This study is a three-arm, individually randomized controlled trial evaluating the impact of digitally delivered nutrition education, layered onto multiple micronutrient supplementation (MMS), on anemia and related health behaviors among adolescents in Dar es Salaam, Tanzania. A total of 1,200 adolescents aged 15-19 years with access to a phone (own or shared) will be enrolled from the Dar es Salaam Health and Demographic Surveillance System and followed for 9 months, with assessments at baseline, 4 months, and 9 months.
All participants will receive a brief in-person nutrition education session, printed brochures on adolescent nutrition and anemia, and a 2-month supply of daily MMS tablets with instructions and access to refills (Control arm). In Intervention Arm I, participants will receive the same package plus weekly one-way SMS/WhatsApp messages reinforcing key nutrition content and adherence to MMS and refills. In Intervention Arm II, participants will receive all components of Arm I plus fortnightly, in-person group digital nutrition education sessions that include interactive content and opportunities to co-create and share digital nutrition messages with peers. All participants will receive information on replenishing the tablets. Participants in Intervention Arm I and Intervention Arm II will receive additional nutrition, diet, and physical activity-related messages along with reminders and motivational encouragement to replenish their supplement stocks.
The primary outcome is anemia prevalence, assessed using hemoglobin concentration and WHO age- and sex-specific cutoffs. Secondary outcomes include moderate/severe anemia, hemoglobin levels, adherence to MMS pick-up and consumption, nutrition literacy, dietary diversity, fruit and vegetable intake, physical activity, underweight/overweight/obesity, and digital literacy. The trial also includes a mixed-methods process evaluation of feasibility, acceptability, reach, engagement with the digital components, and a cost estimation of the digital strategies.
Aged 15-19 years at enrollment.
Resident in the Dar es Salaam HDSS coverage area.
Has access to at least one phone (own or shared within the household; feature phone or smartphone).
Demonstrates basic literacy skills sufficient to understand simple written messages.
Currently pregnant.
Enrolled in the ARISE-NUTRINT trial.
Currently taking iron and folic acid or multiple micronutrient tablets for anemia outside this study.
Known to have HIV infection at the time of screening.
Parallel
Behavioral: SMS Intervention (Intervention Arm I)
BehavioralParticipants in the SMS arm receive the same core package as the control group plus a low intensity digital intervention: Core package (as in Control): One time in person information session on adolescent nutrition, anemia, and correct use of multiple micronutrient supplements (MMS). Printed nutrition education brochures. A 2 month supply of daily MMS tablets, with instructions and access to bimonthly refills. Digital component (Strategy I): Weekly one way SMS/WhatsApp messages sent to a phone number provided at enrollment (adolescent's own or a household/shared phone). Messages reinforce key nutrition and anemia information, remind adolescents to take MMS daily, and prompt them to obtain MMS refills on time. Content is age appropriate and gender sensitive but maintains consistent core messages for all participants. No fortnightly in person digital group sessions are provided in this arm.
Behavioral: In Person Digital Arm (Intervention Arm II)
BehavioralParticipants in the in person digital arm receive the full intervention package: Core package (as in Control): - One time in person information session on adolescent nutrition, anemia, and correct use of MMS. - Printed nutrition education brochures. - A 2 month supply of daily MMS tablets, with instructions and access to bimonthly refills. Digital Strategy I (as in SMS Arm): - Weekly one way SMS messages reinforcing nutrition and anemia messages and reminding adolescents to take MMS and obtain refills. Digital Strategy II (additional in person digital component): - Fortnightly, 1 hour in person digital group nutrition education sessions held in school computer labs or similar settings, facilitated by trained teacher assistants or peer support workers. - Sessions use audio visual and interactive digital content (e.g., animations, quizzes, games) to teach nutrition and anemia related topics. - Adolescents co-create and disseminate digital nutrition content
Anemia prevalence
Anemia prevalence at 9 months post-baseline, defined using WHO age- and sex-specific hemoglobin cutoffs: * Boys aged ≥15 years: hemoglobin \<13.0 g/dL. * Girls aged ≥15 years: hemoglobin \<12.0 g/dL. * Hemoglobin will be measured at baseline, 4 months, and 9 months using finger-prick capillary blood samples and point-of-care devices (e.g., HemoCue hemoglobinometer or equivalent).
Moderate and severe anemia
Moderate and severe anemia at 9 months: Boys aged ≥15 years: Moderate anemia: 8.0-10.9 g/dL. Severe anemia: \<8.0 g/dL. Girls aged ≥15 years: Moderate anemia: 7.0-10.9 g/dL. Severe anemia: \<7.0 g/dL.
Hemoglobin concentration (continuous, g/dL)
Hemoglobin concentration (continuous, g/dL) at baseline and 4 and 9 months after baseline.
Adherence to MMS
* Self-reported daily consumption of MMS. * On-time pick-up of MMS refills from designated facilities. * Where feasible, facility or provider logs will be used to verify refill adherence.
Nutrition literacy
The Adolescent Nutrition Literacy Scale is a 22 item, Likert type (1-5) instrument with good internal consistency (Cronbach's α=0.80), yielding total scores from 22 to 110 where higher scores indicate greater nutrition literacy across three dimensions: functional nutritional literacy (7 items), interactive nutritional literacy (6 items), and critical nutritional literacy (9 items).
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Harvard School of Public Health (HSPH)
Lead sponsor
Africa Academy for Public Health
Collaborator
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