Engagement of Husbands in a Maternal Nutrition Program Substantially Contributed to Greater Intake of Micronutrient Supplements and Dietary Diversity during Pregnancy: Results of a Cluster-Randomized Program Evaluation in Bangladesh

Phuong Hong Nguyen, Edward A Frongillo, Tina Sanghvi, Gargi Wable, Zeba Mahmud, Lan Mai Tran, Bachera Aktar, Kaosar Afsana, Silvia Alayon, Marie T Ruel, Purnima Menon, Phuong Hong Nguyen, Edward A Frongillo, Tina Sanghvi, Gargi Wable, Zeba Mahmud, Lan Mai Tran, Bachera Aktar, Kaosar Afsana, Silvia Alayon, Marie T Ruel, Purnima Menon

Abstract

Background: Although husbands may provide support during pregnancy, limited evidence exists on how to promote husbands' engagement and what impact it has. Alive & Thrive integrated nutrition-focused interventions, targeting both wives and husbands, through an existing Maternal, Neonatal, and Child Health (MNCH) platform in Bangladesh.

Objectives: We evaluated 1) the impact of a nutrition-focused MNCH program, compared with the standard MNCH program, on husbands' behavioral determinants (i.e., awareness, knowledge, self-efficacy) and support to wives to adopt optimal nutrition practices and 2) how much of the previously documented impact on women's supplement intake and dietary diversity was explained by husbands' behavioral determinants and support.

Methods: We used a cluster-randomized design with cross-sectional surveys at baseline (2015) and endline (2016) (n = ∼1000 women and ∼700 husbands/survey). We used mixed linear regression accounting for clustering to estimate difference-in-differences (DIDs) for impact on husbands' behavioral determinants and path analysis to examine how much these determinants explained the impact on women's nutrition behaviors.

Results: Of husbands in the nutrition-focused MNCH group, 62% were counseled by health workers, 66% attended a husbands' forum, and 34% saw video shows. The nutrition-focused MNCH, compared with the standard MNCH group, resulted in greater husbands' awareness (DID: 2.74 of 10 points), knowledge (DID: 1.31), self-efficacy and social norms with regard to optimal nutrition practices (difference: 1.08), and support to their wives (DID: 1.86). Husbands' behavioral determinants and support explained nearly half of the program impact for maternal supplement intake and one-quarter for dietary diversity.

Conclusions: A nutrition-focused MNCH program that promoted and facilitated husbands' engagement during their wives' pregnancies significantly improved husbands' awareness, knowledge, self-efficacy, and support. These improvements substantially explained the program's impact on women's intake of micronutrient supplements and dietary diversity. Targeting wives and husbands and designing activities to engage men in maternal nutrition programs are important to maximize impact. This trial was registered at www.clinicaltrials.gov as NCT02745249.

Figures

FIGURE 1
FIGURE 1
Husbands’ exposure to program interventions at endline showing exposure to counseling from frontline workers’ home visits (A), husbands’ forum (B), and video shows (C). Intervals shown are ±1 SD among subdistricts. Video 1: “Everyone has a responsibility to ensure nutrition and care for pregnant women”; Video 2: “Five rules of pregnant women's nutrition during pregnancy”; Video 3: “Nutritious foods are easily available.” MNCH, Maternal, Neonatal, and Child Health; SK, Shasthya Kormi (salaried health worker); SS, Shasthya Shebika (community health volunteer worker).
FIGURE 2
FIGURE 2
Summary impact of program on husbands’ awareness (A), knowledge (B), self-efficacy (C), and social norms and supports (D). The DID impact estimates from mixed models and 2-tailed P values comparing nutrition-focused MNCH and standard MNCH areas in 2014 and 2015, accounting for geographic clustering, are shown. ***P < 0.001. DID, difference in difference; MNCH, Maternal, Neonatal and Child Health; pp, percentage point.
FIGURE 3
FIGURE 3
Path analysis for IFA consumption during pregnancy. Values are unstandardized regression coefficients from path analyses. The sum of the indirect differences through husbands’ determinants was 47.9% of the total difference. **P < 0.01, ***P < 0.001. FHW, frontline health worker; IFA, iron and folic acid.
FIGURE 4
FIGURE 4
Path analysis for calcium consumption during pregnancy. Values are unstandardized regression coefficients from path analyses. The sum of the indirect differences through husbands’ determinants was 44.6% of the total difference. **P < 0.01, ***P < 0.001. FHW, frontline health worker.
FIGURE 5
FIGURE 5
Path analysis for maternal dietary diversity. Values are unstandardized regression coefficients from path analyses. The sum of the indirect differences through husbands’ determinants was 22.0% of the total difference. *P < 0.05, **P < 0.01, ***P < 0.001. FHW, frontline health worker.

