, and some women were uncomfortable speaking in front of family members.

CONCLUSIONS

It is important to understand gender norms, mobile access, and mobile literacy before implementing an mHealth intervention. The contextual barriers to implementation meant that we were not able to engage family members as much as we had hoped, and we were not able to minimize in-person contact with families. We recommend a flexible approach to mHealth interventions which can be responsive to local context and the situation of participants. Home visits may be more effective for those women who are most marginalized, lack confidence in using a mobile device, and where internet access is poor.

Intrahousehold power inequalities and cooperation: Unpacking household responses to nutrition-sensitive agriculture interventions in rural India

Nutrition-sensitive agriculture (NSA) interventions offer a means to improve the dietary quality of rural, undernourished populations. Their effectiveness could be further increased by understanding how household dynamics enable or inhibit the uptake of NSA behaviours. We used a convergent parallel mixed-methods design to describe the links between household dynamics-specifically intrahousehold power inequalities and intrahousehold cooperation-and dietary quality and to explore whether household dynamics mediated or modified the effects of NSA interventions tested in a cluster-randomized trial, Upscaling Participatory Action and Videos for Agriculture and Nutrition (UPAVAN). We use quantitative data from cross-sectional surveys in 148 village clusters at UPAVAN's baseline and 32 months afterwards (endline), and qualitative data from family case studies and focus group discussions with intervention participants and facilitators. We found that households cooperated to grow and buy nutritious foods, and gendered power inequalities were associated with women's dietary quality, but cooperation and women's use of power was inhibited by several interlinked factors. UPAVAN interventions were more successful in more supportive, cooperative households, and in some cases, the interventions increased women's decision-making power. However, women's decisions to enter into negotiations with family members depended on whether women deemed the practices promoted by UPAVAN interventions to be feasible, as well as women's confidence and previous cultivation success. We conclude that interventions may be more effective if they can elicit cooperation from the whole household. This will require a move towards more family-centric intervention models that empower women while involving other family members and accounting for the varied ways that families cooperate and negotiate.

Study protocol for a randomised controlled trial of a virtual antenatal intervention for improved diet and iron intake in Kapilvastu district, Nepal: VALID

INTRODUCTION

Despite evidence that iron and folic acid (IFA) supplements can improve anaemia in pregnant women, uptake in Nepal is suboptimal. We hypothesised that providing virtual counselling twice in mid-pregnancy, would increase compliance to IFA tablets during the COVID-19 pandemic compared with antenatal care (ANC alone.

METHODS AND ANALYSIS

This non-blinded individually randomised controlled trial in the plains of Nepal has two study arms: (1) control: routine ANC; and (2) 'Virtual' antenatal counselling plus routine ANC. Pregnant women are eligible to enrol if they are married, aged 13-49 years, able to respond to questions, 12-28 weeks' gestation, and plan to reside in Nepal for the next 5 weeks. The intervention comprises two virtual counselling sessions facilitated by auxiliary nurse midwives at least 2 weeks apart in mid-pregnancy. Virtual counselling uses a dialogical problem-solving approach with pregnant women and their families. We randomised 150 pregnant women to each arm, stratifying by primigravida/multigravida and IFA consumption at baseline, providing 80% power to detect a 15% absolute difference in primary outcome assuming 67% prevalence in control arm and 10% loss-to-follow-up. Outcomes are measured 49-70 days after enrolment, or up to delivery otherwise.

PRIMARY OUTCOME

consumption of IFA on at least 80% of the previous 14 days.

SECONDARY OUTCOMES

dietary diversity, consumption of intervention-promoted foods, practicing ways to enhance bioavailability and knowledge of iron-rich foods. Our mixed-methods process evaluation explores acceptability, fidelity, feasibility, coverage (equity and reach), sustainability and pathways to impact. We estimate costs and cost-effectiveness of the intervention from a provider perspective. Primary analysis is by intention-to-treat, using logistic regression.

