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Arcle Type: Research Arcle
Volume 2 Issue 2 - 2024
Eect of Health Education on the Knowledge of Pregnant Women
on Iron and Folic Acid Supplements: A Stepped Wedge Cluster
Randomized Trial
Haron Njiru1*; Mary W Gitahi1; Eunice Njogu2
1Department of Family Medicine, Community Health, and Epidemiology, Kenyaa University, Kenya.
2Department of Food, Nutrion and Dietecs, Kenyaa University, Kenya.
*Corresponding author: Haron Njiru
Department of Family Medicine, Community Health, and
Epidemiology, Kenyaa University, Kenya.
Email: njiru@outlook.com
Received: Mar 25, 2024
Accepted: Apr 15, 2024
Published: Apr 22, 2024
Epidemiology & Public Health - www.jpublichealth.org
Njiru Z © All rights are reserved
Citaon: Njiru H, Gitahi MW, Njogu E. Eect of Health
Educaon on the Knowledge of Pregnant Women on Iron
and Folic Acid Supplements: A Stepped Wedge Cluster
Randomized Trial. Epidemiol Public Health. 2024; 2(2): 1042.
www.jpublichealth.org
Open Access
Introducon
Micronutrients are necessary for growth, development, and
normal funconing. Although required in minute amounts, their
deciency is a global public health challenge. The daily recom-
mended dietary allowance for iron and folate increases by 50%
during pregnancy from 18 milligrams (mg) to 27 mg, and from
400 micrograms (μg) to 600 μg for iron and folate respecvely [1]
due to the rapid mulplicaon of placental and fetal ssues. Diet
alone cannot fully sasfy the increased demand, hence the need
for daily micronutrient supplementaon to avert deciencies.
Deciency of iron and folic acid during pregnancy increases
the risk of anemia which is a leading cause of maternal deaths
and adverse pregnancy outcomes. The global prevalence of
Anemia in Pregnancy (AiP) is esmated at 38.2% or 32.4 million
pregnant, making anemia the most common medical disorder
in pregnancy. At 22% the Western Pacic region, the Americas,
and the European region have the lowest prevalence of AiP [2]
while lower income countries in South East Asia and Sub Saha-
ran Africa have more than double the AiP burden at 46.2% [3].
The AiP prevalence is esmated at 36% in East Africa [4] and
62% in Kenya [5] with women in rural areas being more aected
than those in urban areas at 50.8% and 29.5% respecvely [6].
Studies have associated AiP with low-birth-weight babies
and preterm births [7], suscepbility to childhood diarrhea and
respiratory infecons, and poor neurological development [8],
increased perinatal, postnatal and under-5 mortality [9], and
disrupted growth in adolescent mothers [10]. Indeed, pregnant
women with severe AiP are twice as likely to die [11]. In Kenya,
10% and 20% of maternal and prenatal deaths respecvely are
aributable to anemia [12]. AiP can also trigger geophagy in
pregnancy, a widespread pracce detrimental to maternal and
child health [13].
In populaons at risk of iron deciency, the World Health
Organizaon (WHO) recommends a daily intake of 60 mg iron
and 400 μg of folic acid as a standard of care for prevenng
AiP [1]. Antenatal iron supplements can reduce the risk of iron
deciency, halve the risk of neonatal death and reduce the in-
cidence of low-birth-weight babies [14-16] while folic acid re-
duces the risk of underweight births, pre-eclampsia, placental
abrupon, preterm births, small for gestaonal age infants, and
birth defects, and improve academic performance [17,18]. This
sustains the gains made on the 1st, 4th and 5th Millennium De-
velopment Goals, contributes towards the 2nd Sustainable De-
velopment Goal’s (SDG) target of ending hunger and all forms of
Abstract
Iron deciency poses a signicant public health challenge
during pregnancy. However, opmal uptake of antenatal
micronutrients is hampered by lack of knowledge. We in-
vesgated the eect of health educaon on knowledge of
women regarding antenatal Iron and Folic Acid Supplements
(IFAS). In a 9-month trial, antenatal care clinics received a
maternal IFAS awareness package, which included educaon
for both health workers and pregnant women and health
Informaon Educaon and Communicaon (IEC) materials.
