Anemia is one of the world’s most common public health problems. Globally, 38% of pregnant women and 29% of women of reproductive age are anemic, and relatively little progress has been made in reducing prevalence since 1995¹. Women and children in low- and middle-income countries (LMICs) are the most affected. Anemia is associated with poor birth outcomes, impaired cognitive development, and low productivity in adults². Anemia in pregnant women increases the risk of having low birth-weight infants, preterm delivery, and maternal mortality^3,4. Despite significant achievements in maternal and child health-related programs over the past decade, the prevalence of anemia among pregnant women has shown no reductions but slight increments over the past decade, from 22% in 2011 to 29.1% in 2016⁵.

Currently, WHO recommends that pregnant women consume 60 mg of iron and 0.4 mg of folic acid per day for > 90 days to prevent the risk of maternal anemia, low birth weight, neural tube defect, and preterm birth⁶. Iron-folic acid supplementation (IFAS) increases hemoglobin levels thereby reducing prevalence of anemia and increasing the mean blood hemoglobin level by 10.2 g/l in pregnant women^7,8. In addition, IFAS reduces the incidence of anemia by 69% and iron deficiency anemia by 66% at term⁹ as well as decreasing neonatal mortality by 34-45%^10,11. Ethiopia has implemented programs that provide free, often with folic acid, ANC services. However, adherence to IFAS has remained low over the years and the prevalence of anemia in pregnant women remains persistently high in Ethiopia. For example, according to the 2016 Ethiopian demographic health survey, only 5% of pregnant mothers took an iron with a folic acid tablet for 90 days, and 58% of pregnant mothers did not take⁵. Several factors influence maternal adherence to IFAS, including socio-cultural circumstances, poor knowledge, a negative attitude, and poor awareness towards iron/folic acid deficiency^12,13,14. Galloway et al. found, in an eight-country qualitative study, that inconsistent supply, inappropriate targeting, and inadequate counseling were the major barriers to adherence to IFAS¹⁵.

Nutrition education and counseling are widely used strategies to improve maternal nutritional status during pregnancy¹⁶. Evidence showed that health education intervention is an important tool to improve knowledge on anemia and adherence to the IFAS during pregnancy^17,18. Community-based health education on anemia and IFAS has also proved successful in Cambodia, the Philippines, Vietnam and Kenya where improvements in awareness and knowledge of anemia and IFAS were reported^19,20. A review study also suggested that nutrition education and counseling can improve both anemia outcomes and adherence to IFAS recommendations in low- and middle-income countries (LMIC)²¹. However, in Ethiopia, the routine nutrition education provided for pregnant women by the health extension workers is inconsistent, and counseling about possible side effects of IFAS and how to mitigate them is also missed most of the time²². Therefore, nutrition education and appropriate counseling during pregnancy seem to be of high priority to promote positive maternal and pregnancy outcomes²¹. In Ethiopia, data on the effect of community-based nutrition education and counseling using health belief model constructs along with IFAS on anemia and adherence to IFAS among pregnant women was scarce. Thus, the aim of this study was to assess the effect of community-based nutrition education and IFAS intervention on anemia and adherence to IFAS in pregnant women in southern Ethiopia.

Study design

The details of the study methods adopted for this study was published elsewhere in other article²³.

A quasi-experimental study was conducted among pregnant women who were in the second trimester (gestational ages less than 16 weeks), not suffering from any chronic illness, had no severe anemia and provided verbal consent to participate in the study. Pregnant women were recruited and assigned to receive nutrition education and IFAS in the intervention group and routine antenatal care services only in the control group by two stages. The study was performed as per the principles of Helsinki Declaration.

Study setting and sampling

The study was conducted in Butajira city administration located in 135 km southern part of Ethiopia. In 2022, the population of Butajira city administration is 89, 824 and has increased by 6.8% from 2007.

The sample size was determined by using the formula for comparison of two population proportions for the intervention and control groups.

