Effectiveness of behavioral interventions on knowledge, attitude, and adherence to prenatal Multiple Micro-nutrients Suplement among pregnant women in Ethiopia: a post-test only cluster randomized controlled trial

Multiple Micronutrient Supplementation (MMS) has been identified as a vital strategy to enhance maternal health; however, achieving sustained adherence remains challenging. There is insufficient evidence on the potential of contextually appropriate behavioral interventions to improve MMS-related knowledge, attitudes, and adherence beyond routine antenatal care. Thus, this trial was designed to provide empirical evidence on whether these specific strategies could improve MMS knowledge, attitudes, and adherence among pregnant women in Ethiopia. A post-test-only cluster-randomized controlled trial was conducted from June 20, to October 20, 2024 in 29 health centers across 6 woredas in 5 Regions in Ethiopia to evaluate the effects of three behavioral interventions on MMS (knowledge, attitude, and adherence). A total of 588 pregnant women were assessed at the end-line, with 151 mothers in Treatment 1, 164 in Treatment 2, 106 in Treatment 3, and 167 in the control group. For both primary and secondary outcome variables, we employed mixed-effects logistic regression with a random intercept for the cluster to account for within-cluster correlation. The models adjusted for socio-demographic characteristics and pregnancy related profiles of participants. The mean age of participants was 25.3 years (SD ± 5), with significant differences across the four study arms ( p < 0.001). Overall, participants demonstrated high knowledge and attitude toward MMS, whereas adherence remained suboptimal. Compared to the intervention group the control group had highest knowledge score AOR = 0.20 (95% CI 0.07–0.54, p = 0.002). None of the intervention groups demonstrated a statistically significant impact on attitude toward MMS uptake. The Gameboard intervention had three times effect on adherence to MMS uptake in the last three months compared with the control group (AOR = 3.32 (95% CI 1.73–6.42), p < 0.001). Overall knowledge and attitudes toward MMS were high across all four study groups, while the adherence remained lower. The behavioral interventions exhibited mixed effects on MMS related to knowledge, attitude and adherence. Overall, the findings suggest that behaviorally informed approaches may have potential to support MMS adherence when integrated with routine maternal health services. Trial registration: PACTR202605655695088. Trial protocol: The trial protocol and statistical analysis plan was developed according to WHO’s recommended format for a 'research protocol' and uploaded as supplementary files with Protocol Identifying Code of MMS-BI-ETH-2024/01.