Implementation fidelity of a pilot group-based nutrition intervention for pregnant women (Nutri Pou Ti Moun 2): a mixed method assessment

Implementation fidelity of a pilot group-based nutrition intervention for pregnant women (Nutri Pou Ti Moun 2): a mixed method assessment | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Implementation fidelity of a pilot group-based nutrition intervention for pregnant women (Nutri Pou Ti Moun 2): a mixed method assessment Muriel Suzanne Galindo, Claire Gatti, Ophélie Dupart, Amandine Debruyker, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9023020/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background In the context of an overseas territory of a high-income country characterized by high fertility rates, cultural diversity, and food insecurity, a small-scale collective intervention with a focus on nutrition was implemented among pregnant women. Inspired by centering-based group care, without the health care component and with a food aid component, the interactive group sessions were co-facilitated by an expert on the session's topic and a peer-facilitator. This paper describes the intervention, its underlying theory and presents the fidelity of the intervention following the Conceptual Framework for Implementation Fidelity developed by Carroll et al. (2007) and its modified versions. Method Quantitative data among the study participants were collected internally through questionnaires (pre- and post-intervention), intervention worksheets and medical records. Two ancillary studies provided qualitative information about the intervention participants' experience. Data among deliverers and “people who have influence over the outcome of implementation efforts” were collected quantitatively through self-questionnaires and qualitatively through semi-structured interviews. Descriptive, bivariate, and multivariate analyses were performed using Stata 19.5 software to determine the sociodemographic characteristics of participants and the determinants of assiduity. Results Overall, implementation was aligned with the original plan, with only a few minor adaptations. Despite contextual barriers and competing survival priorities, 77% of the 122 participants attended at least half of the sessions, indicating a satisfactory participation rate. The profile of participants showed that marginal exclusion of the most socioeconomically disadvantaged women appears to have been limited, and bivariate analysis revealed that women who reported suffering from social isolation actually showed greater commitment. Conversely, educational attainment was associated with higher assiduity in nutrition-focused sessions, and living in a single-adult household was negatively associated with overall assiduity, even after adjustment. Although the intervention demonstrated high appropriateness and was well-received from participants and all stakeholders, opportunities for improvement were identified regarding intervention clarity, organizational processes, and the scope of the mediation role. Conclusion These findings inform the subsequent impact evaluation and its mechanisms of action. They also shed light on the potential transferability of a group-based intervention that addresses determinants of food insecurity during the first 1,000 days. Trial registration clinicaltrials.gov number: NCT06528535. Release date: 07/23/2024. Figures Figure 1 Figure 2 Figure 3 Contributions to the Literature Demonstrates the utility of assessing fidelity in the context of a pilot intervention combining mixed data from both internal and external evaluations. Outlines how the group care model can be modified to align with specific contextual characteristics, including food insecurity, many undocumented pregnant women, and the pertinence of implementing actions outside standard prenatal care structures. Introduces a new concept for assessing participant responsiveness that extends beyond traditional attendance metrics by examining relative assiduity , enabling measurement of actual engagement relative to potential participation. Shows how examining the determinants of relative assiduity can advance understanding of engagement disparities in health interventions. Background The antenatal period is critical for the future infant, as conceptualized by the framework for the Developmental Origins of Health and Disease Hypothesis, DOHaD ( 1 ). Despite all the mechanisms designed to redirect maternal reserves to the baby, pregnant women's nutrition is considered to be a determining factor in fetal development and future health ( 2 ). Malnutrition during pregnancy has also been shown to be detrimental to maternal health. Obesity of the mother is linked with pregnancy and obstetric complications, such as gestational diabetes, post-partum hemorrhage, premature birth or stillbirth ( 2 , 3 ). Iron deficiency has been associated with placental hypertrophy ( 4 ), and in varying levels of severity, with prematurity, low birth weight, intrauterine growth restriction, and increased maternal illness ( 5 , 6 ). Other micronutrient deficiencies such as calcium, iodine, vitamin D, folate, vitamin A or zinc are linked with poor health outcomes of the mother and/or the child ( 7 – 9 ). Although the causes of malnutrition are not solely lifestyle-related ( 10 – 12 ), diet and exercise habits are believed to have an impact on health outcomes during pregnancy ( 13 – 17 ). Food security, as defined by the Food and Agriculture Organization of the United Nations (FAO), implies the availability, access and utilization of safe and nutritious food in sufficient quantities and with stability over time ( 18 ). A greater risk of being obese during pregnancy has been associated with food insecurity ( 2 ). Poor dietary pattern - characterized by insufficient intake of fruits and vegetables, whole grains and fish - has been documented among individuals at risk of food insecurity due to low income ( 19 ). The role of mental health as a determinant and/or consequence of food insecurity and malnutrition should not be underestimated ( 20 , 21 ). A dose-response relationship has been observed between food insecurity and mental distress in Brazil ( 22 ) and detrimental interaction between stress and maternal nutrition has been suggested although further research is needed ( 23 , 24 ). In May 2024, the French Audit Office (Cour des Comptes) pointed out the poor perinatal indicators in France compared to its European neighbors, with some territories more affected than others, particularly the overseas regions, such as French Guiana ( 25 ). This territory of 286,618 inhabitants in 2021, located between Surinam and Brazil in South America, had an unemployment rate for people aged 15 to 64 years - of 31,0% - three times higher than in mainland France, and in 2017, 52,9% of the population lived below the poverty line ( 26 , 27 ). The fertility rate of this region was particularly high with 27.5 births per 1,000 inhabitants compared to a national mean of 10.9 births per 1,000 inhabitants ( 28 ). The rate of prematurity - gestational age < 37 weeks' amenorrhea - was double that of mainland France (16.0% vs. 7.0% ) and infant mortality was 2.6 times higher ( 29 , 30 ). Anemia – hemoglobin < 11g/dl – affected twice as many pregnant women (66.4% vs. 25.2%), and the prevalence of hypertension with or without proteinuria was threefold that of mainland France (14.1% vs. 4.3%) ( 30 ). A cross-sectional study among women giving birth in the three main maternity wards – called Nutri Pou Ti’ Moun 1 ( NPTM 1) – was carried out in 2023 with the main objective of assessing the food insecurity prevalence and its determinants. It revealed that 32.4% [95%CI: 28.9–36.0] of women lived in a food insecure household among which 16.4% [95% IC: 13.9–19.4] in a severe food insecure household ( 31 ). Only 45.6% [95%CI: 42.0- 49.2] reached the Minimum Dietary Diversity for Women score and only 11.1% of women consumed the five recommended daily food groups. A quarter (25.4%) of women were overweight and 29.6% of women were obese before pregnancy. Finally, over a third (40%) of women had at least two micronutrient deficiencies. In order to tackle these issues, an intervention called Nutri Pou Ti’ Moun 2 (NPTM 2) was implemented at a small-scale level, targeting vulnerable pregnant women, with the main evaluation outcome being the dietary diversity. Unlike other nutrition interventions, it did not target a specific health issue such as diabetes or obesity and it was not based on individual dietary counseling. With regular group sessions of interactive activities on cross-cutting themes, it was inspired by centering-based group care (CBGC). Without the health care component, its specificity is to complement rather than replace antenatal care. It is also characterized by its focus on diet and nutrition, and its food aid component. Comprehensive knowledge about an intervention is essential in order to determine mechanisms through which group-based behavior-change interventions (GB-BCIs) have impact at individual level ( 32 ). In addition to the understanding of the initial concept and content, and the theory underpinning them, knowing how faithful the intervention is to what was intended, helps to determine whether the results of the intervention - positive, neutral or negative - are the result of design or implementation ( 33 , 34 ). Hence, the fidelity, its moderating factors, the adaptations and the reasons of these adaptations of this pilot intervention will be presented in this article, following the Conceptual Framework for Implementation fidelity developed by Caroll et al. with inputs inspired by its two modified versions by Pérez et. al (2016) and by Hasson, 2010 ( 35 ). Along with a forthcoming article presenting more process and effectiveness outcomes, this work will contribute to assess transferability of the intervention in other settings. Methods Theory and logic modelling Baker and Swift (2009) consider that to be effective, a behavior change intervention should be based on psychosocial theories of behavior change. The choice of behavior change method then depends on the identified predictive determinant it targets and its applicability in the context ( 36 ). Cambon, Moore