The study found that IFAS knowledge improved from 44.8%
to 81.1%, a 36-percentage point increase. To enhance IFAS
knowledge, hence uptake, the study recommends targeted
health educaon emphasizing IFAS benets, management of
IFAS side eects, along with providing standardized informa-
on materials to the clinics.
Epidemiology & Public Health
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Njiru H
malnutrion by 2030 [19], and the rst 3 (of the six) 2025 global
nutrion targets [20].
Advocacy for Iron and Folic Acid Supplements (IFAS) as a
strategy for anemia prevenon is arculated in key global and
naonal commitments and policy frameworks. The global nutri-
on target for 2025 is to achieve a 50% reducon of anemia
among women of reproducve age. Compared to the 2011
baseline [4,20]. To meet this target, 18% of all the investments
towards anemia should be directed towards antenatal IFAS [21].
The naonal IFAS program in Kenya is guided by various naonal
policies on nutrion, food security and micronutrient deciency
control [22]. Kenya has also endorsed the Scaling up Nutrion
(SUN) movement[23], which promotes antenatal IFAS as a core
high impact intervenon.
Despite the manifold benets and the global advocacy, prog-
ress in the uptake of antenatal IFAS has been slow. This has
been aributed to inadequate knowledge of the relaonship
between IFAS and anemia, lack of awareness on the risk of AiP
and limited knowledge on the management of IFAS side eects
[12,24-27].
Health educaon and promoon play crucial roles in en-
hancing knowledge, shaping beliefs, and inuencing atudes.
Consequently, they contribute to greater ulizaon of health
services [28,29]. Consistent health educaon fosters deeper
understanding and encourages posive behavioral shis [24].
Health educaon and promoon should strategically target the
health workers and pregnant women. Health workers play a piv-
otal role in enhancing health literacy, making their empower-
ment essenal for successful implementaon of facility-based
intervenons, [30,31] equally essenal is the need to acvely
engage the pregnant women. The behavior change interven-
ons should create awareness about a desired behavior, mo-
vate change by underscoring the posive and negave conse-
quences, and provide opportunies for praccing the desired
behaviors [32].
The MIA trial sought to enhance knowledge, modify atudes
and beliefs, and skills to posively inuence IFAS uptake using
mulple behavior change techniques [28,29]. This was achieved
through face-to-face health educaon sessions provided to
pregnant women by health workers, provision of study IEC ma-
terials and the pill reminder cards. The trial’s chain of results is
depicted in Figure 1.
Methodology
Study design
A stepped wedge Cluster Randomized Trial (swCRT) was de-
signed using Antenatal Care (ANC) clinics as units of random-
izaon. This design was suitable since individual randomizaon
was impraccal for logiscal and ethical reasons. All clusters
started the trial at the same me and acted as controls unl
they were randomized to crossover from control to the inter-
venon phase.
Study seng
The Maternal IFAS Awareness (MIA) trial was conducted in
Embu County, Kenya. With an esmated populaon of 609,000,
Embu county is the 12th most populous County, out of the 47
counes in Kenya [33]. About half (43%) of the pregnant wom-
en in the County aend ANC, 6% of them consume IFAS for at
least 90 days [34], just over a half (53%) do not complete ANC
visits and one in every six are anemic [35]. The study populaon
were the pregnant women aending ANC clinics at the selected
public health facilies that oered antenatal care.
Intervenon
The study intervenon was grounded on the social cognive
theory of behavior change [32]. The intervenon entailed (1)
IFAS informaon sessions with ANC service providers delivered
in 60 minutes lunchme sessions to minimize interrupon of
service delivery, (2) Daily IFAS literacy sessions with pregnant
women, and (3) provision of Informaon, Educaon and Com-
municaon (IEC) materials (Pill Reminder Card (PRC) and MIA
wall calendars) to pregnant women. The calendars had IFAS
messages and were pre-populated with personalized ANC clinic
return dates. All IEC materials were adapted from the naonal
IFAS program and customized to t the local context based on
evidence from the baseline facility assessment.