The following assumptions were considered when estimating the required minimum sample sizes: the expected proportion of pregnant women with good knowledge (P1) 0.77 and P2 was 0.52²⁴. We wanted to detect an absolute increase of 25% in the intervention group at 5% significance level, and 80% power. The calculated sample size was multiplied by 1.5 to adjust for design effect and added 10% loss to follow up, the final sample size was 198. After assessing for eligibility, primary author randomly assigned pregnant women to the intervention and control groups in a 1:1 ratio using coin tossing (Fig. 1).

Data collection

The trained data enumerator collected data from pregnant women who gave written informed consent to participate in the study. The baseline data was collected using interviewer administered questionnaire. The questionnaires included socio-economic characteristics of women and their households, obstetric history, prenatal health seeking behavior, and measure variables relevant to maternal nutrition during pregnancy, IFA compliance level and biochemical assessment such as hemoglobin level estimation were done.

At the end of intervention, data on IFA compliance and hemoglobin status were collected. Compliance with the IFAS was assessed by pill count based on the number of remaining pills in the retained prescribed bottles. The number of unused pills in the retained pill bottles or strips was counted and recorded at the last visit following the last week of the intervention. If pregnant women were able to take at least ≥ 72 IFAS pills or 80% from the total take period, they were considered an adherent to the IFAS utilization, whereas those who were not able to take < 72 IFAS pills or < 80% from the total intake period were considered non-adherents to the IFAS intakes⁶.

Hemoglobin was measured using a portable and battery-operated machine (HemoCue, Angel Holm, Sweden). After swiping the site with disinfectant, a finger prick was made to obtain blood for hemoglobin measurement. The first two drops were swapped away and the third drop was used to fill the micro cuvette for reading of the hemoglobin. Maternal anemia is defined as Hemoglobin value < 11 g/dl during pregnancy²⁵.

The intervention

Nutrition education was delivered in Amharic. An organized work schedule, counseling cards, and nutrition education were provided to the intervention group. The core messages for the lessons were generated using the health belief model (HBM)²⁶. It was modified in the recommendation to the Ministry of Health (MOH), Ethiopia²⁷. The messages were framed in a way that addresses all components of 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 behavior successfully). The health belief model was selected because the desired behavioral change is at an individual level and due to its convenience and simplicity.

For the intervention and control groups, baseline and endline assessments were collected. Following the gathering of baseline data, intervention groups were placed in groups at nearby village and received nutrition education regularly, once every two weeks, for a period of three months (six sessions) for 30 to 45 min per session. Four nurses with Bachelor of Science (BSc) degrees delivered nutrition education, while two Master of nutrition (MSc) specialists supervised the nutrition education sessions. The core contents of the session were: increasing knowledge about iron-rich food sources, iron-folic acid supplements (IFAS) (how to take the IFAS, when to take it, and how to absorb it more, foods rich in iron and folic acid, common side effects and their management; and enhancers/inhibitors of iron/folic absorption), iodized salt, meal frequency, and portion size with increasing gestational age; food groups; taking day rest; reducing heavy workloads; enhancers and inhibitors of iron absorption; increasing utilization of health services; and interrupting the intergenerational life cycle of malnutrition; increasing pregnant women’s perceptions of undernutrition and factors leading to it; poor eating practices causing inadequate dietary intake and disease; a diet adjustment.

Nutrition education sessions included presentations, discussions, demonstrations, and picture-based exercises. Key messages, realistic activities, and the GALIDRAA (greet, ask, listen, identify, discuss, recommend, agree, and make follow-up appointments) processes were all identified by the trainers as crucial counseling abilities. After the pregnant women were enrolled, reasonable attempts were made to encourage their retention and full follow-up for the duration of the trial by providing them with incentives to reduce missing data. Periodic conversations about compliance with the intervention during routine meetings and home visits by trainers served to retain interest in the study. Moreover, home visits were planned to lessen the strain of follow-up visits among pregnant women.