et.al also recommend to have a thorough knowledge and understanding of the system in which changes are expected to occur but not to consider determinants as independent of one another, and believe that most effective and ethical approaches are not always directly related to the identified proximal determinants. They also suggest to base theory on multiple approaches rather than citing simplistic, off-the-shelf popular theoretical models ( 37 – 39 ). The aim of the NPTM1 study was to explore the determinants of food insecurity. It revealed that being a single mother, lacking social support, and having low self-esteem were determinants of food insecurity. Others studies have shown that lack of social support predicts unhealthy behaviors during pregnancy through its impact on self-efficacy and planning ( 40 ). Social support has also been found to mediate self-esteem during pregnancy ( 41 ). The evaluation of CBGC model revealed encouraging psychological and social outcomes ( 42 ). Two of the three components of the CBGC model i.e. a) collective interactive learning and b) community building were selected to be transferred in our setting. Intervention description The intervention is described through the comparison of the intervention with GC-1000 in Table 1 and the logic and theoretical model (Fig. 1 ). See Additional file 1 for more details about where, by whom, to whom, what, and how. Table 1 Program differentiation of the Nutri Pou TiMoun (NPTM) intervention, compared to the GC-1000 model (as initially planned) Same in both NPTM and GC-1000 Specific to the GC-1000 Specific to the NPTM Group size of 8–12 women of similar gestational age Duration of session: 90–120 minutes Number of sessions greater than 8 The number of sessions is flexible, usually 10 sessions maximum The number of sessions is always 12 Participants sit in a circle Without a table Most of the time with a table Dynamic, fun and engaging way of information sharing, that values knowledge and experience of group members. No formal didactic presentations. Activities are culturally adapted. Each session has a plan but emphasis may vary Possibility of sequential progression of sessions according to pregnancy phase or baby's age, but flexibility according to participants' needs Sequential progression of the 12 sessions and in particular of the 6 diet and nutrition sessions (see Additional file 1). Several topics are similar or identical such as nutrition, breastfeeding, self-esteem, alcohol abuse and physical activity Topics are usually in line with the country guidelines of antenatal and postnatal care Emphasis on diet and nutrition: 1 session out of 2 (6 in total) and one session on budget management. Regular interval between sessions Once a week (expect bank holiday), same day of the week. A facilitator and a co-facilitator The facilitator is a healthcare provider. The co-facilitator can be another healthcare provider or assistant or another person such as a community health worker. Facilitators are not necessarily health professionals, but experts in the subject they are facilitating, contracted for the intervention. The co-facilitator is a peer-facilitator recruited specifically for the intervention. The healthcare providers only have a role of information about the program and identification of potential participants. Both facilitators and co-facilitators are trained in facilitation and listening skills. Co-facilitators have facilitation training with an emphasis on valuing women's experiential knowledge and horizontal transmission. Facilitators are not trained but must have experience and/or previous training of group facilitation. The first group session most commonly happens between 12 to 16 weeks gestation Recruitment criteria: maximum of 22 weeks gestation and ability to speak the language of either the facilitator or the co-facilitator, i.e. French and/or Haitian Creole. Fidelity framework Figure 2 presents the elements of the framework which guided the analysis and presentation of results, based on the Conceptual Framework for Implementation Fidelity and its modified versions ( 33 – 35 ). The indicators, as stated by their originators, are not necessarily independent measures and moderators in particular, may interact or overlap with one another ( 33 ). Study design The evaluation was conducted partly internally by the intervention designers and partly externally by an independent evaluator. Internal evaluation Participants Eligible Women were identified by healthcare providers and then included in the research study by co-facilitators once they were informed and gave their consent. Study participants are not necessarily recipients of the intervention as data among non-participants were also collected. Data collection The quantitative data collected internally are displayed in Table 2 and the details of the questions and variables are presented in Additional file 2. Moreover, certain aspects of the experience of participation were discussed with a sample of the intervention participants as part of two ethnographic studies, using semi-structured interviews. The first study focused on breastfeeding (reference of verbatim: “Participant-B-XX”), while the second concentrated on food practices during pregnancy (reference of verbatim: “Participant-F-XX”). Observation of more than a third of the sessions ( 52 ) was also a source of information. External evaluation Participants Every deliverers and stakeholders or “people who have influence and/or power over the outcome of implementation efforts” as defined in the updated Consolidated Framework for Implementation Research ( 43 ) were solicited. Data collection The data was collected using anonymous self-administered questionnaires (quantitative data) and semi-structured interviews (qualitative data). The self-questionnaire for non-caregiving partners asked about the terms of the partnership, the design of the program, the implementation of the intervention, and satisfaction. The self-questionnaire provided to healthcare providers covered: participation in identification, program design, perceived impact, and satisfaction. The items discussed during the interviews were: appropriateness, feasibility (necessary resources, training) and durability. The interviews were carried out in person, or by phone when not feasible (reference of verbatim: “Role-XX”). They were recorded with the consent of the interviewees and transcribed using Whisper, OpenAI's artificial intelligence speech recognition program. Table 2 -Details on quantitative data collected internally Method of data collection First Questionnaire Second Questionnaire Third Questionnaire Medical record Worksheet & Attendance list Facilitator assessment Interview Interview Interview Data entry from paper medical records Form filling and interview Self-questionnaire Data collectors Co-facilitators and surveyors speaking the language of the population Co-facilitators and surveyors speaking the language of the population Surveyors speaking the language of the population Healthcare providers Data entry by a clinical research associate Co-facilitators Co-facilitators and facilitators Population Study participants Study participants Study participants Study participants All women identified Co-facilitators and facilitators Timing Before the start of the group sessions Between the 10th group session and birth delivery. Minimum term of pregnancy: 29 weeks. Between 2 days and 15 days after birth delivery After birth delivery Worksheet : at inclusion Attendance list : at each group session At each group session Variables - Perceived social support - Feeling socially isolated - State of mind at pregnancy announcement - Reason for participating - Opinion on the project - Socio-economic data (place of birth, education level, occupation, administrative data, source of income, household composition, access to farm land, housing and residence change) - Reason for non-participation - Age* - Term in weeks of pregnancy for the first group session* - Height and weight before pregnancy - Number of pregnancies - Reason for non-inclusion - Reason for non-participation - Declared participation constraints - Attendance data - Group municipality Characteristics of the group session (length, perceived group dynamism, satisfaction indicators, fidelity and adaptations details, tasks of the co-facilitators, difficulties encountered) *These two variables were also collected by healthcare providers for women who did not participate in either the intervention or the research study. Statistical analysis The STATA software 19.5 (STATA Corporation, College Station, TX, USA—version 19.0) was used for descriptive analysis (characteristics of participants) and bivariate and multivariate analysis (determination of co-variates independently associated with the highest tercile of relative assiduity). Variables included in the multivariate logistic regression were selected according to the existence of an association in the bivariate analysis (up to a p-value of 0.2) and the absence of multicollinearity. Results Regarding the internal evaluation, the questionnaires, worksheets and attendance lists were completed between September 12th 2023 and December 18th 2024. Fifteen participants were interviewed in the two ethnographic studies between February 2024 and May 2025. The questionnaires of the external evaluation were completed by the partners between July 3rd and August 28th. Eleven partners, responded, as did ten of the fifteen healthcare professionals involved in identifying pregnant women. Between July 22nd and September 5th, sixteen semi-structured interviews were conducted. The entire staff team (i.e., three co-facilitators and four coordinators), was interviewed. The nine partners interviewed were three facilitators, five other partners (logistics, funders, experts), and one independent midwife. Adherence and adaptations Content The content adherence is summarized in Table 3 . Table 3 Adherence of intervention components, content adaptations and moderating factors The intervention component Extent of adherence Moderating factor of adherence Adaptation(s) Type of adaptation Expected effect of adaptation Sequencing of sessions High Positive factor : Overall