The efficacy of maternal health education and maternal screening on knowledge and the uptake of infant screening for sickle cell disease in Dar-Es-Salaam, Tanzania; a quasi experimental study

BMC Public Health, Volume 23, No. 1, Year 2023

Interpretação

Background: Globally, Sickle cell disease (SCD) is one of the most common genetic disease with high childhood mortality. Early identification of babies with SCD through newborn screening (NBS) and linking them to care are among the recommended interventions. The purpose of this study was to assess the efficacy of maternal health education and maternal screening for SCD on knowledge and the uptake of infant screening for SCD among mother-infant pairs attending antenatal clinics at Government health facilities in Dar-es-salaam, Tanzania. Methods: This study was a pre-test post-test, quasi-experimental which involved pregnant women attending antenatal clinics at three hospitals; Mbagala hospital, Sinza hospital and Buguruni health center in Dar Es Salaam. A structured questionnaire was used in data collection. Knowledge on SCD was assessed for all participants before and after two sessions of health education. Participants in Mbagala and Buguruni were also screened for SCD using Sickle SCAN point-of-care test (BioMedomics Inc, USA). The efficacy for health education intervention was computed as the post-intervention minus baseline knowledge score. For proportions, a two-sample z-test was used. Univariate and multivariate logistic regression were used to analyze the efficacy of health education intervention and also predictors of infant diagnosis. Results: For two sessions of health education intervention, a total of 467 pregnant women completed the sessions. During antenatal visits, a total of 218 were screened for SCD. The proportion of participants with good knowledge of SCD had significantly increased to 85.9% from 12.4% at baseline following the education intervention. In multivariate analysis, sharing the received education on SCD was an independent predictor of the efficacy of health education intervention. Maternal occupation, maternal SCD status as well as sharing the received education on SCD were independent predictors of the uptake of SCD infant diagnosis. Conclusion: This study has demonstrated that maternal health education and maternal screening for SCD are feasible and efficacious interventions in raising knowledge and improving the uptake of infant diagnosis for SCD. These interventions are strongly recommended to be included in the comprehensive care package for pregnant women attending antenatal clinics, particularly in areas with a high burden of SCD. This was a pre-test post-test, quasi-experimental study conducted at three sites (Mbgala, Buguruni and Sinza). In this study, we assessed two interventions, which were: This study involved all pregnant women who were attending the antenatal clinics during our study period (2020 to 2022). We had three study sites; Mbagala hospital, Buguruni health center and Sinza hospital, which are all primary level public health facilities, providing services to urban population in the City of Dar Es Salaam. There is no dedicated SCD clinics from either of the sites, but all are close to the regional referral hospitals which run SCD clinics. Currently, Tanzania does not have a universal newborn or infant screening program for SCD. Services are available at some health facilities, including the regional referral hospitals and national hospital located in Dar-es-salaam. Participants were directed to attend to these facilities upon delivery for their babies to be screened for SCD. The sample size of 440 participants was obtained from the formula, where; p=p0+rp1r+1, P0 is the proportion in population receiving HE only, and P1 is the proportion in population receiving HE and maternal screening, r is the case and control ratio. Assumptions: alpha = 0.05 (two sided), Power = 95%, P0 = 0.5, P.1 = 0.35, m0/m1 = r = 1 The minimum required sample size for this study was 440 participants, being 220 to be screened and receive health education and 220 to receive health education only without screening. Additional 160 participants were recruited to get the final total of 600 participants who were enrolled into the study. Convenient sampling technique was used to select the participants where all pregnant women available at our study sites during the study period, who were willing to take part in our study and met the inclusion criteria were selected and enrolled in our study. The inclusion criteria were; pregnancy at gestation age between 20–28 weeks during first visit (since those with gestation age above 28 weeks during first visit were likely to deliver before completing the series of health education interventions planned in the study); absence of pregnancy complications which risk termination of pregnancy (such as heart failure, pregnancy-induced hypertension, threatened abortion, hyperemesis gravidarum, gestational diabetes), and not having received blood transfusion within the past four months prior enrolment into the study as the donor blood could interfere with the results of SCD screening test (this last criterion was considered only among participants in the screening arm). Health education intervention was provided to all participants from each of the three sites (Buguruni, Mbagala and Sinza health facilities) where each participant controlled for herself using the pre-post-test design while on the screening intervention, participants from Buguruni and Mbagala sites served as intervention group (were screened for SCD) while participants from Sinza served as control group (not screened for SCD). This separation of maternal screening by sites was done to ensure that pregnant women at any particular site received same interventions, thus mitigate concerns regarding preferential treatment and also prevent mix-up of interventions across participants. The three study sites were selected purposively based on their proximity to the referral hospitals with available SCD services where participants could be referred to. This study had three phases; Eligible participants provided informed consent prior enrolment into the study. Following informed consent, a structured questionnaire was