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Attitudes and practices towards micronutrient supplementation among pregnant women in rural Tibet a

b

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Timothy De Ver Dye , Gretel Pelto , Sibylle Kristensen , Arlene c

Samen & Ann Dozier

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Department of Obstetrics and Gynecology, School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA b

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Division of Nutritional Sciences, College of Human Ecology, Cornell University, Ithaca, NY, USA c

OneHEART Worldwide, San Francisco, CA, USA

d

Division of Social and Behavioral Health, Department of Community and Preventive Medicine, University of Rochester, Rochester, NY, USA Published online: 03 Sep 2014.

To cite this article: Timothy De Ver Dye, Gretel Pelto, Sibylle Kristensen, Arlene Samen & Ann Dozier (2015) Attitudes and practices towards micronutrient supplementation among pregnant women in rural Tibet, Global Public Health: An International Journal for Research, Policy and Practice, 10:1, 119-128, DOI: 10.1080/17441692.2014.944551 To link to this article: http://dx.doi.org/10.1080/17441692.2014.944551

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Global Public Health, 2015 Vol. 10, No. 1, 119–128, http://dx.doi.org/10.1080/17441692.2014.944551

Attitudes and practices towards micronutrient supplementation among pregnant women in rural Tibet

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Timothy De Ver Dyea*, Gretel Peltob, Sibylle Kristensenc, Arlene Samenc and Ann Dozierd a Department of Obstetrics and Gynecology, School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA; bDivision of Nutritional Sciences, College of Human Ecology, Cornell University, Ithaca, NY, USA; cOneHEART Worldwide, San Francisco, CA, USA; dDivision of Social and Behavioral Health, Department of Community and Preventive Medicine, University of Rochester, Rochester, NY, USA

(Received 22 October 2013; accepted 21 May 2014) The objective of this study was to identify trends and change in micronutrient supplementation (MNS) knowledge across pregnancy and post-partum and to assess the impact of MNS knowledge (MNS-k) on practice in pregnancy in rural Tibet, an area with endemic micronutrient deficiency. A prospective cohort with repeated measures at early, late and after pregnancy in a rural area in the Tibetan Autonomous Region included women receiving care by community workers. Key messages about MNS-k and optimal MNS practice were communicated through health worker encounters with pregnant women. Outcomes included MNS consumption practice, knowledge and attitudes. The proportion of women in the highest MNS-k category increased by 35% from early to late pregnancy (37.5–50.7%, respectively; p < .005). MNS-k was associated with MNS consumption in a dose–response manner over pregnancy (trend X 2 p-value < .0001), with increasing knowledge associated with increased MNS consumption. By late pregnancy, 32.5% of women had never consumed an MNS in this pregnancy, and 51.5% had not consumed an MNS on the assessed day or the day before. Sustained knowledge of MNS improved in pregnancy and post-partum. Best practice around MNS consumption increased though remained sub-optimal. Keywords: micronutrient; supplementation; Tibet; pregnancy; maternal health

Introduction Micronutrients provided in pharmaceutically prepared supplements are common interventions in pregnancy aimed at reducing micronutrient deficiency and its subsequent morbidity and mortality (Institute of Medicine Committee on Micronutrient Deficiencies, 1998). Micronutrient supplementation (MNS) in pregnancy has been recommended as a component of standard prenatal care in low- and middle-income countries (Fawzi et al., 2007), especially in areas with low to very low food security (World Health Organization, World Food Program, & UNICEF, 2006). Unfortunately, interventions aimed at providing antenatal micronutrient supplements to populations at nutritional risk often fail due to differential and incomplete coverage (Schultink, 1996), inconsistent pill consumption