coordination for all sites, project planning to ensure the availability of the facilitators Negative factor : vulnerability to unforeseen circumstances same facilitators on different sites Slights modifications on the order of the topics were performed for 4 groups due to practical reasons - availability of facilitators and of facilities - but no more than two ranks difference in order. Reactive & unsystematic None Topic sessions High Positive factor : Remuneration of external contractors to be facilitator Open-topic session replaced by a session on the end of pregnancy and the different stages of the maternity ward stay. Proactive & systematic Enhanced appropriateness, acceptability and uptake Sites High Negative factor : obligation to comply with the site managers' organization Positive factor : good partnerships with site managers Only one group experienced a change of site where interactive learning sessions took place Reactive & unsystematic More adapted facility Facilitator profile High (4 out 5) Positive factor : facilitators are external contractors good communication between implementers and facilitators Confusion about the goals & approach led to contract termination with one facilitator, after which a new activity was developed collaboratively with co-facilitators. Reactive & systematic Enhanced acceptability and appropriateness Co-facilitator profile High One facilitator without maternity experience nor Haitian origin but could speak Haitian creole and other language and had mediation experience. Reactive & systematic None Training of co-facilitators High Positive factor : recruitment several months in advance None Details of content High Replacement or addition of messages and activities Proactive & systematic Increased acceptability and efficiency Dose Recruitment, coverage and representativity As part of this pilot phase, the objective was not good coverage of the target population but to form one group in each of the 4 municipalities during 3 different periods. As planned, twelve groups were created. The identification of pregnant women was opened up to independent midwives for the last period in order to achieve a higher headcount per group. For these last groups, a social recruitment criterion was added, namely receiving state medical assistance or being covered by universal health insurance for people without salaried employment or not covered by other specific schemes. Among the difficulties encountered in identifying women, the main reason cited by maternal and child health care center professionals and liberal midwives was “ forgetting to ask the patient ”. The second most cited difficulty for independent midwives was “ lack of time ”. A total of 198 women were identified and their contact details forwarded to the co-facilitators so that they could be invited to take part in the research project and the group sessions. Of the 40 women not included, the reason was documented for 33, as shown in the Fig. 3 , among whom, 27% were not reached at all. Among the 155 women included, 122 participated in at least one group session, the characteristics of which are presented in Table 4 . The majority of women was born in Haiti, foreigners without residence permit, homemakers without allowance, and lived in a household with no source of declared income at the end of pregnancy. Table 4 The characteristics of the pregnant women who participated in at least one group session (n = 122) Variables Categories n (%) Woman Age =35 year. 35 (28.7) NK 0 (0.0) Administrative status French Citizen 9 (7.4) Foreign national with residence permit 48 (39.3) Foreign national without residence permit 57 (46.7) NK 8 (6.6) Health coverage Non or AME 75 ( 61 , 5 ) PUMA 35 ( 28 , 7 ) NK 12 ( 9 , 8 ) Birth country Haiti 86 (70.5) Other 36 (29.5) NK 0 (0.0) Education level Before high school 43 (35.3) Over high school 71 (58.2) NK 8 (6.6) Professional situation at the beginning of pregnancy Declared work 8 (6.6) Undeclared job 18 (14.7) Non-paid training 6 (4.9) Paid training 2 (1.6) Workless with allowance 4 (3.3) Homemaker without allowance 75 (61.5) NK 9 (7.4) Lives with child's father (at the end of pregnancy) Yes 71 (58.2) No 41 (33.6) NK 10 (8.2) Term in weeks of pregnancy for the 1st group session 4–24 104 (85.3) 24–29 18 (14.7) NK 0 (0.0) BMI before pregnancy Underweight ( 40 kg/m²) 3 (2.5) NK 20 (16.4) Nulliparous Yes 26 (21.3) No 93 (76.2) NK 3 (2.5) Household At least 1 member with a declared source of income at the end of pregnancy Yes 21 (17.2) No 90 (73.8) NK 11 (9.0) Running water at home Without 47 (38.5) With 64 (52.5) NK 11 (9.0) Number of children in the household 0 21 (17.2) 1 28 (23.0) 2–3 45 (36.9) 4–11 17 (13.9) NK 11 (9.0) At least one child under 3 years of age Yes 23 (18.9) No 88 (72.1) NK 11 (9.0) Household with no other adult (single-parent) Yes 16 (13.1) No 95 (77.9) NK 11 (9.0) Identified or declared reasons for non-participation are also displayed in flow chart. Table 4 should be here. Exposure Ten of the twelve groups created were offered all twelve planned group sessions. One group in the first period was offered 11 group and one group was offered 10 group sessions. Among the 122 participants, 110 were in capacity to attend at least 10 group sessions (Fig. 3 ). While 61% of nutrition group sessions had between 8 and 13 participants, only 24% of other thematic group sessions reached the minimum number of 8 participants. The duration of the group sessions was 1,5 to 2 hours as expected. At least one woman was late for 65% of the sessions. The median number of food baskets received by participants was 5. Participant responsiveness Recipients responsiveness Attendance The median number of sessions attended was 8; 77% of participants attended at least half of the sessions, and 31% attended 10 to 12 sessions. Considering only the sessions devoted to nutrition, 88% of participants attended at least half of them. Among participants, only 3,3% (n = 4) came to a single session, for reasons other than early pregnancy termination or medical contra-indication to move. Motives for attending sessions Learning new things or specifically learning things about food or cooking emerged as the main declared motive for participation (63.7%, n = 65). More than a third of participants (36.3%, n = 37) said that they participated because their midwife asked them to. Meeting other women and/or feeling less lonely were quoted by 22.5% (n = 23). Whilst the provision of fresh food was cited by only 2.9% of participants as a reason for participating, the attendance rate was higher for nutrition sessions with fresh food baskets (78%) than for sessions without (51%). Some participants confessed during interviews that it was more than a little compensation for coming. Participant-F-05: “ They gave me fruits and vegetables, and it even became a source of income for me”. The reassuring routine associated with the facilitator's consistency during these nutrition sessions could also be a factor in this difference. Participant-F-004: “ It was really good, they taught me a lot, (even though I forgot some things), especially how to eat a balanced diet. I liked their little programs; sitting there made me feel comfortable” . Co-facilitator-01: “There really are some for whom the (food) baskets are very important, but there are others for whom it's about getting out, comfort, feeling comfortable in a different environment, conviviality, soulfulness, happiness—that's what interests them.” Barriers to attendance Although the reason for absence could not be systematically collated, the two main reasons given at least once for an absence were 1) medical appointment by 43 participants, and 2) fatigue or other medical reasons by 42 participants. The qualitative assessment revealed another obstacle, namely the fear of being arrested by local authorities in the event of an irregular administrative situation. Factors of assiduity Assiduity was calculated as the proportion of sessions attended in relation to those in which the participant was able to take part, considering the group (between 10 to 12 sessions), the date of recruitment (in case it was after the start of the sessions) and the date of pregnancy termination (in case it was before the last session). The factors of assiduity were compared between the highest tercile and the two lowest terciles, for nutrition sessions (including the handing of a fresh food basket) on one side, and for non-nutrition sessions (without food basket) - such as physical activity, breastfeeding or budget management - on the other side. Multivariate analysis showed that being born in Haiti, living in a household with at least three children, and having a higher education level were all positively and significantly linked to high assiduity for nutrition sessions. Conversely, living in a household with no other adults and currently enrolled in a course or training were both associated with lower levels of assiduity. For non-nutrition sessions, the only variable associated with high assiduity was mentioning " to take care of myself and the baby " as a reason for participating. It is noteworthy that feeling isolated was positively linked with high assiduity for both nutrition and non-nutrition sessions in bivariate analysis, although significance disappeared after adjustment (See Additional file 3 for the details). Satisfaction of intervention recipients To the question “What do you think of this program?”, no negative comments were registered and 83 out of 87 were positive to highly positive. Again, learning new things was the most valuable aspect cited (18 out of 87 respondents), and was also discussed during interviews. Information transmission appeared to be valued, both vertically (from facilitators) and horizontally (from peers). Participant-B-13: “ That's it, that's it, I like the group sessions too, the discussion groups, talking, exchanging, you give and you take too, that's it .” The vocabulary of well-being and stress relief was frequently used in the questionnaires when opinions were asked for (“brings joy to the heart”, “pleasure”, “pleasant”, “nice”, “happiness”, “living better in pregnancy”, “feel good”, “stress decrease”) and was often associated with breaking isolation or social bonding