The effectiveness of a theory-based intervention program for pregnant women with anemia: A randomized control trial

Efficacy of a Personalized mHealth App in Improving Micronutrient Supplement Use Among Pregnant Women in Karachi, Pakistan: Parallel-Group Randomized Controlled Trial

BACKGROUND

Micronutrient deficiencies in folate, ferritin, calcium, and vitamin D are common during pregnancy in low- and middle-income countries, often due to inadequate diets. Micronutrient supplementation can address this need, whereas innovative awareness strategies in antenatal practices could enhance supplement use compliance.

OBJECTIVE

We evaluated the efficacy of a personalized mobile health (mHealth) intervention, hypothesizing a 30% improvement in supplement use in the intervention group compared to a conventional face-to-face counseling group.

METHODS

In an unblinded randomized controlled trial, we enrolled 306 first-trimester pregnant women from Aga Khan University Hospital between January 2020 and September 2021 who owned smartphones with internet connection. Women on regular medications or with dietary restrictions or critical illnesses were excluded. The intervention group received personalized micronutrient supplement use coaching through an mHealth app (PurUmeed Aaghaz) as thrice-a-week push messages and tailored recommendations over a 24-week period. The comparison group received standard face-to-face counseling at 6, 12, 18, and 24 weeks after enrollment. Baseline sociodemographic, obstetrics, anthropometric, dietary, and lifestyle data were collected through face-to-face interviews. At each follow-up, participants reported their weekly use of folic acid, iron, calcium, and vitamin D supplements, scored as 0 (daily), 1.5 (4-6 times weekly), and 3 (≤3 times weekly). Scores were summed to calculate the cumulative supplement use score (CSUS; 0-12), with higher scores indicating greater inadequacy. Every fourth woman was invited for biochemical micronutrient assessment. Data were analyzed using Stata (version 14), with random-effects linear and logistic panel regression to compare CSUS and supplement use between the 2 groups from baseline to endline.

RESULTS

Of 153 participants per group, 107 (69.9%) in the intervention and 125 (81.7%) in the nonintervention group completed the study. After 24 weeks, the intervention group showed a greater but insignificant reduction in mean CSUS compared to the nonintervention group (β=-.27, 95% CI -0.65 to 0.12; P=.17). Daily supplement use improved by 20% versus 22.4% for folic acid, 11.2 times versus 2.1 times for iron, 1.2 times versus 14.2 times for calcium, and 3 times versus 1.3 times for vitamin D in the intervention versus nonintervention group, respectively. Multivariable analysis showed higher, though insignificant, odds of sufficient folic acid (adjusted odds ratio [aOR] 1.26, 95% CI 0.68-2.36; P=.46) and iron (aOR 1.31, 95% CI 0.95-1.81; P=.10) use in the intervention group, whereas vitamin D use was significantly higher (aOR 1.88, 95% CI 1.43-2.47; P<.001). Calcium intake improved in the nonintervention group (aOR 0.59, 95% CI 0.44-0.79; P<.001). Anemia decreased in the intervention group, whereas ferritin, calcium, and vitamin D deficiencies persisted or worsened, particularly in the nonintervention group.

CONCLUSIONS

An appropriately implemented mHealth intervention can improve antenatal vitamin D supplementation. Affordable, accessible, and personalized counseling through mHealth could ameliorate micronutrient status during pregnancy.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04216446; https://clinicaltrials.gov/study/NCT04216446.

Effect of nutrition education on hemoglobin level of pregnant women in Southeast Ethiopia: a cluster randomized controlled trial

BACKGROUND

Maternal hemoglobin (Hgb) is considered an essential, modifiable risk factor for adverse pregnancy outcomes (APOs). Evidence for the effect of nutrition education on the Hgb levels of pregnant women in low-income countries, including Ethiopia, is inconclusive. This study aimed to assess the effect of nutrition education on the Hgb levels of pregnant women in urban settings in the Bale Zone, Southeast Ethiopia.

METHODS

A community-based two-arm parallel cluster randomized controlled trial was carried out among 447 randomly selected pregnant women attending antenatal care (224 intervention and 223 control groups) at health facilities from February to December 2021. A multistage cluster sampling technique followed by systematic sampling was used to select the pregnant women. Pregnant women who took part in the intervention arm received six nutrition education sessions, whereas pregnant women in the control group received routine standard care. We used a pretested, interviewer-administered, structured questionnaire to collect the data. The Hgb level of pregnant women was measured by collecting a finger-prick blood sample using a HemoCue Hb 301. A generalized estimating equation (GEE) model was used to isolate the net effect of the intervention on Hgb, accounting for the clustering. Beta coefficients (β) along with a 95% confidence interval (CI) were used for interpretations.

RESULTS

The mean difference in Hgb levels between the intervention and control groups was 0.12 ± 0.04 (P value < 0.002). The multivariable GEE linear model revealed that nutrition education significantly improved the Hgb levels of pregnant women [β = 0.36, 95% CI: (0.30, 0.43)]. An increase in the consumption of a cup of coffee or tea decreased Hgb levels by 0.14 g/dL [β = -0.14, 95% CI: (-0.23, -0.06)].