Intervention fidelity

The investigators developed criteria to assess the fidelity of the intervention based on the National Institutes of Health (NIH) Behavioral Change Consortium’s best practice recommendations²⁸. The criteria used include research design, training of nutrition educators, intervention delivery, and receipt of intervention. To balance the variations, equal numbers of eligible participants were selected for the intervention and control groups. In addition, to reduce information contamination between the intervention and control groups, non-adjacent kebeles were selected. Intervention “dose” was adequately described and the same for each group in the study, which also included a comparison group and a counseling manual. To minimize between-educators variation, educators received instruction utilizing a manual, simulated counseling sessions, and ongoing supervision. Educators’ knowledge and skills were assessed by pre- and post-training tests and practical evaluation. Implementation of the intervention was assessed using post-intervention knowledge and attitude towards IFAS. Besides, each woman received an equal number and frequency of counseling, as well as the length of contacts within an intervention group to make the process standardized.

Outcome measure

The primary outcome for this study was the effect of nutrition education and IFAS on anemia level of pregnant women after three months of intervention. Secondary outcomes included the adherence to IFAS.

Data management and analysis

The data were entered, cleaned, coded, and analyzed using Statistical Package for Social Science version 26.0 software. The characteristics of respondents were also described in both the intervention and control groups. The wealth index was computed using principal component analysis as a composite indicator of living standards based on ownership of selected household assets, size of agricultural land, number of livestock, materials used for housing construction, ownership of improved water and sanitation facilities, and household possessions⁵. The wealth index values were calculated by summing up the scores of sixteen components. Ultimately, three categories (low, medium, and high) were generated by splitting the wealth index values into three equal classes.

Comparisons of mean hemoglobin level between and within the control and intervention groups were done using independent and paired sample t-tests (assuming equal variance), respectively. The analysis of the effect of the intervention was done using a Difference-In-Difference (DID) (percentage point change) non-parametric repeated two-samples test to compare outcomes between intervention and control groups before and after intervention. The changes in the dependent variable in the intervention group (from baseline to end line) were compared to the changes in the control group (from baseline to the endline). The intervention effect was measured by the odds ratio and 95% confidence level of the interaction term between study groups (intervention and control) and period of study (baseline and the endline) in the multivariate logistic regression model by adjusting the possible confounding variables. The Generalized Estimation Equation (GEE) was applied in addition to allow correlations of these repeated observations over time since data are collected on the same participants across successive points in time. A p < 0.05 was considered statistically significant.

In the study, 99 pregnant women received nutrition education as well as IFAS, while 99 pregnant women received routine education only. Five pregnant women left the study. Among them, two participants could not be followed up, one shifted residence, and two had abortions (Fig. 1).

There was no significant difference between the intervention and control groups regarding age, parity, educational level, ethnicity, religion, occupation, family size, gravidity, parity, and socioeconomic level (Table 1).

At baseline, only 53.5% of the control group and 48.5% of the intervention group had a good knowledge level about anemia and IFAS. After intervention, more than three-fourths of the pregnant women (84.5%) in the intervention group had a good knowledge level on anemia and IFAS, compared to less than two-thirds (62.9%) in the control group (Table 2). The intervention had a net effect of 27.7% points (35–7.3) of improvement in IFA supplementation knowledge level, resulting in the statistical significance of the difference in difference (DID) between the two groups (p < 0.001).

The study also showed that the level of anemia was decreased by 20.6% points in the intervention group (from 27.8 to 7.2%) as compared to 9.4% points (from 27.1 to 17.7%) in the control group.

The intervention had a net effect of 11.2% points (20.6–9.4) reduction in the prevalence of anemia. Therefore, the statistical significance of the difference in difference (DID) between the two groups was < 0.001.