*Corresponding author. Email: [email protected] © 2014 Taylor & Francis

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practices by pregnant women (Sloan, 1998) and confusing or unclear regimens and schedules for consumption (Pena-Rosas & Viteri, 2006). Micronutrient deficiencies are commonly found in Tibetan communities (Harris et al., 2001; Moreno-Reyes et al., 1998), which also observe some of the highest maternal and infant mortality rates in the region (United Nations Health Partners Group, 2005). Most rural Tibetan communities are remote, in high-altitude environments, with low food diversity that lack micronutrient variation in diet (Goldstein & Beall, 1990). Studies from high-altitude Himalayan communities in this region of the world have helped demonstrate that MNS in pregnancy improves foetal growth (Osrin et al., 2005) and helps reduce early neonatal mortality (Zeng et al., 2008). Evidence around the impact of iron supplementation in pregnancy is more elusive but suggests positive benefits on birthweight (Haider et al., 2013). Community, participatory approaches to design and implementation of programmes and interventions can help regions make progress towards nutritional goals (Underwood, 2003). In the present study, community health workers in a rural Tibetan county who provide ongoing maternal and child health care, including prenatal multivitamin and iron supplementation, received enhanced training and support (including in-service training, on-site mentoring and written health education materials) to improve the effectiveness of their supplementation work. Community health workers prior to this enhanced support often remarked that women did not use supplements appropriately, either saving them, giving them to their animals, family or friends, or consuming the supplements sporadically. Further, as a tea-based society (tea consumption could complicate micronutrient absorption, Zijp, Korver, & Tijburg, 2000, and butter tea and black tea are consumed regularly as part of the Tibetan diet), promotion of optimal pill ingestion practice is an important component of improving the effectiveness of antenatal MNS overall. The purpose of this study is to identify trends and change in MNS knowledge (MNS-k) across pregnancy and post-partum; we hypothesise that MNS-k impacts MNS practice in pregnancy in a remote, rural population in Tibet.

Methods Study design This project represents a quasi-experimental, non-random prospective evaluation design of a public health nutrition education intervention that used Skilled Birth Attendants (SBAs) and community-based paraprofessionals to provide a range of prenatal services to pregnant women residing in a rural area of Tibet (Medrogongkar County). The project represents a community-based participatory approach to collaborating with community organisations and a large non-governmental organisation (OneHEART, Health Education and Research in Tibet) that managed several maternal and child health programmes in the area. OneHEART provided training, supplies and logistical support to community workers who provide care to pregnant women residing in Medrogongkar; the care provided by community workers includes prenatal health education, micronutrient supplement distribution, birth education and linkage to SBAs (if the community worker is not a midwife). This present project – termed the TSAMPA project (Tibet Supplements and Micronutrients in Pregnancy Assessment) – aimed to provide training to these community workers on micronutrient deficiency and to collaboratively develop strategies to improve it through supplementation and dietary diversity for the pregnant women they visit.

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Study site Medrogongkar is a rural county located east of the city of Lhasa and contains eight townships that sustain an approximate population of 40,000 in more than 200 villages (Phuoc, Jones-Le, Bell, & Miller, 2009). Medrogongkar County is one of the poorest in Tibet (Goldstein, Jiao, Beall, & Tsering, 2003), and much of the county is at an altitude that exceeds 4000 metres (12,000 feet). Approximately 20% of Medrogongkar’s villages are nomadic, while the remaining villages sustain farming communities. Groups of community workers were trained on the tracking procedures that comprised this project in addition to receiving enhanced training on micronutrients in pregnancy to help them better provide prenatal nutritional educational services. Sample Community health workers sequentially enrolled pregnant women in the project as they made visits to women estimated to be in their first trimester. In total, 344 pregnant women were enrolled at baseline (early pregnancy), 204 (59.3%) of whom were followed up at late pregnancy and 322 (93.6%) of whom were followed up post-partum. The late pregnancy follow-up sample was significantly less likely (p < .01) to reside in the remote, nomadic areas of the sample (Tsashue and Memba) than the overall sample. This difference can be attributed to the logistical and practical difficulties in reaching women in highly remote areas before delivery. The late pregnancy follow-up sample and the postpartum sample did not differ from the overall intake sample with respect to the MNS-k score, the main variable of interest. Self-reported median weeks pregnant (based on either self-reported gestational age or due date) was 19 weeks at intake (25th–75th percentile range: 12–24 weeks), 32 weeks at late pregnancy (25th–75th percentile range: 28–37 weeks) and 4 weeks post-partum (25th–75th percentile range: 0–13 weeks post-partum). Interviews The data collection instrument was developed based on the project’s objectives, from reviewing the existing literature on micronutrients in pregnancy and from qualitative interviews conducted with stakeholders. The linguistic and conceptual frame for the project was influenced by ethnographic research conducted by the authors and with others affiliated with the same maternal and child health programme (e.g., see Craig, 2009). The instrument was further drawn from the experience of Sloan, Jordan, and Winikoff (2002), Kuhnlein and Pelto (1997) and Swindale and Ohri-Vachaspati (1999). The final instrument contained 39 questions covering a range of demographic characteristics, dietary and micronutrient knowledge, attitudes and practices and was translated into Tibetan for administration. Interviews lasted a median of 40 minutes overall, longer at intake (median = 46 minutes) than at late pregnancy (median = 43 minutes) or postpartum (median = 32 minutes). MNS-k index MNS-k items assessed included perceptions of influence of supplements on pregnant women, perceptions of influence of supplements on the foetus, knowledge of recommended consumption practices, MNS as a source of nutrition and practices to avoid MNS side effects (Figure 1). An MNS-k index was constructed by taking all knowledge questions correlated (using Spearman’s r) with at least half of all knowledge

