ENhancing Intergenerational HeAlth in Nigeria: Peripartum as Critical Life StagE for CardioVascular Health (ENHANCE-CVH)

PROJECT ABSTRACT Nigeria has among the highest burdens of maternal morbidity and mortality, including an estimated 528 (95% uncertainty intervals: 351, 815) maternal deaths per 100,000 lives birth in 2019 (global average: 152 per 100,000). This rate far exceeds the UN Sustainable Development Target 3.1: <70 maternal deaths per 100,000 live births by 2030. Nigeria also has a large and rising burden of noncommunicable diseases, including overweight/obesity, hypertension, diabetes mellitus, and cardiovascular diseases. Unhealthy changes in dietary patterns and physical activity contribute to these adverse trends, especially during critical life stages, such as the peripartum period, infancy, and childhood. Improving maternal health behaviors and subsequent maternal cardiovascular health is a central strategy toward improving family cardiovascular health to blunt and eventually reverse the rising burden of noncommunicable diseases in Nigeria. Nigeria's National Multisectoral Action Plan for the Prevention and Control of Noncommunicable Diseases and National Task Shifting and Sharing Policy are new and relevant policy frameworks that will be leveraged to improve intergenerational cardiovascular health among Nigerians in this proposal. The objective of this study is to test effectiveness and implementation of an adapted HEALTH (Healthy Eating Active Living Taught at Home) intervention on intergenerational cardiovascular health among 1,000 pregnant women with obesity recruited during the antenatal period through a type 2 hybrid cluster randomized (1:1) trial implemented in 40 Nigerian primary healthcare centers. Using the Framework for Reporting Adaptations and Modifications-Expanded, the HEALTH intervention and its implementation will be adapted from the evidence-based, Parents as Teachers home visiting model from the US that has been used and validated by Washington University researchers, including in the NIH-funded ENRICH consortium. We will use a train-the-trainer model including certified trainers to step down training to community health extension workers and community nurse health educators. The primary effectiveness outcome will be change in maternal body weight from baseline to 18-month follow-up with >85% power to detect a between-group of difference of 2.5 kg. Secondary effectiveness outcomes include changes in maternal cardiovascular health. Exploratory outcomes include changes in infant and child growth. Safety data will be collected. RE-AIM will guide quantitative and qualitative implementation outcome assessment, and reach will be the primary implementation outcome with a >50% target of recruiting women with primary school education or less. Our team of US and Nigerian investigators at Washington University, University of Abuja, and New York University have collaborated for >5 years with support from 5 active NIH grants. We have strong support from key Nigerian stakeholders, including at local, state, and national levels. Thus, our proposal is highly feasible, efficient, likely to succeed, responsive to this funding opportunity, aligned with NIH and GACD priorities, and will be mutually beneficial to our team members through embedded capacity building.