FACTORS AFFECTING PARTICIPATION BEHAVIORS OF PREGNANT WOMEN WHO JOINTLY RECEIVED TWO DIFFERENT NUTRITION SUPPLEMENTS IN BANGLADESH A Dissertation Presented to the Faculty of the Graduate School of Cornell University In Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy by JISUNG WOO January 2017 © 2017 JISUNG WOO ii ABSTRACT FACTORS AFFECTING PARTICIPATION BEHAVIORS OF PREGNANT WOMEN WHO JOINTLY RECEIVED TWO DIFFERENT NUTRITION SUPPLEMENTS IN BANGLADESH Jisung Woo, Ph. D. Cornell University 2017 Low participation in nutrition supplementation can cause the true effects of the supplements to be underestimated. Participation behaviors and their associations with personal and socio-cultural characteristics were examined qualitatively and quantitatively when food and micronutrient supplements were provided jointly to pregnant women in rural Bangladesh to find ways to improve effectiveness of nutrition supplementation by enhancing participation. In-depth interviews (IDI) were conducted with 24 multiparous women in Matlab, Bangladesh to elicit information on pregnancy-related cultural issues and their experiences with supplement use. Quantitative analysis was conducted by using data from Maternal and Infant Nutrition Interventions at Matlab (MINIMat), a randomized controlled trial (factorial design of 2 food and 3 micronutrient groups) that collected extensive information on participants’ (n=4,436 pregnant women) characteristics and program features. Supplement consumption was monitored monthly. Levels of participation were examined in terms of initiation and utilization of food, micronutrient, or combined supplements. Relationships between participation behaviors and potential factors were examined through multiple regressions. Text analysis of the IDI revealed that culture-specific beliefs, attitudes, perceptions, and practices set boundaries to pregnant women’s behaviors, including supplement consumption. Based on these results, a psychosocial model was developed to guide the quantitative analysis. Results from the quantitative analysis corroborated the findings from the qualitative analysis. Support from husbands or mothers-in-law, advice from program providers, positive attitudes toward supplementation, and participants’ autonomy were positively associated with supplement consumption, while cultural obligations, a possible cesarean delivery caused by a large-sized baby, poor appetite, and no perceived benefits were negatively associated with the consumption. Generally, participants consumed micronutrient more than food supplementation. Women who started to consume food before micronutrient supplements showed better participation than women with the reverse sequence. Sharing of food packages with others and replacing home meals with the supplements were prevalent. Only 10 % of participants consumed both types of nutrition supplements persistently. These results show that food supplementation needs more attention for persistent participation when provided with micronutrient supplementation. To enhance pregnant women’s participation, it is essential to understand socio-cultural environments of participants along with their perspectives about supplementation and design a program that addresses these issues BIOGRAPHICAL SKETCH Jisung Woo studied ‘Food and Nutrition’ at Seoul National University in South Korea for her BS and became very interested in the field of nutrition, which made it possible for her to obtain academic performance-based scholarship for the entire four years of her undergraduate study. After she graduated with honors ( summa cum laude ), her interest in nutrition, which originally started from her childhood by the influence of her mother who worked for the Korean government as a nutritionist, made her pursue MS in Nutrition with a focus in clinical nutrition at her alma mater. The title of her thesis was “Effects of different dietary fats and carcinogen treatment on the hepatic microsomal drug metabolizing enzymes in hepatocellular carcinogenesis”. During her 2 years of graduate education, she gained considerable understanding about biochemistry and various techniques for animal studies, including hepatectomy of rats to induce carcinogenesis. She also had opportunities to teach lab courses, such as ‘Nutrition lab’ and ‘Organic chemistry lab’. In addition, she participated in a few projects in community nutrition as an assistant researcher and conducted nutrition assessments and surveys. Based on all this background, she decided to study in the US to quality herself with more advanced academic and research experiences and studied ‘General Epidemiology’ at the School of Public Health, University of Michigan. Through the intensive training in epidemiology and biostatistics, she was able to gain knowledge and skills to apply nutritional knowledge and her experiences effectively in the real world. In addition, she was fascinated by the global perspectives of nutrition, which led her to volunteer work in Mongolia. iii As soon as she obtained MPH from University of Michigan, She started her work in Mongolia as the chief researcher of a newly established research center within the Mongolian University of Science and Technology (MUST). During the two and a half years of work in Mongolia, she taught basic and advanced nutrition and statistics to graduate students and professors, trained researchers for conducting nutrition surveys, and organized numerous seminars on various issues in nutrition, such as child nutrition, diet therapy, hazard analysis critical control point (HACCP) for food service, and so on. Moreover, she helped to establish nutrition department within the School of Food and Biotechnology, MUST and by the time she left Mongolia, the university recruited the first students for this major for the first time in Mongolia. Her experience in Mongolia opened her eyes to the world, especially to those who need nutrition interventions to have their basic rights to live health as human beings. Therefore after she returned to Korea, she engaged in a Christian missionary organization that was sending nutritionists to low income countries and supporting them in their professional work in nutrition. As the chief researcher of the research team of this organization, she played a leading role in organizing seminars and education courses and publishing books and manuals. Through all these experiences, she discovered her vocation for the rest of her life in improving the nutrition status of those who are suffering from malnutrition in low-income countries, which made her to apply for Ph.D. program in International nutrition at Cornell University. The excellent educational experiences at Cornell University provided her with qualifications to be a professional in the field. Particularly, she selected Anthropology as her minor and conducted a qualitative study as a part of her dissertation, which expanded her research competence to social sciences. Teaching assistant experiences for numerous classes and iv two oral presentations at Experimental Biology conference in 2011 and 2012 add more qualifications to her, all of which allowed her to have great opportunities to put her visions into practice. In fact, as a Ph.D. candidate, she started to work as a team manager of a Korean NGO, Wholistic Interest Through Health (WITH) and was involved with designing, implementing, monitoring, or evaluating a few nutrition projects. Currently she is preparing a 3-year community-based maternal and child nutrition project in Cambodia as the principal program manager. v ACKNOWLEDGEMENTS I will walk among you; I will be your God, and you will be my people (Lev 26:12, NLT) Praise the Lord, God, who has guided me as my Father from the moment I had decided to pursue a doctorate until now and used all these times to make me suitable for being his people! I would like to express my deepest appreciation to many individuals for their assistance, guidance, support and patience that enabled me to make through with my life dream. First of all, I thank my advisor, Dr. Kathleen M. Rasmussen for her unbelievable mentorship not only for academic achievement but also for life-challenging issues that I have faced. Her instantaneous feedback on my questions, concerns, and works, particularly her great insights for my research and advice on academic English writing, will not be forgotten. Without her persistent encouragement and passion that lasted for almost 10 years, I would not have been able to finish this dissertation. I am sure that she will be a role-model for my career life in the future. I also thank my other committee members. Dr. Gretel Pelto helped me to open my eyes to a new research world and guided me to learn anthropological approach for my work. I am really fascinated by her inspiration and passion for nutritional anthropology and would like to follow her in my work in the future. Her encouragement also made me to continue to pursue this degree. I will really miss her warm and insightful comments and the times we spent together for great discussions. Dr. Rebecca Stoltzfus is another member I would like to follow, particularly her critical insights for research and programs in the field of international nutrition. Dr. Edward Frongillo Jr. led me to think about program participation not only from statistical but also from behavioral science point of view. Thanks to his generous guidance, I was able to analyze the vi gigantic datasets from MINIMat. Dr. Kimberly O’Brien was the perfect field member for me. I will not