There was a significant change in hemoglobin level between intervention and control group after the intervention was implemented. The mean hemoglobin level within intervention group before and after intervention was (11.78 ± 1.33, 12.65 ± 1.26) (p < 0.001 (Table 3). The result showed that the intervention improves the mean hemoglobin level by 0.8 g/dL (Table 4).

After intervention, the proportion of adherence to the IFAS was 60% (n = 116). With regard to adherence within the groups, 79.4% (n = 77) in the intervention group and 40.6% (n = 39) in the control group and the intervention group were significantly higher than in the control group. In the intervention group, the proportion of adherence to the IFAS intake among participants increased by 45.6% points and was statistically different (P < 0⋅001). At the end of the study, the proportion of adherence to the IFAS also increased by 8.2% points in the control group but was not statistically different (P = 0.12). The difference in difference between the two groups of adherence to the IFAS intake was 37⋅4% and they were statistically significant (P < 0⋅001) (Table 5). At the endline, adherence between the groups did differ from the baseline (p = 0.12 vs. p < 0.001).

There was significant improvement in the levels of IFAS knowledge at the end line. The odds of being in compliance with IFAS at endline were 2.7 times higher than those at baseline (AOR = 3.9; 95% CI: 21.672, 4.825), adjusting for other factors (Table 6). Maternal educational status was significantly influenced prenatal IFA supplementation; as compared to women with no formal education, those in secondary and above education had 4 times increased odds of utilizing the supplementation (AOR = 4.076; 95%CI: (1.942, 8.556) (Table 5).

The present study aimed to evaluate the effect of nutrition education and counseling, utilizing health belief model constructs and iron-folic acid supplementation, on the hemoglobin level and adherence to IFAs in pregnant women. The key findings were that the health belief model-based nutrition education and IFAS led to improved pregnant women’s knowledge about anemia and IFAS, hemoglobin levels, a drop in anemia proportion, and adherence to IFAS.

Reduced anemia prevalence has been reported in other studies that used nutrition education as an intervention^29,30. A randomized control trial study conducted in Ghana reported parallel results, indicating a positive association between improved hemoglobin levels and nutrition education³¹. Similarly, a study on Indian pregnant women reported that individual counseling was found to improve hemoglobin levels in the intervention group as compared to the control³². In a study by Alaofe et al., the mean score of knowledge and hemoglobin level showed a significant increase after the intervention in the experimental group as compared to control group³³. The possible reason for the drop in prevalence of anemia and/or improvement of hemoglobin levels might be that education about the consequences of anemia and the benefits of iron on pregnant women and fetus health might have encouraged women to comply with the nutrition advice in reducing anemia. Iron-folic acid supplementation may have also contributed to the reduction in the rate of anemia in the intervention group^34,35.

A review of randomized control trials and quasi-experimental studies showed a substantial reduction of anemia in pregnant women when nutrition education and counseling were provided with nutritional supplements like micronutrient supplements compared to nutrition education alone²¹. For example, according to the Ethiopia Demographic and Health Survey (EDHS), < 11% took an IFAS for the recommended period (≥ 90); about 12% took 60–89 pills; more than one-third (35.7%) took < 60 pills, and around 42.2% did not take any iron tablets during their most recent pregnancy³⁶. Thus, adherence to IFAS is still low in pregnant women in Ethiopia, indicating that Ethiopia is off-track to achieve the World Health Assembly (WHA) target of a 50% reduction of the prevalence of anemia by 2025³⁷. Integration of counseling and nutrition education into routine health extension programs may be considered potential public health interventions to reduce anemia among pregnant women in Ethiopia. Evidence has demonstrated that nutrition education and counseling that is targeted at maternal diet and supplement intakes during pregnancy, even when provided for a brief period of time, can improve multiple maternal and neonatal health outcomes²¹. However, most counseling done during ANC services tends to be general in the context of Ethiopia. Our finding suggests pregnant women who have good nutritional knowledge can have improved adherence to IFAS. Thus, nutrition education and counseling during ANC visits could improve maternal knowledge of IFAS.