The MIA trial ran for 9 months (June 2022 to February 2023).
This entailed one month for baseline data collecon and cus-
tomizaon of health educaon messages, seven months inter-
venon, and another month to nalize the data collecon and
the handover processes. Execuon of the study including avail-
ability of supplies and connuity of counselling was enhanced
through biweekly spot-checks and monthly audits. The inter-
venon is described in detail in the study protocol [36].
Sample size determinaon
The number of clusters to enroll in MIA trial was esmated
using the two equaons proposed by Hayes & Benne [37]. A
total of 12 clusters were required for the survey. With a 5% mar-
gin of error, assuming 6% IFAS uptake and a 5% non-response
rate, the minimum number of respondents for baseline and
endline surveys was 92 women Detailed sample size calculaon
and the sampling technique is shown in the protocol [36].
Data collecon and analysis
Data was collected using an interviewer-administered ques-
onnaire and pill counng. The quesonnaire obtained infor-
maon on sociodemographic characteriscs and levels of IFAS
knowledge among women across 5 areas: Benets of IFAS, gesta-
on age at which IFAS should be iniated, best me to take IFAS,
daily dose requirements, and management of IFAS side eects.
Proporons were used to describe the demographic charac-
teriscs and sources of IFAS informaon. Addionally, the t-test
stasc was employed to compare changes in knowledge levels
between control and intervenon phases. The precision of es-
mates was based on p-values and 95% Condence Intervals (CI),
with signicance set at 0.005.
Logiscal and ethical consideraons
The trial was registered in the Pan African Clinical Trial Reg-
istry (PACTR202202775997127), permit obtained from Na-
onal Commission for Science, Technology and Innovaon
(NACOSTI/P/22/16168), and clearance sought from the County
health authories. Ethical approval was granted by Kenyaa
University Ethics Review Commiee (PKU/2443/11575).
Findings
A total of 11,569 ANC visits were registered at the 12 clusters
between June 2022 and January 2023. All women receiving ANC
services during the intervenon phase were provided with PRCs
to monitor their IFAS uptake. A total of 192 pregnant women
(96 at baseline and 96 during the intervenon period) parci-
02
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pated in the exit surveys. The average age of study parcipants
was 25 years, most were married (78%), unemployed (64%),
lived in rural areas (66%), nulliparous (60%), and had started
ANC at 16 weeks (Table 1).
Women’s knowledge on IFAS was assessed at baseline and
during the intervenon. The knowledge score improved from
44.8% (95% CI: 38.80-50.71) at baseline to 81.1% (95% CI:
79.75-82.49) during the intervenon. This reected a 36.36
(95% CI: 31.82-40.91) percentage point improvement in levels
of IFAS knowledge.
At baseline, knowledge on the daily dose requirement was
the highest at 95.5% while knowledge on of IFAS side eects
was the lowest at 32.6%, sll the laer tailed following the in-
tervenon at 72.5%. Knowledge on the best me to take IFAS
showed the greatest improvement at 47.7 percentage points,
while knowledge on the benets of IFAS was the least impacted
by the intervenon with an eect esmate of 34.7 percentage
points (Table 2).
The main source of informaon for IFAS during the interven-
on was from conversaons with skilled health workers and
peers. This was a shi compared with the baseline situaon
when the main sources of IFAS informaon had been commu-
nity health workers (Table 3).
Improvements in levels of IFAS knowledge following the in-
tervenon were observed across all clusters (Figure 2). Further-
more, a posive but stascally insignicant correlaon was
observed between knowledge and number of ANC contacts. For
every addional ANC contact, knowledge levels improved by a
coecient of 1.1 (95% CI: -2.1-4.3).
Pearson correlaon coecient (r) was calculated to evaluate
the relaonship between IFAS knowledge and uptake. Although
a posive correlaon was observed, it was weak (r=0.228, in-
dicang only a 5% variability between knowledge and uptake).
