Tele-follow-up Empowers Anemic pregnant lady to create demand for therapeutic treatment of anemia and improve compliance: A Case Study

Introduction

Anemia is a major public health problem worldwide. Majority of anemia cases are present in the developing countries. Anemia during pregnancy is very high with prevalence of 56% in developing countries and 18% in developed countries.¹ South Asia region still has one of the highest prevalence (52%) with India topping the list in this region.² National Family Health Survey-3 (NFHS-3) conducted in India in 2005-06 shows that burden of anemia in pregnant women is 58.7%, of which 2.2% suffers from severe anemia.³

The etiology of anemia can be multifactorial with primary cause being the nutritional deficiency.⁴ Despite the provision of iron therapy and folic acid supplements free of cost under government initiative,⁵ prevalence of anemia is still high among pregnant ladies due to low adherence or compliance to the iron therapy.^6–9

Reliable information and effective communication are the major elements in the field of public health practices. Information and communication technologies (ICTs) have shown a tremendous growth in recent times and have proved to be an accelerator of economic and social progress.¹⁰ Mobile Health (m-Health) is an area of electronic health (e-Health) where the provision of health services and information is via mobile technologies such as mobile phones and Personal Digital Assistants (PDAs).¹¹

An operational study was done that employed the use of live calls on the telephones or mobile phones of pregnant ladies for the follow up of the anemia treatment, counseling and addressal of problems regarding adherence to treatment of anemia. The study was done taking in to account only the anemic pregnant ladies. The objective of this study was to assess whether these telephonic conversations can improve the adherence levels to the treatment and to explore whether there will be an improvement in Hb levels or severity of anemia.

In this paper, case study of one of the pregnant woman is described and the pathway of improving compliance is discussed using trans theoretical model of behavior change.

Intervention

After taking consent, an anemic pregnant lady was enrolled in the study in the intervention group during her 10th week of gestation and her Hb recorded from the ANC records during that time was 9.2 g/dl. Enrolment was done from the ANC records of new antenatal registrations available with the ANM of the area.

Discussion

This case study demonstrates that interventions at various stages helped the lady to take different actions. (Figure 1) It not only motivated her to improve her compliance, but also empowered her to act on external barriers such as improper prescriptions We have applied Trans theoretical model or Stages of Change model to explain this behavior change (Figure 2). The TTM model is both an intervention and behavior model. This model firstly describes the stages through which the person passes in order to achieve the desired behavior. So the intervention that is being given to change the behavior must be according to the stage of change the person is experiencing.

1. Pre contemplation stage: The stage when person may not be aware of needing or wanting to change or may be unwilling or uninterested in the change. The pregnant lady was taking IFA supplement and aware of its use in just increasing Hb levels with no realization of its serious implications. The level of knowledge, awareness and motivation related to IFA supplements and dietary pattern was incomplete. This stage needs intervention focusing on creating awareness, providing complete knowledge and information, telling them the serious implications that she might face if she does not change the present practice.
2. Contemplation stage: Person develops desire to change. The lady started taking the correct dosage in consequent follow ups but it was not on a regular basis and we came across a major reason behind this was the rigid behavior of health worker of giving tablets according to 1 tablet per day. So there was a fear of not getting the medicine again if she finishes them early. The intervention here focused on motivating and empowering the lady to talk to health worker of being aware of guidelines and creating demand for the supplements.
3. Preparation stage: The person plan ways to change. The lady planned to talk to the health worker and also visited the health facility for getting her routine checkup and Hb levels done. Again, she rushed to the health facility the next day when she was told that her Hb is too low to be treated by oral dose and she needs to see the doctor immediately in order to get iron sucrose preparation.
4. Action stage: The lady is actually getting checkup done regularly, taking therapeutic treatment according to the guidelines, not missing the doses, getting Hb done regularly, taking care of dietary instructions.
5. Maintenance stage: Maintaining the behavior of action stage for at least a period of 6 months. The lady has shown commitment to follow the treatment plan till her delivery and even continued the IFA intake after delivery as per guidelines. Positive reinforcement and follow-up support help in maintaining the behavior.
6. Relapse: This stage can occur between any two stages in which the person returns to the previous stage. This can be evidently seen in this case study where pregnant lady planned or desired to change her adherence levels to treatment but was not able to do it at various times due to external factors (health system factors) or internal factors (forgetfulness, less motivation, fear etc.).

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