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Do vitamin pills help a pregnant woman?



Do vitamin pills help a baby while it is still inside the mother?



If a woman has side effects from vitamin pills, what should she do?



How often should a pregnant woman take a red prenatal vitamin [iron pill] during her pregnancy?



How often should a pregnant woman take a yellow prenatal vitamin [multivitamin] during her pregnancy?



Should vitamin pills be taken with or without food?



Is this statement true or false: Women can take vitamin pills every day in place of eating a variety of foods.



Which of the following is one way to avoid constipation as a side effect from taking vitamin pills? (Eat more vegetables every day, Take more vitamins until the problem goes

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away, Eat some cheese, Drink chang, All of the above, None of the above)

Figure 1. Questions assessing knowledge of and attitudes towards micronutrient supplements included in antenatal interviews.

items at the r = .20 level and creating an additive scale that summed positive responses to the remaining individual items (Streiner & Norman, 2008). Items assessed for inclusion in the MNS-k index were reduced to dichotomous categories: indication of an affirmative response and no indication of affirmative response (including negative, missing or unknown response). The resulting knowledge index was converted to three categories: low MNS-k (up to 25th percentile of index), middle MNS-k (26th–75th percentile of index) and high MNS-k (over 75th percentile of index). Complete data were unavailable for one woman in the late pregnancy follow-up, yielding a final sample size for the MNS-k index in this group as n = 203.

Consumption practice Compliance with consumption of supplements was self-reported based on women’s recall of consumption of a multivitamin and/or iron pill during the current day, from the prior day or never.

Statistical analysis Statistical significance when comparing proportions as noted in tables is obtained from the use of the corrected Mantel–Haenszel Summary Chi-square, which is equivalent to the corrected McNemar Chi-square test (Donald & Donner, 1987). This test accounts for the prospective matched nature of the data and lack of independence among response observations between time periods. Further, assessment of trend in MNS practice variables across levels of MNS-k was assessed using a Chi-square for trend analysis (Rosner, 2005). Both EpiInfo 3.5 (Centers for Disease Control and Prevention, Atlanta) and JMP 8.0.1 (SAS Institute, Cary, North Carolina) were used to enter, manage and analyse data. Population-attributable risk analysis assessing the potential impact of improving MNS-k on micronutrient supplement consumption was conducted by comparing low–mid knowledge (combined) with high knowledge using OpenEpi 3.0.1 (Atlanta, Georgia).