during interviews. Participant-F-18: “ The sessions helped me a lot. There were things I didn't know that I ended up learning. [...] We became like a family. We were happy and fulfilled... it was really great .” Participant-F-03: “ When we went to the sessions, it was as if we left all our problems behind, as if we had no worries. We also made new friends thanks to the workshop. ” Healthcare providers who were able to follow up with patients who participated in the program responded that the feedback from these patients was generally “somewhat positive” or “positive.” Deliverers responsiveness and its influence on the quality of delivery Quality of program delivery has been defined differently in the literature. It can be measured quantitatively through observation or self-report ( 44 ). In the case of this pilot intervention, normative evaluation was not appropriate, as no criteria or standards exist for assessing how the content has been delivered. However, observation of more than a third of the sessions by 4 observers and self-reporting by, and debriefings with, facilitators and co-facilitators provide qualitative information on the way the sessions were conducted, which can moderate fidelity. To the question “how was the group dynamic”, facilitators and co-facilitators responses were very similar with respectively 78% and 76% of sessions appraised as “good”. Facilitators' satisfaction with the facilitator-co-facilitator pairing—rated as “very good” for 78% of sessions—was also associated with their positive feelings about group dynamics ( p < 0.001). To the question “did you feel you had found your place during the session in relation to the facilitator?” the co-facilitators answered “yes, a lot” for 61% of the sessions, but there was no link with their perceived group dynamics. For 47% of sessions, facilitators replied that co-facilitators did help to make participants feel secure and mentioned it during interviews. Facilitator-02: " What I also found super important in these groups was the presence of the co-facilitators. [...] The way they were present in the group had an impact on the whole group. [...] And in the groups where they were really there and present, we were able to talk about things very freely ." For one municipality, two co-facilitators were equally in charge of the group. The consequence of this dilution of responsibility was less involvement of each co-facilitator during the sessions according to observers and one facilitator. In the meantime, although this was not quantifiable and might have been anecdotic, some deliverers, including healthcare professionals, mentioned the transmission or fear of transmission of misleading or false information. Midwife-01: “ Beware also of co-facilitators who are not health professionals and who use their personal experience as an example. Recommendations and advice are sometimes erroneous .” In addition to that, all respondents, including the co-facilitators themselves, acknowledged that they had been assigned too many tasks, including logistics. The commitment of these co-facilitators to help some of the participants in difficulty went sometimes beyond what was asked of them. Facilitator-01: " They went a bit overboard and weren't recognized. [...] The project team kept saying, ‘Yes, but you don't have to do that.’... Except that when you're in contact with people, you clearly can't. Even I found myself taking a lady home once. Because it's difficult. It's difficult sometimes, even if you set limits ." However, the right boundaries of this engagement were different according to the various people interviewed, which shows how complex it was for these co-facilitators to find the right balance. A lack of preparation to deal with difficult situations was reported, despite attempts to put in place an effective system for referring people to the appropriate facilities. Co-facilitator-02: “ I see myself supporting a woman who has lost her baby. I haven't been trained for that .” Finally, despite the difficulties mentioned, the co-facilitators had a positive attitude toward the project and were convinced of its usefulness in improving the participants' nutrition, social life, and health. Co-facilitator-02: “They eat better with very little money. So, what more could you ask for?” Co-facilitator-03: “ It also helped them break out of their isolation. They learned a lot. They really did. No, they’re happy about it.” Facilitation strategies to improve deliverers responsiveness In order to improve working conditions for co-facilitators, two strategies were implemented. The first consisted of providing mentoring by the association responsible for health education training, and the second of offering the opportunity to meet individually or in groups with a psychologist to help them better manage the stress induced by their role. However, neither of these strategies improved the situation, probably because they came too late and did not resolve the issue of workload. Responsiveness of people who “have influence and/or power over the outcome of implementation efforts” Both health professionals and external partners believed that the issues addressed by the project were priorities, based on their observations in their practice and because they had been identified as public health policy priorities, i.e. perinatal health, food security and care access for the most vulnerable. Partner-02: " There have also been favorable winds at national level, with women's roadmaps, (…), and a national roadmap for the first 1000 days. [...] It's a choice that was made here, [...] it's the food priority [...] this project is coming, in fact, in due course ." During the interviews, the notion of a transdisciplinary approach was cited by several interviewees as one of the added values of this program: Coordinator-02: “ The fact of grafting around nutrition and a nutritional journey around it, really this kind of cross-cutting approach, I think that's what makes ‘Nutri’ (short name of the project) what it is, with the idea of mediation .” Six out of eight healthcare providers said that, in their opinion, the program had a positive impact on the overall health of their patients. Two of them believed that there was no effect. Healthcare provider: “ I saw a very positive effect on the people I was treating, who suddenly became very diligent about their appointments, never canceled, and were very concerned about monitoring their pregnancy, diabetes screening, etc. It's extremely positive .” Some doubts were raised about the sustainability of such a strategy as it stands by different stakeholders. Firstly, the food aid component, frequently mentioned as very useful in this particular context, was also seen as complex to implement routinely as part of a scale-up strategy in terms of cost and logistics. Partner-01: “ The basket was too big for the ladies; I said, instead, it's 35 euros, [...] why not a 25 euros basket? That would be enough for each person, or even to multiply, to be able to reach more ladies”. Secondly, the implementation team was divided on the issue of whether to use external service providers to facilitate the sessions. Some members saw this as an obstacle to durability, while others saw the contractual relationship as a guarantee of fidelity. Comprehensiveness of intervention description Responses to the quantitative questionnaire completed by healthcare providers showed that the program objectives were “fairly clear” for half of them, “clear” for one-third, and “moderately clear” for one in ten. However, the components of the intervention were “rather poorly known” or “moderately known” by healthcare providers for two-thirds of them. Regarding the development of messages to be conveyed during the sessions, some implementers and facilitators regret the lack of co-construction and visibility of the content of the various sessions despite the organization of several multidisciplinary working groups during the design phase, as well as four newsletters throughout the project. Facilitation strategies to improve comprehensiveness of intervention description After the first period, facilitators, co-facilitators, intervention designers, implementation managers, evaluators, and close partners were invited to a meeting during which the initial results of the implementation were presented. A second similar meeting was organized at the end of the pilot phase, during which workshops were added to discuss opportunities for improvement. Setting In terms of inner settings, interviews with the team and partners revealed that most felt that stronger and clearer coordination were needed. As two different structures were responsible for coordinating the intervention, the organizational chart was ambiguous to some people. Some of the deliverers mentioned problems such as an unclear distribution of tasks and responsibilities, and communication difficulties.: Co-facilitator-02: " We can't have five people managing the same thing. Each person must have their place and recognize their place ." Coordinator-01: “ There are two teams. And that's already complicated (…). That didn't make things any easier. So that was one of the big obstacles, one of the big problems, I think, throughout. (…) having two teams where it wasn't always clear who was doing what.” Discussion The overall analysis of data reveals that the fidelity of this intervention compared to what was initially planned was high. In terms of representativeness in relation to the target population identified through logical modelling, the question was whether the intervention reached the individuals with the greatest need ( 31 ). Indeed, given that the identified barriers included transportation, irregular administrative situations (due to administrative appointments and/or fear of arrest by the police) and competing survival priorities, there was a risk of failing to reach those most in need ( 45 ). Although the recruitment criteria tended to exclude the most privileged women, the possibility of “marginal exclusion” could not be ruled out ( 46 – 48 ). The characteristics of the participants did reveal that more than half of them lived in severe financial and administrative precarity. More than a third did not attend school