Effect of community based health education on knowledge and attitude towards iron and folic acid supplementation among pregnant women in Kiambu County, Kenya: A quasi experimental study

Introduction Iron and Folic Acid Supplementation (IFAS) services are currently provided free of charge to pregnant women in Kenya during antenatal care (ANC) but compliance remains low. Poor awareness is an important factor contributing to low utilization of IFAS. Inadequate counselling is one of the key factors associated with poor awareness on IFAS. Community based health education is a promising diversification strategy for IFAS health education to curb this problem. Objectives To determine effect of community based IFAS health education, utilizing CHVs, on IFAS knowledge, levels of counselling on various IFAS topics and attitude towards IFAS among pregnant women in Kiambu County. Methodology A Pretest-Posttest Quasi-Experimental study design, consisting of intervention and control group, was applied among 340 pregnant women 18–49 years, in five health facilities, selected using two stage sampling in Lari Sub-County, Kiambu County, Kenya. Community health volunteers provided IFAS health education with weekly supplements and follow-ups to pregnant women in intervention group, while control group received the same from health care providers. Baseline and endline data were collected during ANC and compared. Quantitative data was analyzed using STATA version 14. Analysis of effect of intervention was done using Difference-In-Difference approach. Results There was an effect difference in maternal IFAS knowledge of 13%, with intervention group levels increasing most by 35 percentage points. The odds of being knowledgeable were 3 times more at endline than baseline. There was significant (p<0.001) change in proportion with positive attitude towards IFAS: the odds of having positive attitude at endline was 9 times that of baseline (OR = 9.2:95%CI 3.1, 27.2). Conclusion Implementation of community based health education improved maternal knowledge, positive attitude and proportion of pregnant women counselled on IFAS, better improvement being recorded in intervention group. Hence, there is need to integrate community based approach with antenatal IFAS distribution to improve supplementation.

This was a pretest-posttest quasi-experimental study design with a control group, used to implement a Community Based Approach (CBA) of IFAS health education in three phases namely inception, implementation and follow-up phases (Fig 1). The first phase was inception phase where study respondents were identified and recruited then baseline data was collected: on socio-demographic characteristics, IFAS knowledge, source of IFAS information and levels of counselling on various IFAS aspects, and attitude towards IFAS, among pregnant women. This refers to the three stages that were followed in the implementation of this study. The second phase was implementation phase which involved training then provision of IFAS health education together with the supplements. For the control group, health care providers, mostly nurses, were taken through a refresher training on IFAS programme. They were then provided with information, communication and education materials on IFAS developed by the Ministry of Health including: health workers training guide; national policy guideline on combined Iron and Folic Acid (IFA) supplementation for pregnant mothers in Kenya; mothers leaflets, in both English and Swahili; dialogue guide for health care providers and assorted posters. The nurses continued providing IFAS health education as well as supplements during antenatal care, as is routinely practiced. For the intervention group, Community Health Volunteers (CHVs) were trained on IFAS programme to enable them to provide IFAS health education together with the supplements to pregnant women in their homes. After training, just like the health care providers, the CHVs were provided with information, communication and education materials on IFAS for providing community based health education to pregnant women including: community health workers counselling guide and mothers’ leaflets, in both English and Swahili. The third phase was follow-up phase where the pregnant women were followed-up until delivery of their babies culminating in collection of endline data. The control group were followed up by HCPs (specifically nurses) through the standard routine practice in health facilities which involved receiving IFAS health education and supplements at health facilities during antenatal care. The intervention group were followed up by CHVs on a weekly basis in their homes. During the weekly home visits, CHVs provided each pregnant woman with IFAS health education by counselling her on various IFAS topics including importance of taking IFAS tablets; causes, symptoms and effects of anaemia in pregnancy; dose, frequency and duration of IFA supplementation; common side effects and their management; how and when it is best to take IFAS; food sources of iron/folate; and enhancers/inhibitors of iron/folate absorption. After health education, they provided the entire week’s supply of IFAS tablets. Also, the CHVs encouraged pregnant women to attend antenatal care clinics to receive the other antenatal care services. A few weeks before delivery (from 