ETHICS AND DISSEMINATION

We obtained ethical approval from Nepal Health Research Council (570/2021) and UCL ethics committee (14301/001). We will disseminate findings in peer-reviewed journal articles and by engaging policymakers in Nepal.

TRIAL REGISTRATION NUMBER

ISRCTN17842200.

What's in a name? Unpacking 'Community Blank' terminology in reproductive, maternal, newborn and child health: a scoping review

INTRODUCTION

Engaging the community as actors within reproductive, maternal, newborn and child health (RMNCH) programmes (referred to as 'community blank') has seen increased implementation in recent years. While evidence suggests these approaches are effective, terminology (such as 'community engagement,' 'community participation,' 'community mobilisation,' and 'social accountability') is often used interchangeably across published literature, contributing to a lack of conceptual clarity in practice. The purpose of this review was to describe and clarify varying uses of these terms in the literature by documenting what authors and implementers report they are doing when they use these terms.

METHODS

Seven academic databases (PubMed/MEDLINE, Embase, CINAHL, PsycINFO, Scopus, Web of Science, Global Health), two grey literature databases (OAIster, OpenGrey) and relevant organisation websites were searched for documents that described 'community blank' terms in RMNCH interventions. Eligibility criteria included being published between 1975 and 1 October 2021 and reports or studies detailing the activities used in 'community blank.' RESULTS: A total of 9779 unique documents were retrieved and screened, with 173 included for analysis. Twenty-four distinct 'community blank' terms were used across the documents, falling into 11 broader terms. Use of these terms was distributed across time and all six WHO regions, with 'community mobilisation', 'community engagement' and 'community participation' being the most frequently used terms. While 48 unique activities were described, only 25 activities were mentioned more than twice and 19 of these were attributed to at least three different 'community blank' terms.

CONCLUSION

Across the literature, there is inconsistency in the usage of 'community blank' terms for RMNCH. There is an observed interchangeable use of terms and a lack of descriptions of these terms provided in the literature. There is a need for RMNCH researchers and practitioners to clarify the descriptions reported and improve the documentation of 'community blank' implementation. This can contribute to a better sharing of learning within and across communities and to bringing evidence-based practices to scale. Efforts to improve reporting can be supported with the use of standardised monitoring and evaluation processes and indicators. Therefore, it is recommended that future research endeavours clarify the operational definitions of 'community blank' and improve the documentation of its implementation.

Storytelling for persuasion: Insights from community health workers on how they engage family members to improve adoption of recommended maternal nutrition and breastfeeding behaviours in rural Bangladesh

Community health workers (CHWs) increasingly provide interpersonal counselling to childbearing women and their families to improve adoption of recommended maternal and child nutrition behaviours. Little is known about CHWs' first‐hand experiences garnering family support for improving maternal nutrition and breastfeeding practices in low‐resource settings. Using focused ethnography, we drew insights from the strategies that CHWs used to persuade influential family members to support recommendations on maternal diet, rest and breastfeeding in a behaviour change communication trial in rural Bangladesh. We interviewed 35 CHWs providing at‐home interpersonal counselling to pregnant women and their families in seven ‘Alive & Thrive’ intervention sites. In‐depth probing focused on how CHWs addressed lack of family support. Thematic coding based on Fisher's narrative paradigm revealed strategic use of three rhetorical principles by CHWs: ethos (credibility), pathos (emotion) and logos (logic). CHWs reported selectively targeting pregnant women, husbands and mothers‐in‐law based on their influence on behavioural adoption. Key motivators to support recommended behaviours were improved foetal growth and child intelligence. Improved maternal health was the least motivating outcome, even among mothers. Logically coherent messaging resonated well with husbands, while empathetic counselling was additionally required for mothers. Mothers‐in‐law were most intransigent, but were persuaded via emotional appeals. Persuasion on maternal rest was most effort‐intensive, resulting in contextually appealing but scientifically inaccurate messaging. Our study demonstrates that CHWs can offer important insights on context‐relevant, feasible strategies to improve family support and uptake of nutrition recommendations. It also identifies the need for focused CHW training and monitoring to address scientifically flawed counselling narratives.

