A Multi-Theoretical Approach to Micronutrient Supplementation among Women of Child-Bearing Age in Ghana

Micronutrient supplementation is a popular approach to addressing the unmet dietary needs of mothers in low- and middle-income countries, as supplement distribution programs can be implemented relatively quickly at comparatively low cost. However, dietary supplementation programs often do not achieve the desired level of impact, due in part to persistent barriers between health programs and the communities they serve. This study examines the effectiveness of a supplementation intervention delivered by community health workers among women of childbearing age in Ghana. In addition to other biological indicators, pill counts were used to measure changes in health behavior among women in the target communities.

A Multi-Theoretical Approach to Micronutrient Supplementation among Women of Child-Bearing Age in Ghana Rachel Jaggi, MA, Scott Benson, MD, PhD, MPH, Stephen Alder, PhD BACKGROUND THEORETICAL FRAMEWORK The IMPART model (Figure 1) serves as the framework for intervention design. This multi-theoretical model incorporates elements of the Transtheoretical model, the Health Belief Model, the Theory of Planned Behavior, the Expectancy-Valence Theory, and Attribution Theory to establish a framework for exploring the complex process of behavior change.4-5 Figure 1: The IMPART Model Perceived susceptibility and severity Perceived barriers and benefits Perceived behavioral control Subjective Norm Attitude toward behavior Pill counts for all 53,624 monthly visits conducted during the study period of August 2013 to May 2016 are presented in Table 1. Table 1: Number of Pills Remaining at all Monthly Visits INTERVENTION The intervention consisted of two theoretically-driven steps: 1) Direct instruction: Women received ongoing education on the benefits of supplementation, the importance of continued use, and specific directions on how to use supplements. 2) Behavioral Cues: Women were reminded to take their supplement through the "keeper" system (women in the communities were encouraged to check in with one another regarding the supplementation) and through visual reminders (e.g. a calendar with pictures of local health professionals and women using supplementation). METHODS Women ages 18-35 from 10 communities in the Barekese subdistrict of Ghana were eligible for study participation. Study participants received monthly visits from community health workers, who: 1) Distributed a new month's supply of the supplement. 2) Provided ongoing education about the benefits of supplementation and answered questions. Intention 3) Conducted pill counts to determine compliance. Cues to action Self-Efficacy Percent of monthly visits Micronutrient supplementation is a popular approach to addressing the unmet dietary needs of mothers in low- and middle-income countries, as supplement distribution programs can be implemented relatively quickly at comparatively low cost.1 However, dietary supplementation programs often do not achieve the desired level of impact, due in part to persistent barriers between health programs and the communities they serve.1-3 This study examines the effectiveness of a supplementation intervention delivered by community health workers among women of childbearing age in Ghana. In addition to other biological indicators, pill counts were used to measure changes in health behavior among women in the target communities. RESULTS 33.8% 35.9% 17.0% 10.9% 2.4% 0 1 to 9 10 to 19 20 or Unknown more Pills Remaining Overall, 69.7% of visits had greater than 70% compliance with daily supplementation. DISCUSSION Pill count data suggests that the intervention design based on the IMPART model was generally successful in helping women make and sustain the behavior change of daily supplementation. Future research on the effectiveness of this model in improving health behavior change could include: • Analysis of association between compliance data and health outcomes (e.g. nutritional biomarkers, birthweights, etc). • Exploration of potential correlations between compliance and demographic factors (e.g. community, age, income, etc). • Qualitative investigation of reasons for low or noncompliance. REFERENCES 1. 2. 3. Behavior 40% 35% 30% 25% 20% 15% 10% 5% 0% 4. 5. Allen L, de Benoist B, Dary O, Hurrell R. Guidelines on Food Fortification with Micronutrients. Geneva, Switzerland: World Health Organization and Food and Agriculture Organization of the United Nations; 2006:3-23. Black RE. Micronutrients in pregnancy. Brit J Nutr. 2001;85(Suppl 2):S193-S197. Hill Z, Kirkwood B, Kendall C, et al. Factors that affect the adoption and maintenance of weekly vitamin A supplementation among women in Ghana. Public Health Nutr. 2007;10(8):827-833. Willardson SL, et al. Forming a supplement intervention using a multi-theoretical behavior model. American journal of health behavior 2013;37(6): 831-840. Alder S, Wuthrich A, Haddadin B, et al. Community intervention model to reduce inappropriate antibiotic use. J Health Educ. 2010;41(1):20-28.