References

    1. Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, de Onis M, Ezzati M, Grantham-McGregor S, Katz J, Martorell R et al. . Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet 2013;382:427–51.
    1. Black RE, Allen LH, Bhutta ZA, Caulfield LE, de Onis M, Ezzati M, Mathers C, Rivera J; Maternal, Child Undernutrition Study Group Maternal and child undernutrition: global and regional exposures and health consequences. Lancet 2008;371:243–60.
    1. Ramakrishnan U, Grant F, Goldenberg T, Zongrone A, Martorell R. Effect of women's nutrition before and during early pregnancy on maternal and infant outcomes: a systematic review. Paediatr Perinat Epidemiol 2012;26(Suppl 1):285–301.
    1. Danaei G, Andrews KG, Sudfeld CR, Fink G, McCoy DC, Peet E, Sania A, Smith Fawzi MC, Ezzati M, Fawzi WW. Risk factors for childhood stunting in 137 developing countries: a comparative risk assessment analysis at global, regional, and country levels. PLoS Med 2016;13:e1002164.
    1. Graham W, Woodd S, Byass P, Filippi V, Gon G, Virgo S, Chou D, Hounton S, Lozano R, Pattinson R et al. . Diversity and divergence: the dynamic burden of poor maternal health. Lancet 2016;388:2164–75.
    1. WHO. WHO recommendations on antenatal care for a positive pregnancy experience. Geneva (Switzeland): WHO; 2016.
    1. Buppasiri P, Lumbiganon P, Thinkhamrop J, Ngamjarus C, Laopaiboon M, Medley N. Calcium supplementation (other than for preventing or treating hypertension) for improving pregnancy and infant outcomes. Cochrane Database Syst Rev 2015:CD007079.
    1. Haider BA, Bhutta ZA. Multiple-micronutrient supplementation for women during pregnancy. Cochrane Database Syst Rev 2015:CD004905.
    1. McCauley ME, van den Broek N, Dou L, Othman M. Vitamin A supplementation during pregnancy for maternal and newborn outcomes. Cochrane Database Syst Rev 2015:CD008666.
    1. Ota E, Mori R, Middleton P, Tobe-Gai R, Mahomed K, Miyazaki C, Bhutta ZA. Zinc supplementation for improving pregnancy and infant outcome. Cochrane Database Syst Rev 2015:CD000230.
    1. Pena-Rosas JP, De-Regil LM, Garcia-Casal MN, Dowswell T. Daily oral iron supplementation during pregnancy. Cochrane Database Syst Rev 2015:CD004736.
    1. Imdad A, Bhutta ZA. Maternal nutrition and birth outcomes: effect of balanced protein-energy supplementation. Paediatr Perinat Epidemiol 2012;26(Suppl 1):178–90.
    1. Girard AW, Olude O. Nutrition education and counselling provided during pregnancy: effects on maternal, neonatal and child health outcomes. Paediatr Perinat Epidemiol 2012;26(Suppl 1):191–204.
    1. Wiradnyani LA, Khusun H, Achadi EL, Ocviyanti D, Shankar AH. Role of family support and women's knowledge on pregnancy-related risks in adherence to maternal iron-folic acid supplementation in Indonesia. Public Health Nutr 2016;19:2818–28.
    1. Davis J, Luchters S, Holmes W. Men and maternal and newborn health: benefits, harms, challenges and potential strategies for engaging men. Melbourne, Australia: Compass: Women's and Children's Health Knowledge Hubs; 2012.
    1. Mullany BC, Becker S, Hindin MJ. The impact of including husbands in antenatal health education services on maternal health practices in urban Nepal: results from a randomized controlled trial. Health Educ Res 2007;22:166–76.
