Effect of Integrated Pictorial Handbook Education and Counseling on Improving Anemia Status, Knowledge, Food Intake, and Iron Tablet Compliance Among Anemic Pregnant Women in Indonesia: A Quasi-experimental Study

Background: Nahrisah et al 2020 is a quasi-experimental, pretest- posttest design conducted in two homogenous municipalities (one intervention and one control) in the province of Aceh, Indonesia. ANC visitors were invited to evaluate the effects of the intervention program on hemoglobin and hematocrit levels in their third- trimester pregnancies (primary outcome), birth weight, knowledge of anemia, iron-rich food intake, and rate of IFA intake (secondary outcome). The intervention program designed using the health belief model provided an individual education session using an anemia pictorial handbook with individual counseling sessions to overcome the barriers to an iron-rich diet and proper IFA intake behavior.

Methods: Random sampling was used to invite and select 163 anemic pregnancies who met the criteria of hemoglobin levels below 11 g/dL, aged 20 years or above, free from obstetrical complication (bleeding, gestational diabetes, pregnancy-induced hypertension), and willing to receive home visits. 70 participants were selected via lottery for both the intervention and control groups. The intervention group participated in two home visits two weeks apart that consisted of individual education through the pictorial handbook and individual counseling.

A set of questionnaires measuring socio-demographic information, knowledge of anemia, the 24 hours food recall questionnaire, and a food frequency questionnaire (FFQ) were used to measure the outcomes of the study during the pre- and post-intervention periods. A blood sample was also taken to measure hemoglobin and hematocrit levels.

Results: There were no significant difference between the intervention and control groups regarding demographics.  Pregnant women who received individual education through an anemia pictorial handbook and counseling had a significant increase in hemoglobin and hematocrit levels, birth weight, knowledge of anemia, iron-rich food intake, and the number of IFA intake compared to the control group. The greatest effects of the intervention were found in FFQ score and number of IFA intake.

Conclusions: Individual education through a pictorial handbook of anemia with counseling had a positive impact on the improvement of hemoglobin and hematocrit levels in anemic pregnant women in their third trimester of pregnancy. Gastrointestinal side-effects of iron supplementation are still a major deterrent to compliance. The government is recommended to emphasize nutrition education during antenatal care, focusing on behavioral intake of affordable and available local foods, and the intake of the iron supplements on a regular basis.