until high school, and more than a third declared living in accommodations without running water, suggesting informal housing. The analysis of assiduity levels showed no significant differences linked to administrative situation, health coverage, housing (with or without running water), or absence of declared source of income. The number of participants experiencing social isolation, was even higher in the last tercile of assiduity for both nutrition and non-nutrition sessions with the bivariate analysis. In addition to being associated with food insecurity in this context, social isolation during pregnancy has also been found to be related to several poor health outcomes, including mental health issues, as documented in the literature ( 31 , 49 – 51 ). The qualitative assessment also confirmed that the search for social bonding was a moderator of engagement. On the opposite, the relationship between high assiduity and living with other adults suggested that being a single-parent, in addition to be factor of poverty and food insecurity, could also be a barrier to attendance ( 31 ). In other settings, being a single-mother was also found to be a negative factor of compliance to prenatal care, and non-single-parenthood family were more likely to meet children health-care needs or engage in Child Mental Health Programs ( 52 – 54 ). The high association between education level and high assiduity for nutrition group sessions, also tends to support the Inverse Equity Hypothesis ( 47 ). Women's education attainment is well known to be a positive determinant of maternal health and dietary diversity ( 55 – 57 ). This relationship is partially mediated through better access to maternal care and better exposure to and utilization of health information or promotion by more educated women ( 52 , 58 – 60 ). In this particular context, this result suggested that provision of fresh food is not the only factor of participation to these sessions. Further adaptation of the format and content of the sessions to different levels of education and health literacy, could increase uptake among less educated women, thereby reducing inequalities. Logically, women born in Haiti were overrepresented among those identified and who participated, given that the recruitment criteria included the ability to speak French or Haitian Creole. However, it was also a positive factor for assiduity levels for nutrition sessions. The fact that two of the three co-facilitators were of Haitian origin and all spoke Haitian Creole may have contributed to facilitate retainment in the program. Similarly, mingling with women who have common culture may have fostered cohesion and encouraged participants to return more often to the next sessions. Having similar sociocultural background for nutrition group counselling or other group therapy has been identified as a factor of effectiveness ( 61 , 62 ). The activities offered during nutrition sessions related to recipes, culinary habits, or valuing knowledge about plants and spices, which are culturally influenced, may also explain why this phenomenon was specifically observed during nutrition sessions. For non-nutritional sessions where no fresh food was provided, citing “ taking care of oneself and the baby ” as the reason for participation was associated with high assiduity. Awareness of that prenatal care would improve the health of both mother and baby has been identified as a motivator that facilitates compliance ( 63 – 65 ). This result aligns with several conceptual models of healthcare utilization, such the modified Gelberg-Anderson behavioral model for vulnerable populations, which identifies health beliefs, in particular the expected benefits of health services, as a predisposing factor for service use ( 66 , 67 ). In this context, this suggests that prior trust and trust built throughout the program may have influenced participation and assiduity, respectively. Responsiveness of co-facilitators was an important moderator of quality of delivery. Their role - outside of sessions - of informing, mobilizing, reminding sessions and responding to individual needs was also a crucial moderator for participants responsiveness. However, their heavy workload and the lack of a clear written framework defining the boundaries of their responsibilities could undermine the fidelity of implementation over time, thereby compromising the sustainability of the intervention. Kangovi et.al also mentioned the risk of burnout and even adverse effects on patients in the absence of program-specific guidelines or protocols for community health workers ( 68 ). Richard et.al identified the development of a clear action plan as a condition of feasibility and success of health mediation implementation ( 69 ). More training, such as mental health first aid course, intensification of accompaniment and better networking among the actors for referring participants to the appropriate structures according to their needs, could also help to improve their working conditions and response to participants needs. Soliciting healthcare professionals in the right way, without taking up too much of their limited time, could help improve their responsiveness, even if appropriateness (or perceived relevance) and acceptability were already high. This would also probably improve the clarity of the program, i.c. the comprehensiveness of an intervention description, thereby moderating the fidelity as described in Carroll's framework ( 33 ). Prenatal care in France combines medical consultations for pregnancy follow-up or preventive care, with elective appointments, up to seven of which are completely free of charge for patients. These latter collective or individual classes are called “childbirth and parenting preparation”. Women without health coverage in French Guiana have less access to these as the majority are offered by independent midwives. Some themes of the non-nutrition sessions i.e. physical activity, breastfeeding and “maternity ward journey” are common with childbirth and parenting preparation classes. Providing the NPTM 2 program to pregnant women who do not usually engage in such classes (not only due to health coverage absence), is complementing the existing offer for the general population. Therefore, it aligns more closely with proportionate universalism than with a strictly targeted approach. Similarly to the group-care strategy, the intervention aimed to reduce the social gradient of health, by seeking cultural relevance, trust-building, empowerment and peer support ( 70 – 72 ). Limitations It was not possible to obtain the number of individuals eligible for the intervention who could have been approached, making it impossible to estimate coverage and analyze participation factors. Furthermore, the small number of participants limited the analysis of assiduity factors. The data on prenatal consultations were insufficient to assess whether the intervention could be a barrier, a facilitator, or a neutral factor for adherence to antenatal care. Finally, this paper did not extensively explore aspects of viable validity ( 73 ) or scalability ( 74 ), all of which will be the subject of future research. Conclusion Carroll et al.’s modified framework was useful for assessing the fidelity of this nutrition pilot intervention inspired by antenatal centering-based group care, and its moderators. The results showed that the intervention was successful in reaching individuals living in precarious situations and retaining socially isolated women in the program. However, the nutrition sessions prompted greater engagement among the most educated women, and the barrier of being a single mother may not have been fully overcome. This work also highlighted the need for a more comprehensive description of the program and improvements to the quality of delivery, providing co-facilitators with better support and clarifying the scope of their roles. Overall, these results will help with process and effectiveness evaluation and with transferability determination in other settings. Declarations Ethics approval and consent to participate All subjects and their legal representatives (if they were under 18) provided informed consent before recruitment. The study was approved by the French ethics committee (“Comité de Protection des Personnes Sud-Est 1”) on 11 September 2023 (ID-RCB number: 2023-A01739-36). Consent for publication Not applicable. Availability of data and materials The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare no competing interests. Funding This study received public funding from the “Agence Régionale de Santé de Guyane” (French Guiana Regional Health Agency), the “Centre Hospitalier Universitaire de Guyane”, the “Dispositif Spécifique Régional de Périnatalité Guyane” and the “Préfecture de Guyane”. Authors' contributions MSG, CB and CG conceptualised the study, OD conceptualised the external evaluation, NT and MSG implemented the study, MSG and CB analysed the data, MSG, CB, CG, OD, AD and MN contributed to interpretation and MG drafted the manuscript. All authors read and approved the final version of the manuscript. Acknowledgements The authors thank all the study participants; the surveyors: Guerline Jean, Yslande Buissereth, Jovany Mac-Intosch and Ruth Alphonse; members of the research support team: Sonia Martin, Mayka Mergeay-Fabre, Christelle Elfort, Estelle Thomas, Linda Matignon, Li Marian and Charlotte Duborgel, as well as close partners: Vanessa Izeros and Jean-Luc Bauza. 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Public Health Res 28 nov. 2013;1(4):1–526. 10.3310/phr01040 . Hunter LJ, Da Motta G, McCourt C, Wiseman O, Rayment JL, Haora P, et al. Better together: A qualitative exploration of women’s perceptions and experiences of group antenatal care. Women Birth 1 août. 2019;32(4):336–45. 10.1016/j.wombi.2018.09.001 . Horn A, Orgill M, Billings DL, Slemming W, Van Damme A, Crone M, et al. Belonging: a meta-theme analysis of women’s community-making in group antenatal and postnatal care. Front Public Health 26 févr. 2025;13:1506956. 10.3389/fpubh.2025.1506956 . PubMed PMID: 40078777; PubMed Central PMCID: PMC11897044. Chen HT. The bottom-up approach to integrative validity: A new perspective for program evaluation. Eval Program Plann. 