administered by a research assistant to each participant. The questionnaire gathered demographic information and contained questions assessing the baseline level of knowledge on SCD (if SCD is related to blood cancer, life expectance of patients SCD, knowledge on the mode of acquiring and diagnosis of SCD as well as the most common signs and symptoms of SCD). After administration of the questionnaire, the first session of health education on SCD was conducted physically at the study sites to either one participant or to a group with maximum number of seven participants, depending on their availability. We used the health education materials which are available at Muhimbili University of Health and Allied Sciences—Sickle Cell Program and are being used in proving health education to the community. These materials covered what SCD is, mode of acquiring and diagnosis, signs and symptoms, complications and cleared different myth on SCD. Each health education session lasted in average of 15 min. However, we provided room for questions and answered all concerns raised by the participants regarding SCD. Further, proper information was given to participants on where and how to access the extended services for SCD involving SCD clinics, infant screening services and diagnostic services. We also provided to study participants contact information for enquiry in case someone wanted to get additional clarification on SCD. Participants from the screening sites were freely screened for SCD using the Sickle SCAN® point-of-care test following manufacturer’s instructions (BioMedomics Inc., United States). The test is capable of identifying Hemoglobin A, S and C variants in blood samples. We conducted maternal screening for SCD at antenatal laboratories where other routine screening activities such as HIV and hemoglobin level took place. Each participant was provided with results of her SCD test on-site. Counselling was given and information was provided on where to get additional SCD services. In one to two months after the first health education session, the second session of health education was conducted upon follow-up of all 600 participants through phone call where every participant was called in-person. All participants who were reachable and were willing to continue with the study received the education by using the same health education materials used in the first session. Two to three months after the second health education session, the post-intervention assessment of the level of knowledge on SCD was conducted to all participants using the same questionnaire that was used for pre-testing. During the education sessions, participants were informed of the locations at the regional referral hospitals and national hospital where SCD screening services can be obtained for their babies upon delivery. Three months after the respective expected dates of delivery (which were collected at enrollment), the post-delivery information of both mother and the baby was collected, including whether the baby was screened for SCD. The latter information was collected for the last time twelve months post expected date of delivery (Fig. 1). All participants who could not be reached three times in different days, those who were not willing to continue with the study as well as the death of the participant, were termed as loss to follow-up. The Flow chart of participants involved in the study from enrollment to follow-up In this study, we had two dependent variables which were: Maternal level of knowledge on SCD and the uptake of infant screening for SCD after delivery. The independent variables were: Age, Level of education, Occupation, Marital status, Maternal screening for SCD, Maternal SCD status, Remembering personal SCD Status and Sharing health education received. We used Stata Version 17 for data analysis. We expressed the descriptive statistics such as the socio-demographic characteristics of the participants and their babies in frequencies and percentages, and presented in tables. We graded the level of knowledge depending on the number of correct responses scored from the questionnaires which was constructed from different literature that assessed the level of knowledge on SCD in different groups including pregnant women, also modified to fit the local context [11–13]. A correct response was scored as “1” while a wrong response was scored as “0”. Total knowledge score ranging from 0 to 10 was calculated as the sum of all correct responses considering the following score range; < 7 poor knowledge, 7–10 good knowledge. We used the two-sample Z test for proportions to ascertain statistical significance of the difference in proportions of the participants with good knowledge on SCD before and after health education intervention. Chi-square test was used in ascertaining the efficacy of maternal screening on the uptake of infant screening for SCD between sites where maternal screening for SCD was provided and those where maternal screening was not provided. Further, we computed “efficacy” of health education intervention as the post-intervention minus baseline score for each individual participant, where optimal efficacious was considered to have been achieved in those who gained 3 points or higher. Subsequently, we dichotomized participants into those where health education intervention was “efficacious” versus those where intervention was “not efficacious” and performed univariate as well as multivariate logistic regression to ascertain the predictors of the efficacy of health education intervention. Further, we performed inferential statistics on predictors of infant screening by comparing the different categories between the dependent variable (if child screened for SCD) with various independent variables (maternal level of education, occupation, maternal screening for SCD, maternal SCD status, level of knowledge post health education intervention and if she shared the health education received) using regression analysis where all independent variables associating with infant diagnosis with p-values of 0.2 or less during univariate logistic regression were included in the final multivariable logistic regression model. We considered a two tailed p-value below 0.05 to be statistically significant.