36th week of gestation), endline data was collected from the respondents who did participate up to the end of the study on socio-demographic characteristics, knowledge, source of IFAS information and levels of counselling on various IFAS topics, and attitude towards IFAS, in both control and intervention groups. The content of the questionnaire used for endline data collection was the same as that used for baseline data collection. Some of the details of methods adopted for recruitment of the pregnant women involved in this study as well as the ethical considerations have been published elsewhere in other articles [3, 22]. The study was conducted in Kiambu County in Kenya. Two stage sampling was adopted to identify one Sub-County (Lari) and five of its major public health facilities (Lari, Githirioini, Kagwe, Kagaa and Kinale) where the study was conducted. Sampling frame consisted of all Sub-Counties in Kiambu County. A criteria was used at each stage. The Sub-County with existing functional (active) community units formed the basis for the intervention, meaning its community health volunteers were actively involved in provision of community health services to community members. All the major public health facilities: with highest client/patient population turnover and with existing and functional (active) community units were used to implement the intervention. These were considered because of the low turn-over of antenatal clients in health facilities in Lari Sub-County. Sample size expected to determine the effect of community based IFAS health education and distribution was calculated using the following formula for a binary outcome [23]: D is the expected effect in IFAS health education of 20% (Control 25% to 45% intervention). A consideration of 30% loss to follow-up was added to this sample, making a total sample size of 170. The final sample size per study group was 170 and in both groups was therefore 340. The study population consisted of all pregnant women who attended antenatal care in the selected health facilities who were: aged 18–49 years, below 33 weeks in their pregnancy gestation, not suffering from any chronic illness and who provided informed consent to participate in the study. Consecutive sampling, was used to include all accessible pregnant women as part of the sample. Consecutive sampling is considered the best type of non-probability sampling with best representation of entire population. All pregnant women who met the inclusion criteria were informed about the study and those who provided both verbal and written informed consent to participate in the study were recruited. Those residing in a community that had a functional community unit with active CHVS, who consented to have IFAS distributed to them in their homes together with health education by CHVs, formed the intervention group. Those residing in a community that did not have a functional community unit formed the control group, who received their IFAS health education and supplementation from fixed health facilities during antenatal care services, until the required sample size of 170 was reached. A semi-structured interviewer-administered questionnaire consisting of 26 closed ended questions including; 11 on socio-demographic data, 9 on IFAS knowledge, 2 on sources of IFAS information, 4 on IFAS counselling content; and a likert scale with 19 statements on attitude and beliefs was developed, pre-tested and used for data collection in this study. To address any potential bias in data collection, training of four research assistants on research ethics and protocol and quality data collection was done at Kiambu level 5 hospital where the research questionnaires were pretested. To ensure reliability of the questionnaire, a test re-test method was adopted in pre-testing, whereby a repeat pre-test was conducted after two weeks, and Cohen’s kappa statistic was used to measure the level of agreement of the results from the two pre-tests. The questions which were tested and re-tested included: on socio-demographic data: age, education level, occupation, income, gestation, parity and gravidity; on maternal knowledge: benefits of IFAS, frequency of taking IFAS, duration of taking IFAS, possible side effects of IFAS, how to manage the side effects, food sources that increase blood levels, consequences of not getting enough iron/folate, and signs and symptoms of anaemia; and the statements on attitude. All the questions repeated had a kappa value of above 0.7 after comparison thus the questionnaire was considered reliable, hence all the questions were retained. To ensure validity of the questionnaire, it was shared and discussed with experts from the Ministry of Health, division of nutrition, and the study supervisors. The feedback obtained from these experts and pre-testing results was used to refine the tool and improve its quality to ensure the questions were able to test what was intended. The trained research assistants administered questionnaires to all pregnant women who met the inclusion criteria and consented to participate in the study at the health facilities selected for the study. To assess the level of knowledge about IFAS during pregnancy, respondents were asked 9 questions: whether they have heard of IFAS or not, benefits of IFAS, frequency of use of IFAS, duration of taking IFAS, side