    1. Manjate Cuco RM, Munguambe K, Bique Osman N, Degomme O, Temmerman M, Sidat MM. Male partners' involvement in prevention of mother-to-child HIV transmission in sub-Saharan Africa: a systematic review. Sahara J 2015;12:87–105.
    1. Varkey LC, Mishra A, Das A, Ottolenghi E, Huntington D, Adamchak S, Khan ME. Involving men in maternity care in India. New Delhi, India: Population Council; 2004.
    1. Aguiar C, Jennings L. Impact of male partner antenatal accompaniment on perinatal health outcomes in developing countries: a systematic literature review. Matern Child Health J 2015;19:2012–9.
    1. Hunter T, Cattelona G. Breastfeeding initiation and duration in first-time mothers: exploring the impact of father involvement in the early post-partum period. Health Promot Perspect 2014;4:132–6.
    1. Shaw A, Golding L, Girard A. Alternative approaches to decreasing maternal anemia: identifying the need for social marketing strategies to promote iron‐folic acid supplementation in the Peruvian highlands. Int J Nonprofit Volunt Sect Mark 2012;17(4):325–33.
    1. Tinago CB, Annang Ingram L, Blake CE, Frongillo EA. Individual and structural environmental influences on utilization of iron and folic acid supplementation among pregnant women in Harare, Zimbabwe. Matern Child Nutr 2017;13(3).
    1. Martin SL, Omotayo MO, Pelto GH, Chapleau GM, Stoltzfus RJ, Dickin KL. Adherence-specific social support enhances adherence to calcium supplementation regimens among pregnant women. J Nutr 2017;147(4):688–96.
    1. Herba CM, Glover V, Ramchandani PG, Rondon MB. Maternal depression and mental health in early childhood: an examination of underlying mechanisms in low-income and middle-income countries. Lancet Psychiatry 2016;3:983–92.
    1. Osamor PE, Grady C. Women's autonomy in health care decision-making in developing countries: a synthesis of the literature. Int J Womens Health 2016;8:191–202.
    1. Senarath U, Gunawardena NS. Women's autonomy in decision making for health care in South Asia. Asia Pac J Public Health 2009;21:137–43.
    1. Faruque AS, Ahmed AM, Ahmed T, Islam MM, Hossain MI, Roy SK, Alam N, Kabir I, Sack DA. Nutrition: basis for healthy children and mothers in Bangladesh. J Health Popul Nutr 2008;26:325–39.
    1. National Institute of Population Research and Training (NIPORT) Mitra and Associates, and ICF International. Bangladesh Demographic and Health Survey 2014. Dhaka, Bangladesh, and Rockville, Maryland, USA: NIPORT, Mitra and Associates, and ICF International; 2016.
    1. Arsenault JE, Yakes EA, Islam MM, Hossain MB, Ahmed T, Hotz C, Lewis B, Rahman AS, Jamil KM, Brown KH. Very low adequacy of micronutrient intakes by young children and women in rural Bangladesh is primarily explained by low food intake and limited diversity. J Nutr 2013;143:197–203.
    1. Fiedler J, D'Agostino A, Sununtnasuk C. Nutrition Technical Brief: A Rapid Initial Assessment of the Distribution and Consumption of Iron–Folic Acid Tablets through Antenatal Care in Bangladesh. Arlington, VA: USAID/Strengthening Partnerships, Results and Innovations in Nutrition Globally (SPRING) Project; 2014.
    1. Nguyen PH, Sanghvi T, Kim SS, Tran LM, Afsana K, Mahmud Z, Aktar B, Menon P. Factors influencing maternal nutrition practices in a large scale maternal, newborn and child health program in Bangladesh. PLoS One 2017;12:e0179873.