AI Digest

Study Justification:

– Sickle cell disease (SCD) is a common genetic disease with high childhood mortality globally.
– Early identification of babies with SCD through newborn screening (NBS) and linking them to care are recommended interventions.
– This study aimed to assess the efficacy of maternal health education and maternal screening for SCD on knowledge and the uptake of infant screening for SCD.

Highlights:

– The study involved pregnant women attending antenatal clinics at three hospitals in Dar-es-salaam, Tanzania.
– Two interventions were assessed: maternal health education and maternal screening for SCD.
– The study found that both interventions were feasible and efficacious in raising knowledge and improving the uptake of infant diagnosis for SCD.
– The proportion of participants with good knowledge of SCD significantly increased from 12.4% to 85.9% following the education intervention.
– Maternal occupation, maternal SCD status, and sharing the received education on SCD were predictors of the uptake of SCD infant diagnosis.

Recommendations:

– Maternal health education and maternal screening for SCD should be included in the comprehensive care package for pregnant women attending antenatal clinics, particularly in areas with a high burden of SCD.
– These interventions can contribute to raising knowledge about SCD and improving the uptake of infant diagnosis, leading to better management and outcomes for babies with SCD.

Key Role Players:

– Healthcare providers at antenatal clinics and hospitals
– Maternal health educators
– Laboratory technicians for SCD screening
– Policy makers and government officials responsible for healthcare planning and implementation

Cost Items for Planning Recommendations:

– Development and dissemination of educational materials on SCD
– Training and capacity building for healthcare providers and educators
– Procurement of SCD screening tests and equipment
– Integration of SCD services into existing healthcare systems
– Monitoring and evaluation of the implementation of maternal health education and screening programs

Força da prova

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a quasi-experimental study design and includes pre-test and post-test measurements. The study involved a large sample size of 467 pregnant women and used structured questionnaires for data collection. The study assessed the efficacy of maternal health education and maternal screening for sickle cell disease (SCD) on knowledge and the uptake of infant screening for SCD. The results showed a significant increase in knowledge of SCD and a high proportion of participants with good knowledge after the education intervention. The study also identified predictors of the efficacy of health education intervention and the uptake of SCD infant diagnosis. However, the abstract does not provide information on potential limitations of the study or suggestions for improvement. To improve the evidence, future studies could consider randomization, longer follow-up periods, and inclusion of control groups to strengthen the study design and provide more robust evidence.