Analysis of narratives of nutrition‐promoting, rural Bangladeshi community health workers (CHWs) suggest that behavior change communication (BCC) strategies to persuade husbands require logical and credible information (logos and ethos) to establish their support, while childbearing women may additionally require emotional appeals (pathos) to adopt promoted behaviors. Mothers‐in‐law, who traditionally influence multiple nutrition behaviors, can be persuaded via strategic use of ethos and pathos.

CHW communication strategies are useful in developing persuasive narratives that capture influential family members’ value beliefs and outcome expectancies and promote behavior change. However, additional programmatic efforts are needed to discourage use of unscientific narratives by CHWs.

Do changes in women's household status in Nepal improve access to food and nutrition?

Women's nutritional status remains poor in South Asia, impacting maternal and infant health outcomes. Women's household status is also low, as evidenced by eating behaviours. We started with triadic qualitative interviews with newly married women, husbands and mothers-in-law to explore the link between women's status and eating patterns, followed by longitudinal data from a cohort of 200 newly married women in rural Nepal to measure associations over time. Quantitative data were collected every 6 months for 18 months (four rounds of data) between 2018 and 2020. Interviews suggested that household relationships, women's status, and how much and what types of food she was given were intricately linked. Using mixed effects logistic regression models, we explore the association between markers of changing women's status (becoming pregnant, giving birth and working outside the home) on two outcomes (eating last always/usually and achieving minimum dietary diversity). We also explore for interaction between women's status and household food insecurity. Pregnancy increases women's dietary diversity, but this is not sustained post-partum. Women who work outside the home are less likely to eat last in the household. Food insecurity is associated with both the order of household eating and dietary diversity. Interactions between food insecurity and giving birth suggested that women who give birth in food insecure households are more likely to eat last in the household. Changes in women's household status are associated with some improvements in dietary diversity and order of household eating, but the associations are not long-lasting and depend on food security status.

The development and feasibility of a group-based household-level intervention to improve preconception nutrition in Nawalparasi district of Nepal

BACKGROUND

In a setting such as Nepal with malnutrition and persistent poor maternal and infant health outcomes, developing interventions to improve the nutrition of preconception and pregnant women is essential.

OBJECTIVE

The objectives of this paper are to describe the full design process of an intervention for newly married women, their husbands, and mothers-in-law to improve maternal nutrition and gender norms, and findings from the feasibility and acceptability pilot.

METHODS

In this paper we describe the three phases of the design of an intervention in rural Nepal. We first conducted a mixed methods formative phase which included in depth interviews with newly married women, their husbands and mothers-in-law (N=60) and a longitudinal study for 18 months with 200 newly married women. We then designed of a household level, group, intervention, in close partnership with community members. Finally, we conducted a pilot intervention with 90 participants and collected both pre/post survey data and in-depth qualitative interviews with a subset (N= 30). All participants from all phases of the study lived in Nawalparasi district of Nepal. Qualitative data was analyzed using a thematic analysis, with inductive and deductive themes and quantitative data was analyzed using descriptive statistics.

RESULTS

Our formative work highlighted lack of awareness about nutrition, and how women eating last, limited mobility, household and community inequitable gender norms and poor household-level communication contributed to low quality diets. Thus we designed Sumadhur, an intervention that brought groups of households (newly married wife, husband, and mother-in-law) together weekly for four months to strengthen relationships and gain knowledge through interactive content. We found Sumadhur to be highly feasible and acceptable by all respondents, with most (83%) attending 80% of sessions or more and 99% reporting that they would like it to continue. Pre/post surveys showed a decrease in the proportion of women eating last and increase in knowledge about nutrition in preconception and pregnancy. Qualitative interviews suggested that respondents felt it made large impacts on their lives, in terms of strengthening relationships and trust, understanding each other, and changing behaviors.