    1. Nguyen PH, Kim SS, Sanghvi T, Mahmud Z, Tran LM, Shabnam S, Aktar B, Haque R, Afsana K, Frongillo EA et al. . Integrating nutrition interventions into an existing maternal, neonatal, and child health program increased maternal dietary diversity, micronutrient intake, and exclusive breastfeeding practices in Bangladesh: results of a cluster-randomized program evaluation. J Nutr 2017;147:2326–37.
    1. Fishbein ME, Ajzen I. Predicting and changing behavior: the reasoned action approach. New York: Psychology Press; 2009.
    1. Vyas S, Kumaranayake L. Constructing socio-economic status indices: how to use principal components analysis. Health Policy Plan 2006;21:459–68.
    1. FAO; FHI360. Minimum dietary diversity for women: a guide for measurement. Available from: Rome (Italy): FAO; 2016. Accessed July 30, 2017.
    1. Gertler P, Martinez S, Premand P, Rawlings L, Vermeersch C: Impact evaluation in practice. Washington (DC): World Bank Publications; 2011.
    1. Snijders TAB, Bosker RJ. Multilevel analysis: an introduction to basic and advanced multilevel modeling. London: Sage Publishers; 2012.
    1. Kline R. Principles and practice of structural equation modeling. 3rd ed.New York: Guilford Press; 2011.
    1. Tweheyo R, Konde-Lule J, Tumwesigye NM, Sekandi JN. Male partner attendance of skilled antenatal care in peri-urban Gulu district, Northern Uganda. BMC Pregnancy Childbirth 2010;10:53.
    1. Sinha D. Empowering communities to make pregnancy safer: an intervention in rural Andhra Pradesh. Health and Population Innovation Fellowship Programme Working Paper No. 5.New Delhi (India): Population Council; 2008.
    1. Catholic Relief Services. Father engagement in nutrition: a qualitative analysis in Muhanga and Karongi districts in Rwanda. 2016.
    1. Mullany BC. Barriers to and attitudes towards promoting husbands' involvement in maternal health in Katmandu, Nepal. Soc Sci Med 2006;62:2798–809.
    1. Kamal MM, Islam MS, Alam MS, Hassan ABME. Determinants of male involvement in family planning and reproductive health in Bangladesh. Am J Hum Ecol 2013;2:83–93.
    1. Story WT, Burgard SA, Lori JR, Taleb F, Ali NA, Hoque DM. Husbands' involvement in delivery care utilization in rural Bangladesh: a qualitative study. BMC Pregnancy Childbirth 2012;12:28.
    1. Midhet F, Becker S. Impact of community-based interventions on maternal and neonatal health indicators: results from a community randomized trial in rural Balochistan, Pakistan. Reprod Health 2010;7:30.
    1. Martin SL, Omotayo MO, Chapleau GM, Stoltzfus RJ, Birhanu Z, Ortolano SE, Pelto GH, Dickin KL. Adherence partners are an acceptable behaviour change strategy to support calcium and iron-folic acid supplementation among pregnant women in Ethiopia and Kenya. Matern Child Nutr 2017;13.
    1. Sternberg P, Hubley J. Evaluating men's involvement as a strategy in sexual and reproductive health promotion. Health Promot Int 2004;19:389–96.
    1. Eldridge S, Ashby D, Bennett C, Wakelin M, Feder G. Internal and external validity of cluster randomised trials: systematic review of recent trials. BMJ 2008;336:876–80.

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