1 août 2010;Child Welfare and the Challenge of the New Americans33(3):205–14. 10.1016/j.evalprogplan.2009.10.002 Milat AJ, King L, Bauman AE, Redman S. The concept of scalability: increasing the scale and potential adoption of health promotion interventions into policy and practice. Health Promot Int 1 sept. 2013;28(3):285–98. 10.1093/heapro/dar097 . Additional Declarations No competing interests reported. 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Galindo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCElEQVRIiWNgGAWjYJCCAwwFQJKdsYGBh8EmASyUUMDAj1+LAZBkBmtJS2BgA2kxYJBswGsPWAsQ8zAchmhhwKNFd0buwwMfDBjs+puZ2x68qTifxy/fnfjhgQGDhDkOPWY30g0OzjBgSJ5xmLHdcM6Z28WSbbybJYAOk5A5gEtLGsNhHqAWhsOMbdK8bbcTNxzj3QDSUieBw2FgLX+AWuQhWs6BtGz+AbIFrxagZ+0MIFoOgLRsk8Cr5cwzhoM9BhIJhkAtknPOJCfObMvdZpFgIIFby/E05g8/Kmzs5Y63P5N4U2GX2M98dvNNoAhOLVAgkdiALoJfAxDYE1QxCkbBKBgFIxcAAC/fWJpFlwp+AAAAAElFTkSuQmCC","orcid":"","institution":"Centre d’Investigation Clinique (Inserm 1424), UA 17, Institut Santé des Populations en Amazonie","correspondingAuthor":true,"prefix":"","firstName":"Muriel","middleName":"Suzanne","lastName":"Galindo","suffix":""},{"id":630523251,"identity":"af60413c-24a6-4db3-ad4f-3b71677e4288","order_by":1,"name":"Claire Gatti","email":"","orcid":"","institution":"Centre d’Investigation Clinique (Inserm 1424), UA 17, Institut Santé des Populations en 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18:24:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9023020/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9023020/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108397315,"identity":"249d2024-721c-448d-966a-f5fd01076fdc","added_by":"auto","created_at":"2026-05-04 08:21:02","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":406934,"visible":true,"origin":"","legend":"\u003cp\u003eLogic and theoretical model\u003c/p\u003e","description":"","filename":"image1.png","url":"https://assets-eu.researchsquare.com/files/rs-9023020/v1/450beb9a6ac800b61e797d34.png"},{"id":108493179,"identity":"1aeb57ed-b7bb-4568-b0b6-97bd54108ea7","added_by":"auto","created_at":"2026-05-05 09:59:34","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":231783,"visible":true,"origin":"","legend":"\u003cp\u003eAssessment of fidelity of the pilot intervention following the Conceptual Framework for Implementation Fidelity and its modified versions (33–35)\u003c/p\u003e","description":"","filename":"image2.png","url":"https://assets-eu.researchsquare.com/files/rs-9023020/v1/69e0efbdd1f11f2e7b818330.png"},{"id":108397322,"identity":"3300f056-fc61-4907-a82f-f013a36dfe70","added_by":"auto","created_at":"2026-05-04 08:21:02","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":445287,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of referrals, inclusions and participation\u003c/p\u003e","description":"","filename":"image3.png","url":"https://assets-eu.researchsquare.com/files/rs-9023020/v1/2589b13c88bd25836d0a057a.png"},{"id":108804822,"identity":"05b8f85c-ad78-42cb-951f-7855149e56c0","added_by":"auto","created_at":"2026-05-08 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08:21:02","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":19098,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-9023020/v1/4bb95490558db4510dba6b62.docx"},{"id":108397319,"identity":"b44fe71f-484e-42d8-9507-4db6abb19d9f","added_by":"auto","created_at":"2026-05-04 08:21:02","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":18160,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile2.docx","url":"https://assets-eu.researchsquare.com/files/rs-9023020/v1/94ba76ccb4c9e0fcdcd4bad5.docx"},{"id":108492400,"identity":"5c5df0db-a80c-4009-b6e2-b7a82fd48536","added_by":"auto","created_at":"2026-05-05 09:57:40","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":43018,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile3.docx","url":"https://assets-eu.researchsquare.com/files/rs-9023020/v1/95cdb51f99fd5bde3753c86d.docx"},{"id":108397321,"identity":"846a498e-2d0d-4f73-944f-0feeb0485240","added_by":"auto","created_at":"2026-05-04 08:21:02","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":14660,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile4.docx","url":"https://assets-eu.researchsquare.com/files/rs-9023020/v1/ae85a26ec41c7223f4a838de.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Implementation fidelity of a pilot group-based nutrition intervention for pregnant women (Nutri Pou Ti Moun 2): a mixed method assessment","fulltext":[{"header":"Contributions to the Literature","content":"\u003cul\u003e\n \u003cli\u003eDemonstrates the utility of assessing fidelity in the context of a pilot intervention combining mixed data from both internal and external evaluations.\u003c/li\u003e\n \u003cli\u003eOutlines how the group care model can be modified to align with specific contextual characteristics, including food insecurity, many undocumented pregnant women, and the pertinence of implementing actions outside standard prenatal care structures.\u003c/li\u003e\n \u003cli\u003eIntroduces a new concept for assessing participant responsiveness that extends beyond traditional attendance metrics by examining \u003cem\u003erelative assiduity\u003c/em\u003e, enabling measurement of actual engagement relative to potential participation.\u003c/li\u003e\n \u003cli\u003eShows how examining the determinants of \u003cem\u003erelative assiduity\u003c/em\u003e can advance understanding of engagement disparities in health interventions.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Background","content":"\u003cp\u003eThe antenatal period is critical for the future infant, as conceptualized by the framework for the Developmental Origins of Health and Disease Hypothesis, DOHaD (\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e). Despite all the mechanisms designed to redirect maternal reserves to the baby, pregnant women's nutrition is considered to be a determining factor in fetal development and future health (\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e). Malnutrition during pregnancy has also been shown to be detrimental to maternal health. Obesity of the mother is linked with pregnancy and obstetric complications, such as gestational diabetes, post-partum hemorrhage, premature birth or stillbirth (\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e). Iron deficiency has been associated with placental hypertrophy (\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e), and in varying levels of severity, with prematurity, low birth weight, intrauterine growth restriction, and increased maternal illness (\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e). Other micronutrient deficiencies such as calcium, iodine, vitamin D, folate, vitamin A or zinc are linked with poor health outcomes of the mother and/or the child (\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e–\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e). Although the causes of malnutrition are not solely lifestyle-related (\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e–\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e), diet and exercise habits are believed to have an impact on health outcomes during pregnancy (\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e–\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFood security, as defined by the Food and Agriculture Organization of the United Nations (FAO), implies the availability, access and utilization of safe and nutritious food in sufficient quantities and with stability over time (\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e). A greater risk of being obese during pregnancy has been associated with food insecurity (\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e). Poor dietary pattern - characterized by insufficient intake of fruits and vegetables, whole grains and fish - has been documented among individuals at risk of food insecurity due to low income (\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe role of mental health as a determinant and/or consequence of food insecurity and malnutrition should not be underestimated (\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e). A dose-response relationship has been observed between food insecurity and mental distress in Brazil (\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e) and detrimental interaction between stress and maternal nutrition has been suggested although further research is needed (\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn May 2024, the French Audit Office (Cour des Comptes) pointed out the poor perinatal indicators in France compared to its European neighbors, with some territories more affected than others, particularly the overseas regions, such as French Guiana (\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e). This territory of 286,618 inhabitants in 2021, located between Surinam and Brazil in South America, had an unemployment rate for people aged 15 to 64 years - of 31,0% - three times higher than in mainland France, and in 2017, 52,9% of the population lived below the poverty line (\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e). The fertility rate of this region was particularly high with 27.5 births per 1,000 inhabitants compared to a national mean of 10.9 births per 1,000 inhabitants (\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e). The rate of prematurity - gestational age \u0026lt; 37 weeks' amenorrhea - was double that of mainland France (16.0% vs. 7.0% ) and infant mortality was 2.6 times higher (\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e). Anemia – hemoglobin \u0026lt; 11g/dl – affected twice as many pregnant women (66.4% vs. 25.2%), and the prevalence of hypertension with or without proteinuria was threefold that of mainland France (14.1% vs. 4.3%) (\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA cross-sectional study among women giving birth in the three main maternity wards – called \u003cem\u003eNutri Pou Ti’ Moun 1\u003c/em\u003e (\u003cem\u003eNPTM 1)\u003c/em\u003e – was carried out in 2023 with the main objective of assessing the food insecurity prevalence and its determinants. It revealed that 32.4% [95%CI: 28.9–36.0] of women lived in a food insecure household among which 16.4% [95% IC: 13.9–19.4] in a severe food insecure household (\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e). Only 45.6% [95%CI: 42.0- 49.2] reached the Minimum Dietary Diversity for Women score and only 11.1% of women consumed the five recommended daily food groups. A quarter (25.4%) of women were overweight and 29.6% of women were obese before pregnancy. Finally, over a third (40%) of women had at least two micronutrient deficiencies.