The Journal of Nutrition
Community and International Nutrition
Engagement of Husbands in a Maternal
Nutrition Program Substantially Contributed
to Greater Intake of Micronutrient
Supplements and Dietary Diversity during
Pregnancy: Results of a Cluster-Randomized
Program Evaluation in Bangladesh
Phuong Hong Nguyen,1 Edward A Frongillo,2 Tina Sanghvi,3 Gargi Wable,4 Zeba Mahmud,3
Lan Mai Tran,3 Bachera Aktar,5 Kaosar Afsana,6 Silvia Alayon,3 Marie T Ruel,1 and Purnima Menon1
1
Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC; 2 University of South Carolina,
Columbia, SC; 3 FHI 360, Washington, DC; 4 Division of Nutritional Sciences, Cornell University, Ithaca, NY; 5 James P Grant School of
Public Health, BRAC University, Dhaka, Bangladesh; and 6 BRAC, Dhaka, Bangladesh
Abstract
Background: Although husbands may provide support during pregnancy, limited evidence exists on how to promote
husbands’ engagement and what impact it has. Alive & Thrive integrated nutrition-focused interventions, targeting both
wives and husbands, through an existing Maternal, Neonatal, and Child Health (MNCH) platform in Bangladesh.
Objectives: We evaluated 1) the impact of a nutrition-focused MNCH program, compared with the standard MNCH
program, on husbands’ behavioral determinants (i.e., awareness, knowledge, self-efficacy) and support to wives to adopt
optimal nutrition practices and 2) how much of the previously documented impact on women’s supplement intake and
dietary diversity was explained by husbands’ behavioral determinants and support.
Methods: We used a cluster-randomized design with cross-sectional surveys at baseline (2015) and endline (2016)
(n = ∼1000 women and ∼700 husbands/survey). We used mixed linear regression accounting for clustering to estimate
difference-in-differences (DIDs) for impact on husbands’ behavioral determinants and path analysis to examine how much
these determinants explained the impact on women’s nutrition behaviors.
Results: Of husbands in the nutrition-focused MNCH group, 62% were counseled by health workers, 66% attended a
husbands’ forum, and 34% saw video shows. The nutrition-focused MNCH, compared with the standard MNCH group,
resulted in greater husbands’ awareness (DID: 2.74 of 10 points), knowledge (DID: 1.31), self-efficacy and social norms
with regard to optimal nutrition practices (difference: 1.08), and support to their wives (DID: 1.86). Husbands’ behavioral
determinants and support explained nearly half of the program impact for maternal supplement intake and one-quarter
for dietary diversity.
Conclusions: A nutrition-focused MNCH program that promoted and facilitated husbands’ engagement during their
wives’ pregnancies significantly improved husbands’ awareness, knowledge, self-efficacy, and support. These improvements substantially explained the program’s impact on women’s intake of micronutrient supplements and dietary diversity. Targeting wives and husbands and designing activities to engage men in maternal nutrition programs are important
to maximize impact. This trial was registered at www.clinicaltrials.gov as NCT02745249. J Nutr 2018;148:1–12.
Keywords: Bangladesh, cluster-randomized trial, interpersonal counseling, engagement of husbands, maternal
nutrition program
Introduction
Undernutrition among women of reproductive age, manifested
by short stature, underweight, and micronutrient deficiencies,
remains pervasive in Asia and Africa (1). Nutritional deficit
during pregnancy contributes to maternal deaths during childbirth (1, 2), adverse birth outcomes (3), and stunting by age
2 y (4). Maternal undernutrition also contributes to deaths and
preventable illnesses in >1,000,000 children before age 5 y
(2). Thus, improving maternal nutrition during pregnancy is
© 2018 American Society for Nutrition. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://
creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.
Manuscript received February 20, 2018. Initial review completed March 26, 2018. Revision accepted March 26, 2018.
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important to reduce the global burden of maternal and child
undernutrition, morbidity, and mortality (5).