Resumo

This was a pre-test post-test, quasi-experimental study conducted at three sites (Mbgala, Buguruni and Sinza). In this study, we assessed two interventions, which were: This study involved all pregnant women who were attending the antenatal clinics during our study period (2020 to 2022). We had three study sites; Mbagala hospital, Buguruni health center and Sinza hospital, which are all primary level public health facilities, providing services to urban population in the City of Dar Es Salaam. There is no dedicated SCD clinics from either of the sites, but all are close to the regional referral hospitals which run SCD clinics. Currently, Tanzania does not have a universal newborn or infant screening program for SCD. Services are available at some health facilities, including the regional referral hospitals and national hospital located in Dar-es-salaam. Participants were directed to attend to these facilities upon delivery for their babies to be screened for SCD. The sample size of 440 participants was obtained from the formula, where; p=p0+rp1r+1, P0 is the proportion in population receiving HE only, and P1 is the proportion in population receiving HE and maternal screening, r is the case and control ratio. Assumptions: alpha = 0.05 (two sided), Power = 95%, P0 = 0.5, P.1 = 0.35, m0/m1 = r = 1 The minimum required sample size for this study was 440 participants, being 220 to be screened and receive health education and 220 to receive health education only without screening. Additional 160 participants were recruited to get the final total of 600 participants who were enrolled into the study. Convenient sampling technique was used to select the participants where all pregnant women available at our study sites during the study period, who were willing to take part in our study and met the inclusion criteria were selected and enrolled in our study. The inclusion criteria were; pregnancy at gestation age between 20–28 weeks during first visit (since those with gestation age above 28 weeks during first visit were likely to deliver before completing the series of health education interventions planned in the study); absence of pregnancy complications which risk termination of pregnancy (such as heart failure, pregnancy-induced hypertension, threatened abortion, hyperemesis gravidarum, gestational diabetes), and not having received blood transfusion within the past four months prior enrolment into the study as the donor blood could interfere with the results of SCD screening test (this last criterion was considered only among participants in the screening arm). Health education intervention was provided to all participants from each of the three sites (Buguruni, Mbagala and Sinza health facilities) where each participant controlled for herself using the pre-post-test design while on the screening intervention, participants from Buguruni and Mbagala sites served as intervention group (were screened for SCD) while participants from Sinza served as control group (not screened for SCD). This separation of maternal screening by sites was done to ensure that pregnant women at any particular site received same interventions, thus mitigate concerns regarding preferential treatment and also prevent mix-up of interventions across participants. The three study sites were selected purposively based on their proximity to the referral hospitals with available SCD services where participants could be referred to. This study had three phases; Eligible participants provided informed consent prior enrolment into the study. Following informed consent, a structured questionnaire was administered by a research assistant to each participant. The questionnaire gathered demographic information and contained questions assessing the baseline level of knowledge on SCD (if SCD is related to blood cancer, life expectance of patients SCD, knowledge on the mode of acquiring and diagnosis of SCD as well as the most common signs and symptoms of SCD). After administration of the questionnaire, the first session of health education on SCD was conducted physically at the study sites to either one participant or to a group with maximum number of seven participants, depending on their availability. We used the health education materials which are available at Muhimbili University of Health and Allied Sciences—Sickle Cell Program and are being used in proving health education to the community. These materials covered what SCD is, mode of acquiring and diagnosis, signs and symptoms, complications and cleared different myth on SCD. Each health education session lasted in average of 15 min. However, we provided room for questions and answered all concerns raised by the participants regarding SCD. Further, proper information was given to participants on where and how to access the extended services for SCD involving SCD clinics, infant screening services and diagnostic services. We also provided to study participants contact information for enquiry in case someone wanted to get additional clarification on SCD. Participants from the screening sites were freely screened for SCD using the Sickle SCAN® point-of-care test following manufacturer’s instructions (BioMedomics Inc., United States). The test is capable of identifying Hemoglobin A, S and C variants in blood samples. We conducted maternal screening for SCD at antenatal laboratories where other routine screening activities such as HIV and hemoglobin level took place. Each participant was provided with results of her SCD test on-site. Counselling was given and information was provided on where to get additional SCD services. In one to two months after the first health education session, the second session of health education was conducted upon follow-up of all 600 participants through phone call where every participant was called in-person. All participants who were reachable and were willing to continue with the study received the education by using the same health education materials used in the first session. Two to three months after the second health education session, the post-intervention assessment of the level of knowledge on SCD was conducted to all participants using the same questionnaire that was used for pre-testing. During the education sessions, participants were informed of the locations at the regional referral hospitals and national hospital where SCD screening services can be obtained for their babies upon delivery. Three months after the respective expected dates of delivery (which were collected at enrollment), the post-delivery information of both mother and the baby was collected, including whether the baby was screened for SCD. The latter information was collected for the last time twelve months post expected date of delivery (Fig. 1). All participants who could not be reached three times in different days, those who were not willing to continue with the study as well as the death of the participant, were termed as loss to follow-up. The Flow chart of participants involved in the study from enrollment to follow-up In this study, we had two dependent variables which were: Maternal level of knowledge on SCD and the uptake of infant screening for SCD after delivery. The independent variables were: Age, Level of education, Occupation, Marital status, Maternal screening for SCD, Maternal SCD status, Remembering personal SCD Status and Sharing health education received. We used Stata Version 17 for data analysis. We expressed the descriptive statistics such as the socio-demographic characteristics of the participants and their babies in frequencies and percentages, and presented in tables. We graded the level of knowledge depending on the number of correct responses scored from the questionnaires which was constructed from different literature that assessed the level of knowledge on SCD in different groups including pregnant women, also modified to fit the local context [11–13]. A correct response was scored as “1” while a wrong response was scored as “0”. Total knowledge score ranging from 0 to 10 was calculated as the sum of all correct responses considering the following score range; < 7 poor knowledge, 7–10 good knowledge. We used the two-sample Z test for proportions to ascertain statistical significance of the difference in proportions of the participants with good knowledge on SCD before and after health education intervention. Chi-square test was used in ascertaining the efficacy of maternal screening on the uptake of infant screening for SCD between sites where maternal screening for SCD was provided and those where maternal screening was not provided. Further, we computed “efficacy” of health education intervention as the post-intervention minus baseline score for each individual participant, where optimal efficacious was considered to have been achieved in those who gained 3 points or higher. Subsequently, we dichotomized participants into those where health education intervention was “efficacious” versus those where intervention was “not efficacious” and performed univariate as well as multivariate logistic regression to ascertain the predictors of the efficacy of health education intervention. Further, we performed inferential statistics on predictors of infant screening by comparing the different categories between the dependent variable (if child screened for SCD) with various independent variables (maternal level of education, occupation, maternal screening for SCD, maternal SCD status, level of knowledge post health education intervention and if she shared the health education received) using regression analysis where all independent variables associating with infant diagnosis with p-values of 0.2 or less during univariate logistic regression were included in the final multivariable logistic regression model. We considered a two tailed p-value below 0.05 to be statistically significant.