\u003c/p\u003e \u003cp\u003eIn order to tackle these issues, an intervention called \u003cem\u003eNutri Pou Ti’ Moun 2\u003c/em\u003e (NPTM 2) was implemented at a small-scale level, targeting vulnerable pregnant women, with the main evaluation outcome being the dietary diversity. Unlike other nutrition interventions, it did not target a specific health issue such as diabetes or obesity and it was not based on individual dietary counseling. With regular group sessions of interactive activities on cross-cutting themes, it was inspired by centering-based group care (CBGC). Without the \u003cem\u003ehealth care\u003c/em\u003e component, its specificity is to complement rather than replace antenatal care. It is also characterized by its focus on diet and nutrition, and its food aid component.\u003c/p\u003e \u003cp\u003eComprehensive knowledge about an intervention is essential in order to determine mechanisms through which group-based behavior-change interventions (GB-BCIs) have impact at individual level (\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e). In addition to the understanding of the initial concept and content, and the theory underpinning them, knowing how faithful the intervention is to what was intended, helps to determine whether the results of the intervention - positive, neutral or negative - are the result of design or implementation (\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e). Hence, the fidelity, its moderating factors, the adaptations and the reasons of these adaptations of this pilot intervention will be presented in this article, following the Conceptual Framework for Implementation fidelity developed by Caroll \u003cem\u003eet al.\u003c/em\u003e with inputs inspired by its two modified versions by Pérez \u003cem\u003eet. al\u003c/em\u003e (2016) and by Hasson, 2010 (\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e). Along with a forthcoming article presenting more process and effectiveness outcomes, this work will contribute to assess transferability of the intervention in other settings.\u003c/p\u003e "},{"header":"Methods","content":"\u003cp\u003eTheory and logic modelling\u003c/p\u003e\u003cp\u003eBaker and Swift (2009) consider that to be effective, a behavior change intervention should be based on psychosocial theories of behavior change. The choice of behavior change method then depends on the identified predictive determinant it targets and its applicability in the context (\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e). Cambon, Moore \u003cem\u003eet.al\u003c/em\u003e also recommend to have a thorough knowledge and understanding of the system in which changes are expected to occur but not to consider determinants as independent of one another, and believe that most effective and ethical approaches are not always directly related to the identified proximal determinants. They also suggest to base theory on multiple approaches rather than citing simplistic, off-the-shelf popular theoretical models (\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e–\u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe aim of the NPTM1 study was to explore the determinants of food insecurity. It revealed that being a single mother, lacking social support, and having low self-esteem were determinants of food insecurity. Others studies have shown that lack of social support predicts unhealthy behaviors during pregnancy through its impact on self-efficacy and planning (\u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e). Social support has also been found to mediate self-esteem during pregnancy (\u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e). The evaluation of CBGC model revealed encouraging psychological and social outcomes (\u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e). Two of the three components of the CBGC model i.e. a) \u003cem\u003ecollective interactive learning\u003c/em\u003e and b) \u003cem\u003ecommunity building\u003c/em\u003e were selected to be transferred in our setting.\u003c/p\u003e\u003cp\u003eIntervention description\u003c/p\u003e\u003cp\u003eThe intervention is described through the comparison of the intervention with GC-1000 in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e and the logic and theoretical model (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). See Additional file 1 for more details about where, by whom, to whom, what, and how.\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003ctable id=\"Tab1\" border=\"1\"\u003e \u003ccaption\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eProgram differentiation of the Nutri Pou TiMoun (NPTM) intervention, compared to the GC-1000 model (as initially planned)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003c/colgroup\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\"\u003e \u003cp\u003eSame in both NPTM and GC-1000\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eSpecific to the GC-1000\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eSpecific to the NPTM\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eGroup size of 8–12 women of similar gestational age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eDuration of session: 90–120 minutes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eNumber of sessions greater than 8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eThe number of sessions is flexible, usually 10 sessions maximum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eThe number of sessions is always 12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eParticipants sit in a circle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eWithout a table\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eMost of the time with a table\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eDynamic, fun and engaging way of information sharing, that values knowledge and experience of group members. No formal didactic presentations. Activities are culturally adapted.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eEach session has a plan but emphasis may vary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003ePossibility of sequential progression of sessions according to pregnancy phase or baby's age, but flexibility according to participants' needs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eSequential progression of the 12 sessions and in particular of the 6 diet and nutrition sessions (see Additional file 1).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eSeveral topics are similar or identical such as nutrition, breastfeeding, self-esteem, alcohol abuse and physical activity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eTopics are usually in line with the country guidelines of antenatal and postnatal care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eEmphasis on diet and nutrition: 1 session out of 2 (6 in total) and one session on budget management.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eRegular interval between sessions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eOnce a week (expect bank holiday), same day of the week.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eA facilitator and a co-facilitator\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eThe facilitator is a healthcare provider.\u003c/p\u003e \u003cp\u003eThe co-facilitator can be another healthcare provider or assistant or another person such as a community health worker.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eFacilitators are not necessarily health professionals, but experts in the subject they are facilitating, contracted for the intervention.\u003c/p\u003e \u003cp\u003eThe co-facilitator is a peer-facilitator recruited specifically for the intervention.\u003c/p\u003e \u003cp\u003eThe healthcare providers only have a role of information about the program and identification of potential participants.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eBoth facilitators and co-facilitators are trained in facilitation and listening skills.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eCo-facilitators have facilitation training with an emphasis on valuing women's experiential knowledge and horizontal transmission.\u003c/p\u003e \u003cp\u003eFacilitators are not trained but must have experience and/or previous training of group facilitation.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eThe first group session most commonly happens between 12 to 16 weeks gestation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eRecruitment criteria: maximum of 22 weeks gestation and ability to speak the language of either the facilitator or the co-facilitator, i.e. French and/or Haitian Creole.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/table\u003e\u003c/div\u003e\u003cp\u003eFidelity framework\u003c/p\u003e\u003cp\u003eFigure \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e presents the elements of the framework which guided the analysis and presentation of results, based on the Conceptual Framework for Implementation Fidelity and its modified versions (\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e–\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e). The indicators, as stated by their originators, are not necessarily independent measures and moderators in particular, may interact or overlap with one another (\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eStudy design\u003c/p\u003e\u003cp\u003eThe evaluation was conducted partly internally by the intervention designers and partly externally by an independent evaluator.