An adjusted linear predicon model revealed that even with a
perfect 100% knowledge score, IFAS uptake would only reach a
maximum of 47.3% (Figure 3).
Figure 2: Cluster level knowledge of pregnant women on IFAS.
38 41
49
33 38 40 43 40 46 43
67 67
45
80 79 78 82 86 80 84 78 82 82 85 80 81
1 2 3 4 5 6 7 8 9 10 11 12 Overall
Knowledge score (%)
Clusters
Baseline Intervention
Figure 1: The MIA trial results chain.
Figure 3: Predicted associaon between knowledge and IFAS up-
take.
Table 1: Demographic characteriscs of survey respondents at baseline.
Characterisc Respondents (n=96)
Age (years) 25.3(5.9)
20 years and above 82(85%)
Below 20 years 14(15%)
Marital status
Married 75(78%)
Not married 21(22%)
Level of educaon
Primary 38(40%)
Secondary 43(45%)
College 15(16%)
Place of residence
Rural 63(66%)
Urban 33(34%)
Employment status
Employed/business 35(36%)
Unemployed 61(64%)
Parity
Mulparous 38(40%)
Nulliparous 58(60%)
Gestaon at rst ANC 16.2(8.1)
Within inial 12 weeks 36(38%)
Aer 12 weeks 60(62%)
Data are n (%) or mean (SD)
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Table 2: Knowledge on IFAS.
Aspect of IFAS knowledge
Control Intervenon Eect esmate
mean (SD) mean (SD) (95% CI)
Benets of IFAS 47.7(26.3) 82.4(15.2) 34.7(27.5-41.8)
Gestaon age to start IFAS 56.8(52.1) 98.8(16.7) 42.0(31.0-53.0)
Best me to take IFAS 43.1(58.1) 90.9(28.9) 47.7(34.1-61.3)
Daily dose of IFAS 95.5(21.1) 100.0(--) 4.5(0.1-9.0)
Management of side eects 32.6(22.7) 72.5(8.0) 40.0(34.6-45.3)
Overall 44.8(19.6) 81.1(6.5) 36.4(31.8-40.9)
Table 3: Sources of IFAS informaon.
Source of IFAS informaon Control
(n=44)
Intervenon
(n=88)
Pearson’s x2
p-value
Skilled health workers 21(48%) 74(84%) <0.001*
Peers / friends 21(48%) 70(80%) <0.001*
Community health workers 26(59%) 46(52%) 0.5
Family member 20(45%) 43(49%) 0.7
Magazine / newspapers / posers 24(55%) 41(47%) 0.4
Radio/ TV 11(25%) 20(23%) 0.8
Other sources 10(23%) 17(19%) 0.6
Facebook/ Internet 5(11%) 12(14%) 0.7
Discussion
The baseline levels of IFAS knowledge among pregnant
women were low, at 44.8%. Knowledge on management of side
eects and IFAS benets were the lowest at 32% and 47% re-
specvely. Only daily dose had a knowledge score above 90%
at baseline. Low levels of IFAS knowledge have been shown in
other studies. A quasi experimental study in Kiambu - Kenya
showed a 57% IFAS knowledge at baseline [38] and a general
lack of awareness in western Kenya and Ethiopia [27,39].
Limited knowledge on benets of any intervenon coupled
with limited knowledge on how to manage potenal side ef-
fects, as observed in the MIA trial at baseline, could hinder up-
take, especially if the intervenon has side eects, and when the
benet of an intervenon is not instant, as is the case with IFAS.
The IFAS knowledge increased from 44.8% at baseline to
81.1% during the intervenon, a dierence of 36.4 percentage
points. The baseline assessment had idened key knowledge
gaps and the design of IEC materials for the MIA trial had been
customized to address these gaps among health workers and
pregnant women. In addion, the IFAS sessions with health
workers at the study incepon together with the availability of
relevant IEC materials provided an enabling environment for
discussion between health workers and pregnant women [31]
which could explain the observed improvement in knowledge
levels. Furthermore, the main sources of informaon switched
from community health workers at baseline to skilled health
workers and peers during the intervenon period. This could
imply that in addion to boosng their condence, [31] pro-
viding health workers with IEC materials provided them with a
structured and beer way to counsel women on IFAS, which in
turn increased the women’s level of knowledge on antenatal
IFAS.