Materiais

N/A

Inovações

The study recommends implementing maternal health education and maternal screening for sickle cell disease (SCD) as interventions to improve knowledge and the uptake of infant screening for SCD among mother-infant pairs attending antenatal clinics. These interventions were found to be feasible and efficacious in raising knowledge and improving the uptake of infant diagnosis for SCD. The study suggests including these interventions in the comprehensive care package for pregnant women attending antenatal clinics, particularly in areas with a high burden of SCD. The recommendation is based on the findings of a quasi-experimental study conducted in Dar-Es-Salaam, Tanzania, which showed a significant increase in knowledge of SCD and the proportion of participants who underwent screening for SCD after receiving maternal health education and maternal screening. The study was published in BMC Public Health in 2023.

AI Innovations Description

The recommendation from this study is to implement maternal health education and maternal screening for sickle cell disease (SCD) as interventions to improve knowledge and the uptake of infant screening for SCD among mother-infant pairs attending antenatal clinics. The study found that these interventions were feasible and efficacious in raising knowledge and improving the uptake of infant diagnosis for SCD. The interventions are strongly recommended to be included in the comprehensive care package for pregnant women attending antenatal clinics, particularly in areas with a high burden of SCD. This recommendation is based on the findings of a quasi-experimental study conducted in Dar-Es-Salaam, Tanzania, which showed a significant increase in knowledge of SCD and the proportion of participants who underwent screening for SCD after receiving maternal health education and maternal screening. The study was published in BMC Public Health in 2023.

AI Innovations Methodology

The methodology used in the study to simulate the impact of the recommendations on improving access to maternal health involved a pre-test post-test, quasi-experimental design. The study was conducted at three government health facilities in Dar-Es-Salaam, Tanzania: Mbagala hospital, Sinza hospital, and Buguruni health center. The study included pregnant women attending antenatal clinics during the study period from 2020 to 2022.

The sample size for the study was determined using a formula, and a total of 600 participants were enrolled. Convenient sampling technique was used to select participants who met the inclusion criteria, which included being between 20-28 weeks of gestation, absence of pregnancy complications, and not having received a blood transfusion within the past four months (for participants in the screening arm).

The interventions included maternal health education and maternal screening for sickle cell disease (SCD). Health education sessions were conducted at the study sites, and participants received information on SCD, including its mode of acquisition, diagnosis, signs and symptoms, complications, and dispelling myths. The education sessions lasted approximately 15 minutes, and participants were given the opportunity to ask questions and seek clarification.

Participants at the screening sites (Mbagala and Buguruni) were also screened for SCD using the Sickle SCAN point-of-care test. The test identified Hemoglobin A, S, and C variants in blood samples. Maternal screening for SCD was conducted at antenatal laboratories, and participants received their test results on-site. Counseling was provided, and information on where to access additional SCD services was given.

The efficacy of the health education intervention was assessed by comparing the post-intervention knowledge scores with the baseline scores. The proportion of participants with good knowledge of SCD significantly increased following the education intervention. The efficacy of the intervention was also analyzed using logistic regression.

The uptake of infant screening for SCD after delivery was assessed as an outcome variable. Factors such as maternal occupation, maternal SCD status, and sharing the received education on SCD were analyzed as predictors of infant diagnosis using univariate and multivariate logistic regression.

Data analysis was conducted using Stata Version 17, and descriptive statistics were presented in frequencies and percentages. The two-sample Z test for proportions and chi-square test were used to determine statistical significance.

In conclusion, the study demonstrated that maternal health education and maternal screening for SCD are feasible and efficacious interventions in improving knowledge and the uptake of infant diagnosis for SCD. The study recommends including these interventions in the comprehensive care package for pregnant women attending antenatal clinics, particularly in areas with a high burden of SCD.

The study was published in BMC Public Health, Volume 23, No. 1, in the year 2023.

Autor

Dima Health

Identifiers:

DOI: 10.1186/s12889-022-14859-2

Research Areas:

Cancer, Community Interventions, Genetics and Genomics, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Noncommunicable Diseases, Quality of Care, Sexual and Reproductive Health

Study Countries:

Tanzania

Study Design:

Cohort Study, Cross Sectional Study, Grounded Theory, Quasi Experimental Study, randomised-control-trial

Study Approach:

Quantitative

Participants Gender:

Female

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