The WHO recently released new recommendations on antenatal care (ANC), which include specific recommendations
to improve diets and nutrient intake during pregnancy, along
with health assessments, disease prevention, and health system strengthening to improve the utilization and quality of
ANC (6). The guidelines recommend that, in addition to receiving specific micronutrient supplements and balanced energy
and protein dietary supplementation (in food-insecure areas),
women should receive relevant and timely counseling about
healthy diets, physical activity, and adequate weight gain during
pregnancy. To date, most large-scale nutrition interventions in
developing countries either focus on specific micronutrient supplementation (7–11) or balanced energy and protein supplementation (3, 12) and solely target women of childbearing age without regard for their autonomy within the household and their
ability to adopt the promoted behaviors on their own (13, 14).
Engaging husbands, especially when they are the head of the
household and primary decision makers on family health care,
is important to improve care-seeking for women and children
(15, 16).
The importance of male partner support for improving maternal health-seeking behaviors and practices is evident in the
health literature related to the prevention of mother-to-child
transmission of HIV (17), family planning (18), maternal care
(19), and breastfeeding (20). Studies in Peru (21), Zimbabwe
(22), and Kenya (23) have also highlighted the importance of
spousal support to improve adherence to micronutrient supplements among pregnant women. In addition, fathers’ support
is reported to avert postpartum maternal depression, which,
in turn, affects the mother-child interaction during breastfeeding and child feeding (24). Although these studies underscore
the benefits of engaging husbands for specific nutritional interventions, evidence of the impact of interventions targeting
husbands to improve maternal nutrition is lacking. Including
husbands in social behavior-change programs for nutrition is
particularly important in South Asia, where the prevalence of
maternal short stature and anemia remains critically high (1,
2), women’s decision-making autonomy is particularly low, and
households are predominantly male-headed (25, 26).
In Bangladesh, more than half of pregnant women are anemic, and 20% of ever-married women 15–49 y of age are underweight (27, 28). Nutritional inadequacies among women and
Supported by the Bill & Melinda Gates Foundation; the Canadian Department
of Foreign Affairs, Trade, and Development, through Alive & Thrive, managed by
FHI 360; and the Global Affairs Canada (GAC) Research Program on Agriculture
for Nutrition and Health (A4NH), led by the International Food Policy Research
Institute.
Author disclosures: PHN, EAF, TS, GW, ZM, LMT, BA, KA, SA, MTR, and PM,
no conflicts of interest. Alive & Thrive, represented by co-authors TS, ZM, SA,
BA, and KA, participated in the study design but not in the data collection or
analysis. Alive & Thrive provided specific inputs to the manuscript with regard
to intervention design and provided feedback on the interpretation of results.
Freedom to publish the study findings was protected contractually in the agreement between the respective funding sources and the International Food Policy
Research Institute. All final decisions on the manuscript were made by the researchers.
Supplemental Table 1 is available from the “Supplementary data” link in the
online posting of the article and from the same link in the online table of contents
at https://academic.oup.com/jn/.
Address correspondence to PHN (e-mail: p.h.nguyen@cgiar.org).
Abbreviations used: ANC, antenatal care; DID, difference-in-difference; IFA, iron
and folic acid; MNCH, Maternal, Neonatal, and Child Health; SK, Shasthya Kormi (salaried health worker); SS, Shasthya Shebika (community health volunteer
worker).
2
children are high due to a lack of dietary diversity and low
intake of micronutrient supplements (29). Yet, less than half of
pregnant women received iron and folic acid (IFA) during antenatal consultations (30), and women often consumed only ≤90
IFA tablets (31), an amount that is lower than recommended.
To address the challenges of maternal undernutrition in
Bangladesh, the Alive & Thrive initiative leveraged BRAC’s existing Maternal, Neonatal, and Child Health (MNCH) platform
(i.e., “standard MNCH” program) and incorporated a strong
maternal nutrition package of interventions to 1) promote increased dietary intake, diet diversity, and adequate rest; 2) provide free IFA and calcium supplements; and 3) monitor weight
gain during pregnancy. This integrated program is referred to
as the “nutrition-focused MNCH” program. We showed previously that, compared with the standard MNCH program, the
nutrition-focused MNCH program successfully improved multiple outcomes such as maternal dietary diversity and micronutrient supplement consumption during pregnancy and exclusive
breastfeeding practices (32). Given the recognized importance
of male partner support for improving maternal health-seeking
behaviors and practices (15, 19), the nutrition-focused MNCH
also included specific interventions to promote greater engagement of husbands and support to their wives during pregnancy.
