preference and acceptability of alternative delivery ... preference and acceptability of alternative

PREFERENCE AND ACCEPTABILITY OF ALTERNATIVE

DELIVERY VEHICLES FOR PRENATAL CALCIUM

SUPPLEMENTATION AMONG PREGNANT WOMEN IN

BANGLADESH

by

Jo-Anna Bernadette Baxter

A thesis submitted in conformity with the requirements

for the degree of Master of Science

Graduate Department of Nutritional Sciences

University of Toronto

© Copyright by Jo-Anna Bernadette Baxter (2013)

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Preference and acceptability of alternative

delivery vehicles for prenatal calcium supplementation

among pregnant women in Bangladesh

Jo-Anna Baxter

Master of Science

Department of Nutritional Sciences – University of Toronto

2013

ABSTRACT

In populations with low dietary calcium intake, prenatal calcium supplementation is

recommended by the WHO to decrease the risk of hypertensive diseases of pregnancy. This

study evaluated preference and acceptability for four different calcium delivery vehicles

(conventional tablets, chewable tablets, unflavoured powder, and flavoured powder) among

pregnant women in urban Bangladesh. Participants (n=132) completed a 4-day run-in period in

which each vehicle was sampled once, followed by a 21-day selection period during which

participants were free to select a vehicle of their choice on each day. The probability that

participants selected the conventional tablets was greatest (62%), followed by chewable tablets

(19%), flavoured powder (12%), unflavoured powder (5%), and no delivery vehicle (2%). The

present assessment of participants’ actual supplement use and expressed perceptions of

acceptability suggested that a tablet formulation is likely to be the most appropriate calcium

delivery vehicle for future use in field studies and scale-up planning.

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ACKNOWLEDGEMENTS

I am so grateful to have had the opportunity to work with Dr. Stanley Zlotkin and Dr. Daniel

Roth. Your continual encouragement, contextual guidance, and thoughtful critiques were greatly

appreciated - hopefully I have come to think a little more like a scientist! My general Masters

experience, project development process, and thesis would not have been what they were

without your input and mentorship.

Much gratitude also goes to my committee members, Dr. Daniel Sellen, Dr. Jonathon Maguire,

Dr. Mary L'Abbé, and Dr. Pauline Darling. Your insight surrounding the conceptualization of

this project, experimental design, and interpretation of the results was helpful and I appreciated

our discussions.

To our dedicated collaborators at icddr,b and Shimantik, thank you for helping make this work

possible – my experience and time in Bangladesh were very full. I am grateful our co-

investigators: Mr. Abdullah Al-Mahmud for his assistance with project coordination, as well as

advice provided during project design by Dr. Munirul Islam and Dr. Tahmeed Ahmed and

database development by Qazi Sadeq-ur Rahman. To the Acceptability Study personnel (Taib,

Rubama, Nasima, Shikha, Saera, and Sherin), it was a pleasure working closely with you in the

field. I was so fortunate to have been paired with such a hardworking and sincere group of

people, and greatly appreciated your continual reminders that you supported my educational

aspirations.

To our participants, thank you so much for welcoming us into your homes on a weekly basis.

Without your active participation this work would not have been possible. Your willingness to

aid us in informing the present understanding surrounding calcium supplementation was very

meaningful.

To the team at SickKids, your support over the past two years has been humbly appreciated. I

must particularly recognize the Saving Lives at Birth group, including Ashley Aimone Phillips,

Brendon Pezzack, Diego Bassani, Elaine Gergolas, and Nandita Perumal. I have thoroughly

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enjoyed our Thursday meetings and am thankful to have been a member of the SLAB team.

Eddy De Oliveira, thank you for your administrative support; Sohana Shafique, thank you

sincerely for all of your research, contextual, and moral support, Bangladesh-related and

otherwise.

I would not be where I am without the continual support of my parents, Joe and Dores. Through

ups and downs, I always know that you are walking with me in my adventures no matter the

miles between us.

Many people have contributed in various aspects to this project that I have not mentioned. These

individuals span cities, countries, and continents – your friendship, support, and assistance along

the way have meant so much.

The past two years have been quite the journey. It was truly an honour to have worked on this

project, all the while learning valuable research-related and life lessons. Thank you all!

This research was funded by the Sprinkles Global Health Initiative and the Department of

Paediatrics at the Hospital for Sick Children. Personal support was provided by the Ontario

Ministry of Training, Colleges, and Universities Ontario Graduate Scholarship (OGS) and a

studentship through the Research Training Competition (Restracomp) from the Hospital for Sick

Children Foundation Student Scholarship Program.

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TABLE OF CONTENTS

ABSTRACT ........................................................................................................................ ii

ACKNOWLEDGEMENTS .................................................................................................. iii

TABLE OF CONTENTS ....................................................................................................... v

LIST OF TABLES ................................................................................................................. ix

LIST OF FIGURES .............................................................................................................. xii

LIST OF ABBREVIATIONS ............................................................................................. xiv

LIST OF DEFINITIONS ..................................................................................................... xv

LIST OF APPENDICES ..................................................................................................... xvi

CHAPTER 1 INTRODUCTION ......................................................................................... 1

CHAPTER 2 LITERATURE REVIEW ............................................................................. 3

2.1. Micronutrient requirements during pregnancy ............................................................ 3

2.1.1. Importance of micronutrients during pregnancy ................................................ 3

2.1.2. Micronutrient deficiency and populations at risk ............................................... 3

2.1.3. Global burden of micronutrient deficiencies during pregnancy ......................... 4

2.1.4. Strategies for reducing micronutrient deficiencies ............................................. 4

2.2. Targeted micronutrient supplementation strategies during pregnancy ........................ 5

2.2.1. Iron-folic acid supplementation .......................................................................... 5

2.2.2. UNIMMAP ......................................................................................................... 5

2.2.3. Calcium supplementation ................................................................................... 6

2.3. Preference and acceptability within supplementation regimens .................................. 7

2.3.1. The role of preference and acceptability ............................................................ 7

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2.3.2. Adherence within micronutrient supplementation regimens .............................. 7

2.3.3. Evaluation of supplement acceptability .............................................................. 9

2.3.4. Acceptability of supplement use among pregnant women in developing

countries ............................................................................................................ 10

2.4. Hypertensive diseases of pregnancy .......................................................................... 11

2.4.1. Classifications of hypertensive diseases of pregnancy and risk factors ........... 11

2.4.2. Health complications stemming from hypertensive diseases of pregnancy ..... 11

2.4.3. Etiology of HDP ............................................................................................... 12

2.4.4. Prevalence of hypertensive diseases of pregnancy in Bangladesh ................... 12

2.5. Calcium ...................................................................................................................... 12

2.5.1. Sources of calcium ............................................................................................ 12

2.5.2. Calcium absorption ........................................................................................... 14

2.5.3. Role and maintenance of calci