CONCLUSION

The findings showed that a comprehensive nutrition education intervention using the health belief model (HBM) and theory of planned behaviour (TPB) designed to improve dietary diversity substantially improved hemoglobin (Hgb) levels among pregnant women. While we found no single dietary factor to be significant, in this group of pregnant women in Ethiopia, an increase in the daily consumption of a cup of coffee or tea decreased Hgb levels. As a consequence, pregnant women should be advised to limit their coffee or tea consumption. The study was registered on Clinicaltrials.gov retrospectively with the registration number PACTR202201731802989 on 24/01/2022.

Effectiveness of Health Education Interventions in Enhancing Iron-Folic Acid Supplement Utilization Among Pregnant Women: Systematic Review and Meta-analysis

CONTEXT

During pregnancy, the underutilization of iron-folic acid supplements (IFAS) remains a considerable maternal and child health issue. Hence, health education intervention trials were conducted following the recommendation of the World Health Organization and epidemiological studies to enhance the utilization level of the supplements during pregnancy.

OBJECTIVE

The objective of this meta-analysis was to evaluate the effectiveness of health education interventions in enhancing IFAS utilization during pregnancy.

DATA SOURCES

A thorough search was conducted across PubMed, EMBASE, Scopus, CINAHL, Web of Science, Medline, the Cochrane Library, and Google Scholar from August 28 until October 31, 2023.

DATA EXTRACTION

This study incorporated randomized and quasi-experimental studies that examined the effectiveness of health education interventions in enhancing IFAS utilization during pregnancy.

DATA ANALYSIS

Comprehensive Meta-Analysis, version 4, which includes the prediction interval, was used for the analysis.

RESULTS

In this meta-analysis and systematic review, 21 articles comprising 6643 pregnant women from different countries were included. The random-effects model was applied to determine the pooled standardized differences in means (0.786; 95% CI: 0.551, 1.021). The prediction interval shows the range of true standardized differences in means (95% CI: -0.168, 1.740), which indicates the variations in the true effect size of health education interventions in enhancing IFAS utilization during pregnancy.

CONCLUSION

In addition to pooled effect size, another significant advantage of this meta-analysis is conducting the prediction interval to determine the range of the true effect size, which ranges from -0.168 to 1.740 across the groups of different pregnant women, indicating variability in the effectiveness of the interventions in enhancing IFAS utilization during pregnancy. This might occur because most of the primary studies in this meta-analysis were conducted at healthcare facilities and mostly focused on anemic pregnant women attending antenatal care, which did not control for sociocultural determinants. Therefore, future researchers should consider these limitations.

Effect of Nutrition Education During Pregnancy on Iron-Folic Acid Supplementation Compliance and Anemia in Low- and Middle-Income Countries: A Systematic Review and Meta-analysis

CONTEXT

Stakeholders implement nutrition education to prevent and control anemia during pregnancy. Nutrition education during pregnancy can increase the consumption of iron-folic acid (IFA) supplements and encourage behavioral changes. However, there is no comprehensive meta-analysis to determine the effectiveness of this intervention.

OBJECTIVE

This review aimed to determine the effect of nutrition education on IFA supplementation (IFAS) compliance, hemoglobin level change, and prevalence of anemia in low- and middle-income countries.

DATA SOURCES

The systematic searches on Ovid Medline, Scopus, Embase (Elsevier), Web of Science, Health and Medical Collection (ProQuest), and Google Scholar were conducted until September 11, 2023. The updated searches were performed on November 16, 2023.

DATA EXTRACTION

In total, 12 436 records were imported to Covidence. Of these, 9109 records were screened by title and abstract. A total of 112 records were evaluated in full, and 53 articles were ultimately included based on eligibility.

RESULTS

Fifty-three peer-reviewed research articles met the inclusion criteria, involving 13 475 pregnant women. Those who received nutrition education during pregnancy were 2.80 times more likely to comply with IFAS (odds ratio = 2.80; 95% CI: 2.04, 3.83; I2 = 66.20%). There was an average increase of 0.88 g/dL (Cohen's d = 0.88; 95% CI: 0.63, 1.13; I2 = 96.17%) in hemoglobin levels among women who received nutrition education. A meta-regression analysis revealed that 61.85% (adjusted R2 = 61.85%) of heterogeneity between standardized mean differences was explained by anemia status, intervention duration, and geographic region. Also, pregnant women in the nutrition education group had a 34% (relative risk = 0.66; 95% CI: 0.54, 0.80, I2 = 86.85%) lower risk of anemia compared with the control group.

CONCLUSION

Nutrition education during pregnancy improves compliance with IFAS, increases hemoglobin levels, and reduces the risk of anemia. Therefore, it is crucial to enhance the existing nutrition education program to prevent and control anemia during pregnancy.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42023454241.

Digital versus non-digital health interventions to improve iron supplementation in pregnant women: a systematic review and meta-analysis

Objective

To investigate the effects of digital health interventions for improving adherence to oral iron supplementation in pregnant women.

