Intervention
malnutrition
MALNUTRITION
Participants were either assigned to control or intervention group. Pregnant women assigned to control group received routine health education given by health care system and pregnant women in in intervention group received a package of intensive nutrition education and counseling (INECP) which contains 3 components. The intervention includes; intensive nutrition counseling given using health believe model by trained midwives in three sessions, weekly serial SMS(short message service) text delivered on mobile phone using local languages. Each pregnant woman has received a total of 18 SMS during the study period. Take home brochures prepared in local languages were distributed to pregnant women at intervention health centers.A three-day intensive training with role-playing was given to the counselors and supervisors using the training manual. The training module was modified from blended and integrated nutrition learning module (BINLM). The core message was adapted from World Health Organization and Ethiopian Ministry of Health national nutrition module.Six BSc midwives were recruited as counselors and supervisors of the counseling process respectively. The training was facilitated by the principal investigator. Invited nutritionists who has certified by training of trainers (TOT) in BINLM supervised the training process. The nutrition education and counseling were provided based on the HBM and the information were framed in a way that addresses all HBM constructs like Perceived susceptibility(the belief about the likelihood of developing a health problem or experiencing negative outcomes),Perceived severity(the assessment of the seriousness or consequences of a health problem),Perceived benefits (the belief about the positive effects of taking action to prevent or treat a health problem), Perceived barriers (the belief about the costs or obstacles of taking action), Cues to action (the factors that trigger or motivate action, such as symptoms, media messages, or social influences), Self-efficacy (the confidence in one's ability to perform a health behaviour successfully). Health belief model was selected because, the desired behavioral change is at an individual level and due to its convenience and simplicity.The training had a brief lecture and explanation on nutritional education and counselling intervention during pregnancy which includes; Promoting a healthy eating habits by increasing the diversity and amount of foods consumed with increasing gestational age, giving emphasis on iron reach meal, promoting adequate sufficient protein and energy intake, promoting consistent and continued use of iron folic acid supplements, use of iodized salt, counseling about healthy eating and reducing heavy workload, preventive deworming after the first trimester and impregnated bed net use and utilization of health care services.Moreover, susceptibility, severity and consequences of malnutrition to pregnant women and her fetus were also discussed during counseling. The benefits of taking an adequate amount of diversified meals and barriers that interfere with taking a balanced diet and developing self-confidence to follow the right dietary practice were also included in the counseling guide. Additionally, the training was aimed to improve important counseling skills and GALIDRA steps (Greet, Ask, Listen, Identify, Discuss, Repeat, and Appoint) was discussed in detail. The training session had a brief discussion on using health belief model in nutrition education and counseling as a delivering modality of messages and recommendations.The training was supported by power point presentations, discussions and role plays. Trainees were also provided additional materials such as modules and summary pamphlets. The training was evaluated by the results of Pre-post test questions given to the participants. A close follow up was made on counseling process by supervisors and identified challenges and gaps were solved.Each pregnant woman attended three counseling sessions throughout her pregnancy period. Individual nutrition counseling was given by trained midwives. The first counselling session was before 16 weeks, second session 24 – 28 weeks and the third session were after 28 weeks of gestation. During counseling, counselors used a client-centered approach to identify pregnant women’s dietary practices and their specific needs in terms of nutrition. Counselors considered women’s needs, household income and identified gaps and allowed the women to choose recommendations that were locally available, acceptable and affordable.Counseling was delivered monthly using a counseling guide with the core contents and each counseling session lasts for 30-45 minutes. The first counseling was given before 16weeks of gestation, focused on basic nutrition, food groups, food selection, preparation, meal frequency, portion size, and iodized salt utilization. The second sessions of the counseling were given during the second trimester of pregnancy and covered the whole contents of the counseling guide. The last counseling was given based on the identified gaps during the early third trimester of pregnancy. Module, pamphlets, MUAC tape and revised ANC logbook was provided to health centers in intervention group.Take home brochures prepared in local languages (Afan Oromo and Amharic) was distributed to pregnant women attending intervention health facilities. The brochures include simple and easy to understand key messages and doable actions of maternal recommendations as bullet points and explanations of components of pregnancy nutrition. Messages of the leaflet and serial short SMS text prepared in local language delivered to intervention group also incorporated health belief model as a way of delivering the message.