HERD International, Sainbu Awas Cr-10 Marga, Bhaisepati, Lalitpur, Nepal.
UCL Institute for Global Health, 30 Guilford Street, London, WC1N 1EH, UK.
BMC Public Health. 2023 Jul 6;23(1):1301. doi: 10.1186/s12889-023-16195-5.
Anemia is estimated to cause 115,000 maternal deaths each year. In Nepal, 46% of pregnant women have anemia. As part of an integrated anemia-prevention strategy, family engagement and counseling of pregnant women can increase compliance to iron folic acid tablets, but marginalized women often have lower access to these interventions. We implemented the VALID (Virtual antenatal intervention for improved diet and iron intake) randomized controlled trial to test a family-focused virtual counseling mHealth intervention designed to inclusively increase iron folic acid compliance in rural Nepal; here we report findings from our process evaluation research.
We conducted semi structured interviews with 20 pregnant women who had received the intervention, eight husbands, seven mothers-in-laws and four health workers. We did four focus groups discussions with intervention implementers, 39 observations of counseling, and used routine monitoring data in our evaluation. We used inductive and deductive analysis of qualitative data, and descriptive statistics of monitoring data.
We were able to implement the intervention largely as planned and all participants liked the dialogical counseling approach and use of story-telling to trigger conversation. However, an unreliable and inaccessible mobile network impeded training families about how to use the mobile device, arrange the counseling time, and conduct the counseling. Women were not equally confident using mobile devices, and the need to frequently visit households to troubleshoot negated the virtual nature of the intervention for some. Women's lack of agency restricted both their ability to speak freely and their mobility, which meant that some women were unable to move to areas with better mobile reception. It was difficult for some women to schedule the counseling, as there were competing demands on their time. Family members were difficult to engage because they were often working outside the home; the small screen made it difficult to interact, and some women were uncomfortable speaking in front of family members.
It is important to understand gender norms, mobile access, and mobile literacy before implementing an mHealth intervention. The contextual barriers to implementation meant that we were not able to engage family members as much as we had hoped, and we were not able to minimize in-person contact with families. We recommend a flexible approach to mHealth interventions which can be responsive to local context and the situation of participants. Home visits may be more effective for those women who are most marginalized, lack confidence in using a mobile device, and where internet access is poor.
据估计，贫血每年导致 11.5 万名产妇死亡。在尼泊尔，46%的孕妇贫血。作为综合贫血预防策略的一部分，让家庭成员参与并对孕妇进行咨询可以提高她们对铁叶酸片的依从性，但边缘化的妇女往往获得这些干预措施的机会较少。我们实施了 VALID（虚拟产前干预以改善饮食和铁摄入）随机对照试验，以测试一种以家庭为中心的虚拟咨询移动健康干预措施，旨在包容性地提高尼泊尔农村地区铁叶酸片的依从性；在此，我们报告来自我们的过程评估研究的结果。
我们对接受干预的 20 名孕妇、8 名丈夫、7 名婆婆和 4 名卫生工作者进行了半结构化访谈。我们与干预实施者进行了 4 次焦点小组讨论，观察了 39 次咨询，并在评估中使用了常规监测数据。我们对定性数据进行了归纳和演绎分析，并对监测数据进行了描述性统计。
我们能够基本按照计划实施干预，所有参与者都喜欢对话式咨询方法和使用讲故事来引发对话。然而，不可靠和无法访问的移动网络妨碍了对家庭进行有关如何使用移动设备、安排咨询时间和进行咨询的培训。妇女使用移动设备的能力并不平等，对一些人来说，需要频繁访问家庭以解决问题，这使干预措施失去了虚拟性。妇女缺乏代理权限制了她们自由表达的能力和行动能力，这意味着一些妇女无法搬到移动信号更好的地区。一些妇女难以安排咨询，因为她们的时间有其他竞争需求。由于家庭成员经常外出工作，因此很难让他们参与进来；小屏幕使得互动变得困难，一些妇女在家庭成员面前感到不舒服。
在实施移动健康干预措施之前，了解性别规范、移动接入和移动扫盲非常重要。实施过程中的障碍意味着我们无法像预期的那样让家庭成员参与进来，也无法最大限度地减少与家庭的面对面接触。我们建议采取灵活的移动健康干预措施方法，可以对当地情况和参与者的情况做出响应。对于那些最边缘化、对使用移动设备缺乏信心且互联网接入较差的妇女，家访可能更有效。