Literature search

Five databases were searched from their inception to October 2023 with no date restrictions.

Study selection

Randomized controlled trials (RCTs) that assessed the effects of digital health interventions on adherence to oral iron supplementation (e.g., tablets and capsules) compared to non-digital health interventions for pregnant women were eligible.

Data synthesis

We calculated standardized mean differences (SMDs) and mean differences (MDs) with 95% confidence intervals (CIs) for continuous variables using the inverse variance method. We calculated odds ratios (OR) with 95%CI for categorical variables using the Mantel-Haenszel model. The certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. The risk of bias of the included RCTs was assessed using the Cochrane risk of bias tool 2.0.

Results

Ten trials with 1,633 participants were included. Based on 7 trials, digital health interventions can improve objective adherence rate comparing with non-digital health interventions (1,289 participants, OR = 4.07 [2.19, 7.57], p < 0.001, I2 = 69%) in pregnant women. Digital health interventions can improve subjective adherence behavior comparing with non-digital health interventions (3 trials, 434 participants, SMD = 0.82 [0.62, 1.01], p < 0.001, I2 = 0%) in pregnant women. Based on 3 trials, digital health interventions can improve tablets consumption comparing with non-digital health interventions (333 participants, SMD = 1.00 [0.57, 1.42], p < 0.001, I2 = 66%) in pregnant women. Digital health interventions can improve hemoglobin level comparing with non-digital health interventions (7 trials, 1,216 participants, MD = 0.59 [0.31, 0.88], p < 0.001, I2 = 93%) in pregnant women.

Conclusion

Digital health interventions were effective at improving adherence to oral iron supplementation and hemoglobin levels in pregnant women.

Knowledge, attitudes, and practices among patients with anemia towards disease management

Objective

This study aimed to assess the knowledge, attitudes and practices among anemia patients toward disease management.

Methods

This web-based cross-sectional study was conducted between September and December 2023 at The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine). A self-designed questionnaire was developed to collect demographic information of anemia patients, and assess their knowledge, attitudes and practices (KAP) toward disease management.

Results

A total of 396 valid questionnaires were collected. The mean age of the participants was 57.44 ± 16.80 years, and 52.02% were female. The mean knowledge, attitudes, and practices scores were 11.47 ± 1.73 (possible range: 0-14), 27.32 ± 2.96 (possible range: 7-35), and 40.49 ± 6.06 (possible range: 10-50), respectively. Multivariate analysis showed that bachelor's degree or above was independently associated with sufficient knowledge (OR = 2.372, 95%CI: 1.160-4.853, p = 0.018). Knowledge (OR = 1.350, 95%CI: 1.166-1.563, p < 0.001) and hemoglobin within 60-90 g/L (OR = 1.782, 95%CI: 1.090-2.912, p = 0.021) were independently associated with positive attitudes. Moreover, attitudes (OR = 1.618, 95%CI: 1.454-1.799, p < 0.001) and diagnosis ≥1 year (OR = 1.949, 95%CI: 1.171-3.243, p = 0.010) were independently associated with proactive practices. The path analysis demonstrated that knowledge was directly and positively correlated with attitudes (β = 0.484, 95% CI: 0.363-0.647, p = 0.008), and attitudes was directly and positively correlated with practices (β = 1.195, 95% CI: 1.062-1.332, p = 0.007). Moreover, knowledge was indirectly and positively correlated with practice (β = 0.579, 95% CI: 0.434-0.805, p = 0.004).

Conclusion

Anemia patients have sufficient knowledge, negative attitudes, but proactive practices toward the toward disease management Comprehensive training programs are needed to improve anemia patients practices in this area.

Development and validation of the information-motivation-behavioural skills model-based human immunodeficiency virus education kit for adolescents in Malaysia

The growing Human Immunodeficiency Virus (HIV) incidences and insufficient HIV knowledge among Malaysian late adolescents necessitate immediate attention to HIV prevention via education. This study aims to develop and validate an Information-Motivation-Behavioural skills (IMB) model-based education kit for adolescents, PREM-Kit, to educate on HIV prevention among Malaysian late adolescents. Utilizing the Analysis, Design, Development, Implementation, and Evaluation model, we conducted the study in three phases: needs assessment, development of PREM-Kit, and validation of PREM-Kit by applying the IMB model to map the PREM-Kit's contents. PREM-Kit, developed in Malay language, consisted of an infographic flip chart and videos. Five multi-disciplinary experts validated the PREM-Kit using the content validity index (CVI), and 13 end-users validated the PREM-Kit using the Malay version of the Patient Education Materials Assessment Tool for Printable and Audiovisual Materials. The infographic flip chart comprised three modules covering 15 topics, and an animated video accompanied each module. PREM-Kit achieved CVI scores of 1.0 and median scores of over 80% for understandability and actionability. Overall, the newly developed IMB model-based HIV education kit has good content validity, is simple to comprehend and apply, and is ready for testing its effectiveness in improving adolescents' knowledge, attitudes, and practices for HIV prevention.