Cognitive testing of questions about antenatal care and nutrition interventions in southern Nepal

L-Thorne-Lyman, Andrew; Lama, Tsering Pema; Heidkamp, Rebecca; Manandhar, Porcia; Subedi, Seema; Munos, Melinda; Bryce, Emily; Khatry, Subarna K.; LeClerq, Steven C.; Katz, Joanne

doi:10.1016/j.socscimed.2022.115318

Cited by 4 publications

(5 citation statements)

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“…This could explain the finding that the presence of MILs and/or husbands during the interview was associated with a significantly greater overestimation of the number of ANC visits. Cognitive testing 27 conducted in this same population revealed that women were confused about whether visits to providers outside of health posts including for sonograms should be counted towards their estimate of ANC visits or not, and it is possible that women might be more likely to count such visits when in the presence of other household members.…”

Section: Discussionmentioning

confidence: 99%

How does social desirability bias influence survey-based estimates of the use of antenatal care in rural Nepal? A validation study

Thorne‐Lyman¹,

Lama²,

Heidkamp³

et al. 2023

BMJ Open

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ObjectivesSocial desirability bias is often speculated to influence survey responses but seldom studied in healthcare. The objective was to explore whether social desirability scores (SDS) or the presence of interview observers is associated with inaccurate recall and overestimation of antenatal care (ANC) services.DesignLongitudinal validation study comparing recalled receipt of ANC services and nutrition components of ANC against direct observations of care. An adapted short form Marlowe-Crowne questionnaire was used to generate an SDS, and the presence of interview observers was treated as a separate exposure. We assessed accuracy and overestimation of recalled receipt of ANC services against observed receipt using log-binomial regression, adjusting for age, education, first-pregnancy and socioeconomic status.SettingRural Southern Nepal with recruitment from five government health posts.Participants401 pregnant women.ResultsSocial desirability scores did not significantly predict accuracy or overestimation of most types of ANC care except counselling on nausea. Higher SDS was associated with more accurate recall (adjusted RR, aRR 1.08 (95% CI 1.03, 1.12)) and less overestimation (aRR 0.85 (0.80, 0.91)). The presence of mothers-in-law or husbands during interviews was associated with greater overestimation of the number of ANC visits received by more than three visits (aRR 2.07 (1.11, 3.84)) and (aRR 4.19 (2.17, 8.10)), respectively. Those interviewed with friends present tended to overestimate the receipt of counselling on nausea, avoiding alcohol and not smoking.ConclusionThe presence of observers can lead to overestimation of the receipt of ANC care and support the conduct of interviews in private settings despite challenges of doing so in village contexts. Findings that the SDS did not predict the accuracy of most types of ANC care might reflect a reality that such questions may not be sensitive from a social-norms perspective. Additional local adaptation of SDS is recommended.

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Section: Discussionmentioning

confidence: 99%

How does social desirability bias influence survey-based estimates of the use of antenatal care in rural Nepal? A validation study

Thorne‐Lyman¹,

Lama²,

Heidkamp³

et al. 2023

BMJ Open

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“…In this case, the language used during the postpartum interview, which was specifically designed to resemble that used in the DHS, could be misunderstood. A study of cognitive testing of questions about ANC suggested that over-reporting and under-reporting may be related to the definition of an ANC visit 18. ANC visits are meant to be regular preventive checkups in pregnancy.…”

Section: Discussionmentioning

confidence: 99%

“…ANC visits are meant to be regular preventive checkups in pregnancy. However, if a woman came for care because she was sick, this would be counted as an ANC visit in the gold standard observed count but might not be counted as an ANC check-up visit by the woman at the time of recall 6 months postpartum 18. Social desirability bias is the inclination of people to report more socially desired activities than they actually performed (over-reporting) or understate undesirable attributes (under-report) 19.…”

Section: Discussionmentioning

confidence: 99%

“…A study of cognitive testing of questions about ANC suggested that over-reporting and under-reporting may be related to the definition of an ANC visit. 18 ANC visits are meant to be regular preventive checkups in pregnancy. However, if a woman came for care because she was sick, this would be counted as an ANC visit in the gold standard observed count but might not be counted as an ANC check-up visit by the woman at the time of recall 6 months postpartum.…”

Section: Discussionmentioning

confidence: 99%

“…However, if a woman came for care because she was sick, this would be counted as an ANC visit in the gold standard observed count but might not be counted as an ANC check-up visit by the woman at the time of recall 6 months postpartum. 18 Social desirability bias is the inclination of people to report more socially desired activities than they actually performed (over-reporting) or understate undesirable attributes (under-report). 19 In the study scenario, women who had less than four ANC tended to report more and meet the social standard in front of the interviewer and sometimes the presence of their husbands, resulting in the under-reporting of 1–3 visits group and over-reporting of the 4 visits group.…”

