Investing in healthcare provider capacity and interpersonal counselling is cost-effective for improving iron and folic acid supplementation among pregnant Bangladeshi women: modelling results from a quasi-experimental study

Summary:

Nutrition International investigated the cost-effectiveness of increasing iron folic acid supplement (IFAS) consumption and adherence among pregnant women through frontline healthcare provider training and use of behavior change communication (BCC) materials alongside interpersonal counselling (IPC) in two districts of Bangladesh from 2011-2014. Cross-sectional data was collected in intervention and comparison districts from women who had recently given birth (n=400 at baseline; 600 at endline) and healthcare providers (n=84 at baseline; 180 at endline). Impact effectiveness was assessed using difference-in-difference regression analyses, and cost-effectiveness was assessed using estimates of disability-adjusted-life years (DALYs) with sensitivity and probabilistic analyses. In program districts, mean IFAS consumption increased by 43.96 tablets (p-value < 0.001) and adherence (at least 90 tablets) increased by 43% (p-value < 0.001). Knowledge of IFAS dosage and benefits also increased among health workers and women. The program cost $44.15 USD (2018) per DALY saved, which is considered very cost-effective according to several known cost-effectiveness thresholds. This study differs from observational studies in that it allowed identification of changes in IFAS consumption and adherence directly caused by clinic-level investments in healthcare provider training. Such an approach can advance understanding of the health economics of BCC. These results offer a promising opportunity to greatly improve the effectiveness of micronutrient supplementation programs, helping accelerate progress towards global nutrition targets and gender equality. Future efforts to scale programs involving SBCC should focus on capacity building of frontline healthcare providers.

Background/Objectives:

Nutrition is integral to both the World Health Assembly target of reducing anemia by 50% in women of reproductive age by 2025 and Sustainable Development Goal (SDG) #2, which includes ending all forms of malnutrition. IFAS programs are a key component of reducing the risk of anemia among pregnant women in low resource settings. However, limited capacity of frontline health workers is a barrier to the effectiveness of such programs. This study investigated the cost-effectiveness of increasing IFA consumption and adherence among pregnant women through frontline healthcare provider training and use of BCC alongside IPC.

Description of Intervention and/or Methods/Design:

Nutrition International, in partnership with the Government of Bangladesh, implemented a program to increase IFAS consumption in two districts from 2011-2014. Healthcare providers were trained every 6 months on IFAS, BCC through IPC, health promotion materials during antenatal contacts, and the use of health information systems to track IFAS coverage and consumption. The program also included ongoing supportive supervision. Cross-sectional data was collected in intervention and comparison districts via surveys of women who had recently given birth (n=400 at baseline; 600 at endline) and healthcare providers (n=84 at baseline; 180 at endline). Main outcomes of interest were: healthcare provider training; changes in IFAS receipt, consumption, and adherence; use of IPC and health promotion materials; and knowledge of IFAS. Impact effectiveness was assessed using bivariate analyses and difference-in-difference regression analyses; cost-effectiveness was assessed using estimates of disability-adjusted-life years (DALYs) with sensitivity and probabilistic analyses. Results/Lessons Learned: In the program districts, mean consumption increased by 43.96 IFA supplements (p-value < 0.001) and adherence increased by 43 percentage points (p-value < 0.001). Knowledge of IFAS dosage and benefits also increased among frontline health workers and pregnant women. The program cost $44.15 USD (2018) per disability-adjusted life year (DALY), which is considered very cost-effective when evaluated against several demand and supply-side cost-effectiveness thresholds. Even after controlling for improvements in IFAS consumption observed in the comparison districts, reported adherence nearly doubled and mean consumption more than doubled in the program districts. Moving beyond an observational design, this study found that health-clinic-level investments in frontline healthcare provider training are a cost-effective way to address barriers to IFAS consumption and adherence in Bangladesh, a region with a high burden of anaemia.

Discussion/Implications for the Field:

Capacity building of frontline healthcare providers, a target within SDG #3, is a cost-effective method of reducing the risk of anemia among pregnant women in resource-constrained areas. This study design, showing direct causal impact of investing in IPC on improvements in IFAS adherence, advances understanding of the health economics of BCC interventions. Future efforts to scale programs involving micronutrient supplementation for pregnant women should invest in building capacity of frontline healthcare providers in IPC. These insights hold potential to accelerate progress towards global nutrition targets and greater women's empowerment as good nutrition and gender equality are mutually reinforcing.

Abstract submitted by:

Allison Verney - Nutrition International
Vanessa Pike - Nutrition International
Dylan Walters - Nutrition International
Jennifer Busch-Hallen - Nutrition International
Jennifer Hatchard - Nutrition International