In this study, the adherence to IFAS intake was 33.8% before the intervention and 79.4% after the intervention within the intervention group, compared with the 32.4 and 40.6% (before and after intervention) within the control group, and the average number of tablets taken in the intervention group was significantly higher than in the control group. This means there was an improvement in the proportion of women who consistently took the IFAS tablets as recommended. Therefore, targeted nutrition education, along with link to IFAS is one of the promising interventions that could improve the pregnancy and birth outcome. Similar results were reported by other studies conducted with the nutrition education and individual counseling in Nepal, Indonesia and India^30,32,38. Studies conducted by Abdisa et al. and Berhane et al. showed that nutrition education and counseling during pregnancy can improve adherence to IFAS^17,18. A study by Araban et al. also showed that nutritional education based on the Health Belief Model increased iron and folic acid intake in pregnant women³⁹.

Furthermore, we assessed the behavior-related factors of maternal adherence to IFAS and showed a decrease in side effects reported at endline compared to baseline, especially in the intervention group. In addition, the study showed more awareness of the mitigation of IFAS side effects in the intervention group. The number of women who reported IFAS-related side effects in the intervention group dropped from 26 to 12% at the endline. This result can be explained by the fact that by providing ample information about the benefits of IFAs and the consequences of not doing so, there is a high possibility that the pregnant women perceived that the benefits of taking IFA tablets outweighed the side effects. Studies also reported that forgetfulness and side effects are one of the main factors contributing non-adherence to IFA tablet supplementation^32,40. Other studies have shown that educating pregnant women on how to mitigate the side effects of IFAS often leads to higher adherence^24,41. Therefore, it is highly recommended to make pregnant women aware of the possible side effects and how to mitigate them in order to improve adherence to IFAS as indicated elsewhere^20,24.

The findings of the present study show that the odds of adherence to IFAS were 2.3 times higher among those women who received nutrition education than those who did not. This finding is in agreement with studies conducted in Kenya and Ethiopia, which resulted in improved adherence to IFAS among women who received education compared to the control group^17,20,42. Additionally, primary and above maternal educational status was positively associated with adherence to IFAS. Consistent findings were reported by the study conducted in Senegal⁴³, Iran⁴⁴ and Ethiopia⁴². Maternal education could create opportunities for women to easily access information disseminated through health professionals and media about personal healthcare, IFAS, and its benefits. Moreover, pregnant women who have good knowledge and a positive attitude about IFAS were more likely to adhere to IFAS than women who had poor knowledge and a negative attitude towards IFAS. This might be due to the fact that knowledge helps a woman to have a good perception of the advantage of taking IFA tablets and the consequences of not taking the supplement during pregnancy. Studies conducted in India⁴⁰, Kenya²⁰ and Ethiopia⁴⁵ have indicated a significant association between knowledge of IFAS and increased adherence to IFA tablets.

The present study has some limitations. Firstly, the sample size included in this study was smaller; therefore, the findings cannot be generalized to a wider population. Secondly, since only hemoglobin levels were measured, we did not assess iron deficiency, nutritional deficiency or inflammation anemia. Thirdly, pregnant women were assigned to either the control or intervention groups purposively. So, there was a chance of bias due to a lack of randomization.

Our study revealed that the provision of Health Belief Model-based nutrition education and counseling, along with IFA tablet supplementation, improved hemoglobin levels and adherence to IFAS intake among pregnant women. Nutrition education and counseling intervention strategies based on HBM constructs can improve adherence to folic acid intake and hemoglobin levels in pregnant women in primary health care settings in Ethiopia. Therefore, integration of theory-based nutrition education and counseling into routine antenatal care services in the primary health care systems is important to reduce the prevalence of anemia among women and achieve Sustainable Development Goal 2. A study that tests whether interventions grounded in theories of complex behavior change, that address other determinants of IFAS or adult educational theories are more effective than present nutrition education and counseling approaches is needed.