effects, management of side-effects, effect of iron/folate deficiency, signs and symptoms of anaemia, and food sources for iron during pregnancy. A correct answer for each item was scored as “1” and incorrect answer scored as “0”. A summation of all the scores for each participant was done then converted into percent score. Based on references from other studies [24–26], those who scored above the average value (50%) were considered as somehow knowledgeable and those who scored below the average value were considered as less knowledgeable. The respondents’ attitude towards IFAS was assessed on 19 Likert scale items. A correct answer for each item was scored as “5” and incorrect answer scored as “1”. The scores were summed then converted into percent score. Using references from other studies [24, 25] and in consideration of majority score, a respondent was considered to have a positive attitude if they scored 70% and above and a negative attitude if they scored less than 70%. Women who reported not to have heard of IFAS were excluded in the assessment of attitude. In order to examine effectiveness of the intervention, baseline and endline surveys were conducted in both study groups, using a similar questionnaire. To ensure adherence to optimal data quality standards, there was close supervision of the research assistants by the researcher. Quantitative data at both baseline and endline was coded after collection then entered into the computer, cleaned and validated using Statistical Package for Social Sciences (SPSS) statistical software version 22. Data entry was done during the study to minimize errors. It was then exported to STATA version 14 for analysis. To ensure confidentiality, the computer access was restricted by password protection. Each questionnaire had a unique identifier to allow validation. Data cleaning and validation was done prior to analysis. Descriptive statistics, including univariate analysis: simple proportions, n (%), for categorical variables and mean with standard deviation for continuous variables, were reported at baseline and endline. Characteristics of respondents were also described in both intervention and control groups. Knowledge, sources of IFAS information and whether counselling was offered on various IFAS topics to pregnant women were recorded. To ensure the change caused by the intervention was not by chance, baseline characteristics were similar in both groups. Homogeneity of study groups at baseline was determined by comparing socio-demographic characteristics of both groups. Bivariate analysis, using the chi-square test, was done for comparison between groups and multivariate analysis was used to control for confounders. The analysis of effect of the intervention was done using a Difference-In-Difference (DID) regression model to compare outcomes between intervention and control groups before (baseline) and after (endline) the intervention. The changes in the dependent variables in the intervention group (from baseline to endline) were compared to changes in the control group (from baseline to endline) as shown in Table 1 below [27]. The intervention effect was measured by odds ratio and 95% confidence level of the interaction term between study groups (intervention and control) and period of survey (baseline and endline) in the multiple logistic regression model. A p-value of 0.05 was considered statistically significant. Since the same respondents who participated in the baseline are the same who participated in the end term evaluation, the analysis considered using a paired analysis with repeated measures instead of treating the respondents in baseline and endline as independents groups. Therefore, Generalized Estimation Equation (GEE) was applied in addition to allow correlation of these repeated observations over time since data are collected on the same participants across successive points in time. This is because GEE has been found to be more efficient for correlated longitudinal data, focusing on estimating the average response over the population ("population-averaged" effects) instead of estimating the effect of one or more covariates on a given individual [28–30]. Source: Kothari and Garg, 2014 pg 41. Scientific and ethical approval was obtained from Kenyatta National hospital/University of Nairobi Ethics and Research Committee (KNH-ERC/A/90 protocol number–P706/11/2015) and research permit obtained from the National Commission for Science, Technology and Innovation (NACOSTI/P/18/81499/22319). Permission to conduct the study was obtained from managerial authorities at Kiambu County, Lari Sub-county and all health facilities involved. Respondents were fully protected from any form of harm. Participation in the study was purely voluntary. The purpose of study was made clear to respondents who were required to give informed verbal and written consent. Emphasis on confidentiality and privacy were made clear at the time of consenting to participate and upheld throughout the study. No name appeared on the questionnaires so no participant identification with information could occur. Respondents were at liberty to discontinue from the study at any time without facing any adverse consequences. Information was kept confidential by restricted access and coding of questionnaires.

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