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Ethical considerations This project was reviewed and approved by the University of Rochester Research Subjects Review Board and the Tibetan Autonomous Region Tibetan Medicine Clinical Research Institute Institutional Review Board. Results Attitudes towards and knowledge of micronutrient supplements As shown in Table 1, there was a statistically significant increase (p < .01) in the proportion of women indicating that ‘vitamin pills can help pregnant women’ and/or ‘can help foetuses’ between the baseline antenatal and post-partum periods. The proportion of women indicating ‘vitamin pills can help pregnant women’ increased by 22% from early antenatal to post-partum, and the proportion of women indicating vitamins ‘can help foetuses’ increased by 19%. At both baseline (i.e., early antenatal) and post-partum, women were significantly more likely to report that they thought supplements helped the foetus than they were to report that supplements helped the pregnant woman (p < .05 at baseline and p < .01 at post-partum). The most common reasons indicated for benefits of supplements for both women and foetuses include ‘increase nutrition’, ‘increase the blood’, ‘grow well’, ‘good sleep’, ‘baby becomes fat and grows well’ and ‘become strong and healthy’. Table 1. Knowledge and attitudes towards prenatal micronutrient supplements among pregnant women in a rural Tibetan county. Early antepartum (n = 344), % (n) Vitamin pills help a pregnant woman 53.8 (185) (‘Yes’ response) Vitamin pills help a baby while still 63.4 (218) inside the mother (‘Yes’ response) Vitamin pills should be taken with 50.3 (173) food (‘Yes’ response) 18.0 (62) Women can take vitamin pills every day in place of eating a variety of foods (‘True’ response) Should take yellow pill (multivitamin) daily 48.0 (165) (‘Yes’ response) Should take red pill (iron) daily (‘Yes’ response) 58.1 (200) Ways to avoid constipation as a side effect of taking vitamin pills Eat more vegetables 56.1 (193) Take more vitamins 14.8 (51) Eat cheese 18.0 (62) Drink changa 16.9 (58) All of the above 20.1 (69) None of the above 9.9 (34)

Late antepartum (n = 204), % (n)

Post-partum (n = 322), % (n)

68.6 (140)**

65.8 (212)**

74.0 (151)

75.5 (243)**

68.6 (140)***

59.9 (193)

14.7 (30)

7.8 (25)***

63.7 (130)***

74.8 (241)***

75.9 (153)***

73.9 (238)***

60.8 15.7 18.1 18.6 22.5 10.3

59.3 17.1 22.4 19.3 21.1 10.2

(124) (32) (37) (38) (46) (21)

(191) (55) (72) (62) (68) (33)

Note: Statistical significance: **p < .01; ***p < .001 (not noted = not statistically significant), compared to baseline (early antepartum). a chang is a commonly consumed fermented beverage made from barley.

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Knowledge of basic MNS consumption practice changed over pregnancy as well. As presented in Table 1, the proportion of women indicating that ‘vitamins should be taken with food’ significantly increased (p < .001) across pregnancy, as did the proportion of women indicating that supplements should be ‘taken every day’ (p < .001). No significant difference over pregnancy was observed in how women should treat constipation, a commonly reported side effect of micronutrient supplement consumption.

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Knowledge and consumption of micronutrient supplements As shown in Table 2, MNS-k improved from early to late pregnancy: the proportion of women in the highest knowledge category increased by 35% from early to late pregnancy (from 37.5% to 50.7%, respectively), while the proportion of women in the lowest knowledge category decreased by more than 60% (from 25.6% to 9.9%, respectively). As MNS-k increased, poor pill-taking practice decreased. For example, women in the lowest MNS-k category (either at baseline or at late pregnancy) were less likely to consume an MNS (multivitamin or iron) when compared with women in the highest MNS-k category, and, similarly, were less likely to consume an MNS that day or the day before. While MNS-k increased throughout pregnancy (as previously mentioned), women who remained in the lowest MNS-k category by late pregnancy were even less likely than their counterparts in early pregnancy to consume any MNS to date, or any MNS on that day or sooner. Further, as Table 3 shows, women for whom MNS-k worsened across pregnancy (30.5% of women overall) were significantly less likely to consume an MNS (multivitamin or iron) to date, or on that day or the day before. Using population-attributable risk analysis (data not shown), if the MNS-k disparity at baseline was eliminated altogether, MNS consumption could expect to increase by Table 2. Level of knowledge about MNS and pill-taking behaviour and early and late pregnancy, Medrogongkar County, Tibet. Early pregnancy (n = 344)

MNS-k score

Distribution, % (n)

Low (0–1) Medium (2–4) High (5–6) Total X 2 for trend (p-value)

25.6 36.9 37.5 100.0

(88) (127) (129) (344)

Low (0–1) Medium (2–4) High (5–6) Total X 2 for trend (p-value)

9.9 39.4 50.7 100.0

(20) (80) (103) (203)

MV, multivitamin.

Never took MV pill, % (n) 83.0 44.9 34.1 50.6 52.5

(73) (57) (44) (174) (

Attitudes and practices towards micronutrient supplementation among pregnant women in rural Tibet.

The objective of this study was to identify trends and change in micronutrient supplementation (MNS) knowledge across pregnancy and post-partum and to...
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