That parcipants in the MIA trial had signicantly higher
knowledge levels aer the intervenon is promissory. However,
not achieving 100% knowledge levels is disappoinng. This fail-
ure could have been due to varying knowledge-retenon capac-
ies among respondents owing to the dierences in levels of
academic achievements, and the delity of the intervenon im-
plementaon. Faced with a heavy workload occasioned by the
free maternity services policy, health workers are likely to pay
less emphasis on the needs of individual women, as required
for the MIA intervenon, and this could have weakened the in-
tensity of knowledge transfer. This phenomenon is reinforced
with the observaon that knowledge improved with increasing
number of ANC contacts, albeit insignicantly. A similar shorall
was observed in a study in Uganda where IFAS knowledge im-
proved from 57 to 92% [38].
There was a posive but weak correlaon between the lev-
els of IFAS knowledge and uptake. That beer knowledge leads
to improved uptake of IFAS has also been reported in other
studies [26,38,40,41]. Those who had beer knowledge were
more likely to adhere but only up to a maximum of 47.3%. This
implies that while knowledge is necessary for uptake, knowl-
edge alone is not sucient to achieve sustained uptake. The
observaon that coverage exceeded 47.3% indicates presence
of other factors that movated women to take IFAS over and
above their knowledge about IFAS. This could be the eect of
PRC, but needs further exploraon.
Having a PRC with informaon on IFAS served mulple func-
ons: First, it was a mnemonic, and secondly it was informaon-
al. On the other hand, wall calendars served as visual reminders
of the importance of IFAS, addionally reminding women about
the ANC return date during which their IFAS supplies would be
relled, they would also interact with peers, and learn more
about IFAS from the healthcare providers. Furthermore, health
workers were also provided with IEC materials and a structured
way of communicang about IFAS to women, with a focus on
importance of IFAS, potenal side eects, and how to migate
the laer. The importance of visual aids such as the MIA wall
calendars and PRC have been previously documented, though
not in relaon to antenatal IFAS [42].
Conclusion
Pregnant women have low levels of IFAS knowledge. Women
are generally oblivious of the IFAS benets. This hinders opmal
uptake of IFAS, a situaon exasperated by limited knowledge
of women on how to manage the IFAS side eects. The levels
of IFAS knowledge increased with the number of ANC contacts
and that IFAS knowledge had a posive, albeit weak, inuence
on IFAS uptake.
Recommendaons
The MIA trial has shown that public health educaon has
the potenal to improve IFAS knowledge and thereby uptake
in antenatal care sengs. The government should provide ANC
clinics with IFAS guidelines and IEC materials to ensure preg-
nant women receive comprehensive IFAS informaon as part of
roune ANC care. Furthermore, health workers should be sen-
sized about the MoH IFAS guidelines to improve the quality
and consistency of messages passed to pregnant women, and
lastly, health workers should educate pregnant women on IFAS
at every ANC visit to improve their IFAS knowledge and uptake.
Epidemiology & Public Health
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Declaraons
Author contribuons: HN draed the study ndings, inter-
pretaon of the ndings and discussion. All authors contributed
to renement of the ndings and approved the nal manuscript.
Funding: This research received no grant from any funding
agency.
Compeng interests: The authors have no nancial or other
compeng interests to declare.
Acknowledgements: We extend our hearelt gratude to
the Kenya Ministry of Health, parcularly the Embu County
health management team and the dedicated facility in-charges.
Their collaboraon was instrumental in the success of this trial.
We also express our appreciaon to every expectant woman
whose parcipaon was the cornerstone of this trial, and to our
research assistants, Caleb Karanja and Rose Kendagor.
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