In this article, we report results from our analysis of the following: 1) the impact of providing nutrition-focused MNCH compared with standard MNCH programs on husbands’ awareness,
knowledge, self-efficacy, and support for optimal nutrition practices of their wives and 2) the extent to which the impact of the
program previously reported on micronutrient supplement intake and dietary diversity was explained by differences in the
husbands’ engagement in the program as reflected by differences
in related behavioral determinants and support to their wives
during pregnancy.
Methods
Study context and intervention description. This study used
data from a cluster-randomized study conducted to evaluate the feasibility and impact of integrating intensified maternal nutrition interventions into the existing MNCH program platform in Bangladesh. A
detailed description of the intervention package has been provided elsewhere (32). Briefly, Alive & Thrive designed a nutrition-focused MNCH
program (including interpersonal counseling, community mobilization,
distribution of free micronutrient supplements, and weight-gain monitoring) targeted to both wives and husbands, with the overall goal of
improving maternal nutrition. All components of the maternal nutrition
interventions started in 10 subdistricts in August 2015 and continued
until the end of August 2016.
Interpersonal counseling was delivered by 2 frontline workers,
Shasthya Kormi (SK; salaried health worker) and Shasthya Shebika (SS;
community health volunteer worker), through monthly home visits for
all pregnant women. Husbands of these women were encouraged to attend the home-based counseling sessions as well. The nutrition-focused
interventions delivered during home visits included the following: 1)
demonstrating a specific diet plan (both quality and quantity), 2) providing free supplements (IFA and calcium tablets) and advice on using
them, 3) measuring weight and explaining optimal weight-gain patterns,
4) counseling on adequate rest during pregnancy, and 5) engaging husbands and other family members to ensure enough varied foods and
supplements being available and supporting pregnant women to consume them.
Community mobilization in the nutrition-focused MNCH model involved husbands’ forums (i.e., meetings), small group meetings with
community opinion leaders, entertaining video shows, and popular
theater for the entire community. Husbands of pregnant women were
Nguyen et al.
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invited to attend 2 husbands’ forums during pregnancy (in the second
and third trimesters) to discuss several topics including the following: 1)
benefits of ensuring good maternal nutrition for the mother and child,
2) husbands’ role in purchasing nutritious foods and motivating their
mothers and wives to ensure that the recommended quantities of diverse
foods are consumed by their wives daily, 3) ensuring adequate supplies
of IFA and calcium supplements and reminding their wives to take them
daily, and 4) reviewing their wives’ weight gain and supporting healthy
weight gain. Video shows and interactive communication were carried
out for the community, covering multiple topics related to nutrition during pregnancy and aiming at shifting social norms through spreading
awareness about the recommended practices and the need to support
pregnant women. These targeted multiple audiences included women,
their husbands and family members, local elites (religious leaders, community leaders, teachers), village doctors, medical drug sellers, pharmacists, and government health workers. In the standard MNCH program,
women received ANC with standard nutrition counseling; there were no
community mobilization or husband engagement activities being promoted.
Study design and participants. The study design has been
described in detail elsewhere (32). Briefly, a cluster-randomized,
nonblinded, impact-evaluation design was used to compare the
nutrition-focused MNCH and the standard MNCH programs. Twenty
subdistricts (upazilas) from 4 districts (Mymensingh, Rangpur, Kurigram, and Lalmonirhat), where BRAC’s rural MNCH program already
existed, were randomly assigned to nutrition-focused MNCH or standard MNCH. Cross-sectional household surveys were conducted at
baseline (July–August 2015) and endline (July–August 2016) in the
same villages.
A total of 1000 women with children aged
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