CONCLUSIONS

We show how a designing an intervention in close partnership with the target recipients and local stakeholders can lead to an intervention that is able to target complicated and culturally held practices and beliefs, positively benefit health and wellbeing, and that is very well received.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04383847 , registered 05/12/2020.

Comprehensive Anaemia Programme and Personalized Therapies (CAPPT): protocol for a cluster-randomised controlled trial testing the effect women's groups, home counselling and iron supplementation on haemoglobin in pregnancy in southern Nepal

BACKGROUND

Anaemia in pregnancy remains prevalent in Nepal and causes severe adverse health outcomes.

METHODS

This non-blinded cluster-randomised controlled trial in the plains of Nepal has two study arms: (1) Control: routine antenatal care (ANC); (2) Home visiting, iron supplementation, Participatory Learning and Action (PLA) groups, plus routine ANC. Participants, including women in 54 non-contiguous clusters (mean 2582; range 1299-4865 population) in Southern Kapilbastu district, are eligible if they consent to menstrual monitoring, are resident, married, aged 13-49 years and able to respond to questions. After 1-2 missed menses and a positive pregnancy test, consenting women < 20 weeks' gestation, who plan to reside locally for most of the pregnancy, enrol into trial follow-up. Interventions comprise two home-counselling visits (at 12-21 and 22-26 weeks' gestation) with iron folic acid (IFA) supplement dosage tailored to women's haemoglobin concentration, plus monthly PLA women's group meetings using a dialogical problem-solving approach to engage pregnant women and their families. Home visits and PLA meetings will be facilitated by auxiliary nurse midwives. The hypothesis is as follows: Haemoglobin of women at 30 ± 2 weeks' gestation is ≥ 0.4 g/dL higher in the intervention arm than in the control. A sample of 842 women (421 per arm, average 15.6 per cluster) will provide 88% power, assuming SD 1.2, ICC 0.09 and CV of cluster size 0.27. Outcomes are captured at 30 ± 2 weeks gestation. Primary outcome is haemoglobin concentration (g/dL). Secondary outcomes are as follows: anaemia prevalence (%), mid-upper arm circumference (cm), mean probability of micronutrient adequacy (MPA) and number of ANC visits at a health facility. Indicators to assess pathways to impact include number of IFA tablets consumed during pregnancy, intake of energy (kcal/day) and dietary iron (mg/day), a score of bioavailability-enhancing behaviours and recall of one nutrition knowledge indicator. Costs and cost-effectiveness of the intervention will be estimated from a provider perspective. Using constrained randomisation, we allocated clusters to study arms, ensuring similarity with respect to cluster size, ethnicity, religion and distance to a health facility. Analysis is by intention-to-treat at the individual level, using mixed-effects regression.

DISCUSSION

Findings will inform Nepal government policy on approaches to increase adherence to IFA, improve diets and reduce anaemia in pregnancy.

TRIAL REGISTRATION

ISRCTN 12272130 .

Relative power: Explaining the effects of food and cash transfers on allocative behaviour in rural Nepalese households

We estimate the effects of antenatal food and cash transfers with women's groups on household allocative behaviour and explore whether these effects are explained by intergenerational bargaining among women. Interventions were tested in randomised-controlled trial in rural Nepal, in a food-insecure context where pregnant women are allocated the least adequate diets. We show households enrolled in a cash transfer intervention allocated pregnant women with 2-3 pp larger shares of multiple foods (versus their mothers-in-law and male household heads) than households in a control group. Households in a food transfer intervention only increased pregnant women's allocation of staple foods (by 2 pp). Intergenerational bargaining power may partly mediate the effects of the cash transfers but not food transfers, whereas household food budget and nutrition knowledge do not mediate any effects. Our findings highlight the role of intergenerational bargaining in determining the effectiveness of interventions aiming to reach and/or empower junior women.