Section: Discussionmentioning

confidence: 99%

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Validation of maternal recall of number of antenatal care visits attended in rural Southern Nepal: a longitudinal cohort study

Xie,

Munos,

Lama

et al. 2023

BMJ Open

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ObjectivesThis study aimed to examine the validity of maternal recall of total number of antenatal care (ANC) visits during pregnancy and factors associated with the accuracy of maternal recall.DesignThis was a longitudinal cohort study conducted from December 2018 through November 2020.SettingFive government health posts in the Sarlahi district of Southern Nepal.Participants402 pregnant women between ages 15 and 49 who presented for their first ANC visit at the study health posts.Main outcomesThe observed number of ANC visits (gold standard) and the reported number of ANC visits at the postpartum interview (maternal recall).ResultsOn average, women in the study who had a live birth attended 4.7 ANC visits. About 65% of them attended four or more ANC visits during pregnancy as recommended by the Nepal government, and 38.3% of maternal report matched the categorical ANC visits as observed by the gold standard. The individual validity was poor to moderate, with the highest area under the receiver operating characteristic curve (AUC) being 0.69 (95% CI: 0.65 to 0.74) in the 1–3 visits group. Population-level bias (as distinct from individual-level bias) was observed in the 1–3 visits and 4 visits groups, where 1–3 visits were under-reported (inflation factor (IF): 0.69) and 4 ANC visits were highly over-reported (IF: 2.12). The binary indicator ANC4+ (1–3 visits vs 4+ visits) showed better population-level validity (AUC: 0.69; IF: 1.17) compared with the categorical indicators (1–3 visits, 4 visits, 5–6 visits and more than 6 visits). Report accuracy was not associated with maternal characteristics but was related to ANC frequency. Women who attended more ANC visits were less likely to correctly report their total number of visits.ConclusionMaternal report of number of ANC visits during pregnancy may not be a valid indicator for measuring ANC coverage. Improvements are needed to measure the frequency of ANC visits.

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The effect of prenatal multiple micronutrient supplementation on birth weight in Ethiopia: protocol for a pragmatic cluster-randomised trial

Marchant,

Alemayehu,

Asfaw

et al. 2024

Preprint

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Introduction This programme effectiveness study responds to the need for evidence of the effect on birth weight of switching from iron-folic acid supplementation to multiple micronutrient supplementation as part of routine antenatal care in Ethiopia. A 2019 meta-analysis reported a mean increase of 35 grammes in birth weight amongst newborns of women who took multiple micronutrient supplements in pregnancy compared to those who took iron-folic acid. Responding to that evidence, the government of Ethiopia decided to implement a 21 district pilot of the use of multiple micronutrient supplementation in routine antenatal care and requested an evaluation of implementation outcomes, including on birth weight. Methods and analysis A pragmatic, facility-based, randomised trial is being conducted in 42 districts over 5 regions of Ethiopia between January 2023 and December 2024. Districts have been randomised to one of two arms, either to retain iron-folic acid supplementation as part of routine antenatal care or switch to multiple micronutrient supplementation. During the study period the birth weights of all eligible babies born in enrolled health facilities in these 42 districts are continuously recorded alongside data on maternal receipt and use of either multiple micronutrient or iron-folic acid supplementation. We hypothesise that newborns of women resident in the 21 multiple micronutrient supplementation districts will have higher mean birthweight than newborns of women resident in the 21 iron-folic acid supplementation districts. Facility surveys involving pregnant women and health care workers at baseline, midline, and endline contribute to a process evaluation and cost and cost-effectiveness evaluation. Discussion Results from this pragmatic trial will be used by the government of Ethiopia in assessing success of the MMS pilot and for decision making about subsequent scale-up. The findings will also inform global decision making, particularly in settings where a transition from iron-folic acid to multiple micronutrient supplementation is being contemplated at scale.

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Cognitive testing of questions about antenatal care and nutrition interventions in southern Nepal

Cited by 4 publications

References 20 publications

How does social desirability bias influence survey-based estimates of the use of antenatal care in rural Nepal? A validation study

How does social desirability bias influence survey-based estimates of the use of antenatal care in rural Nepal? A validation study

Validation of maternal recall of number of antenatal care visits attended in rural Southern Nepal: a longitudinal cohort study

The effect of prenatal multiple micronutrient supplementation on birth weight in Ethiopia: protocol for a pragmatic cluster-randomised trial

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