\u003c/p\u003e\u003cp\u003eInternal evaluation\u003c/p\u003e\u003cp\u003eParticipants\u003c/p\u003e\u003cp\u003e Eligible Women were identified by healthcare providers and then included in the research study by co-facilitators once they were informed and gave their consent. Study participants are not necessarily recipients of the intervention as data among non-participants were also collected.\u003c/p\u003e\u003cp\u003eData collection\u003c/p\u003e\u003cp\u003eThe quantitative data collected internally are displayed in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e and the details of the questions and variables are presented in Additional file 2. Moreover, certain aspects of the experience of participation were discussed with a sample of the intervention participants as part of two ethnographic studies, using semi-structured interviews. The first study focused on breastfeeding (reference of verbatim: “Participant-B-XX”), while the second concentrated on food practices during pregnancy (reference of verbatim: “Participant-F-XX”). Observation of more than a third of the sessions (\u003cspan class=\"CitationRef\"\u003e52\u003c/span\u003e) was also a source of information.\u003c/p\u003e\u003cp\u003eExternal evaluation\u003c/p\u003e\u003cp\u003eParticipants\u003c/p\u003e\u003cp\u003eEvery deliverers and stakeholders or “people who have influence and/or power over the outcome of implementation efforts” as defined in the updated Consolidated Framework for Implementation Research (\u003cspan class=\"CitationRef\"\u003e43\u003c/span\u003e) were solicited.\u003c/p\u003e\u003cp\u003eData collection\u003c/p\u003e\u003cp\u003eThe data was collected using anonymous self-administered questionnaires (quantitative data) and semi-structured interviews (qualitative data).\u003c/p\u003e\u003cp\u003eThe self-questionnaire for non-caregiving partners asked about the terms of the partnership, the design of the program, the implementation of the intervention, and satisfaction.\u003c/p\u003e\u003cp\u003eThe self-questionnaire provided to healthcare providers covered: participation in identification, program design, perceived impact, and satisfaction.\u003c/p\u003e\u003cp\u003eThe items discussed during the interviews were: appropriateness, feasibility (necessary resources, training) and durability.\u003c/p\u003e\u003cp\u003eThe interviews were carried out in person, or by phone when not feasible (reference of verbatim: “Role-XX”). They were recorded with the consent of the interviewees and transcribed using Whisper, OpenAI's artificial intelligence speech recognition program.\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003c/div\u003e\u003ctable id=\"Tab2\" border=\"1\"\u003e \u003ccaption\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e-Details on quantitative data collected internally\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003c/colgroup\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eMethod of data collection\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eFirst Questionnaire\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eSecond Questionnaire\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eThird Questionnaire\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eMedical record\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eWorksheet \u0026amp; Attendance list\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eFacilitator assessment\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\"\u003e \u003cp\u003eInterview\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eInterview\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eInterview\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eData entry from paper medical records\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eForm filling and interview\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\"\u003e \u003cp\u003eSelf-questionnaire\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e\u003cb\u003eData collectors\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eCo-facilitators and surveyors speaking the language of the population\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eCo-facilitators and surveyors speaking the language of the population\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eSurveyors speaking the language of the population\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eHealthcare providers\u003c/p\u003e \u003cp\u003eData entry by a clinical research associate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eCo-facilitators\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eCo-facilitators and facilitators\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e\u003cb\u003ePopulation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eStudy participants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eStudy participants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eStudy participants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eStudy participants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eAll women identified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eCo-facilitators and facilitators\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e\u003cb\u003eTiming\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eBefore the start of the group sessions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eBetween the 10th group session and birth delivery. Minimum term of pregnancy: 29 weeks.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eBetween 2 days and 15 days after birth delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eAfter birth delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e\u003cem\u003eWorksheet\u003c/em\u003e:\u003c/p\u003e \u003cp\u003eat inclusion\u003c/p\u003e \u003cp\u003e\u003cem\u003eAttendance list\u003c/em\u003e: at each group session\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eAt each group session\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e\u003cb\u003eVariables\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e- Perceived social support\u003c/p\u003e \u003cp\u003e- Feeling socially isolated\u003c/p\u003e \u003cp\u003e- State of mind at pregnancy announcement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e- Reason for participating\u003c/p\u003e \u003cp\u003e- Opinion on the project\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e- Socio-economic data (place of birth, education level, occupation, administrative data, source of income, household composition, access to farm land, housing and residence change)\u003c/p\u003e \u003cp\u003e- Reason for non-participation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e- Age*\u003c/p\u003e \u003cp\u003e- Term in weeks of pregnancy for the first group session*\u003c/p\u003e \u003cp\u003e- Height and weight before pregnancy\u003c/p\u003e \u003cp\u003e- Number of pregnancies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003e- Reason for non-inclusion\u003c/p\u003e \u003cp\u003e- Reason for non-participation\u003c/p\u003e \u003cp\u003e- Declared participation constraints\u003c/p\u003e \u003cp\u003e- Attendance data\u003c/p\u003e \u003cp\u003e- Group municipality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\"\u003e \u003cp\u003eCharacteristics of the group session (length, perceived group dynamism, satisfaction indicators, fidelity and adaptations details, tasks of the co-facilitators, difficulties encountered)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/table\u003e\u003c/div\u003e\u003cp\u003e*These two variables were also collected by healthcare providers for women who did not participate in either the intervention or the research study.\u003c/p\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eThe STATA software 19.5 (STATA Corporation, College Station, TX, USA—version 19.0) was used for descriptive analysis (characteristics of participants) and bivariate and multivariate analysis (determination of co-variates independently associated with the highest tercile of relative assiduity).\u003c/p\u003e\u003cp\u003eVariables included in the multivariate logistic regression were selected according to the existence of an association in the bivariate analysis (up to a p-value of 0.2) and the absence of multicollinearity.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eRegarding the internal evaluation, the questionnaires, worksheets and attendance lists were completed between September 12th 2023 and December 18th 2024.\u003c/p\u003e \u003cp\u003eFifteen participants were interviewed in the two ethnographic studies between February 2024 and May 2025.\u003c/p\u003e \u003cp\u003eThe questionnaires of the external evaluation were completed by the partners between July 3rd and August 28th. Eleven partners, responded, as did ten of the fifteen healthcare professionals involved in identifying pregnant women.\u003c/p\u003e \u003cp\u003eBetween July 22nd and September 5th, sixteen semi-structured interviews were conducted. The entire staff team (i.e., three co-facilitators and four coordinators), was interviewed. The nine partners interviewed were three facilitators, five other partners (logistics, funders, experts), and one independent midwife.\u003c/p\u003e \u003cp\u003eAdherence and adaptations\u003c/p\u003e \u003cp\u003eContent\u003c/p\u003e \u003cp\u003eThe content adherence is summarized in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAdherence of intervention components, content adaptations and moderating factors\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe intervention component\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExtent of adherence\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerating factor of adherence\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdaptation(s)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eType of adaptation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eExpected effect of adaptation\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSequencing of sessions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003ePositive factor\u003c/em\u003e: Overall coordination for all sites, project planning to ensure the availability of the facilitators\u003c/p\u003e \u003cp\u003e\u003cem\u003eNegative factor\u003c/em\u003e:\u003c/p\u003e \u003cp\u003evulnerability to unforeseen circumstances\u003c/p\u003e \u003cp\u003esame facilitators on different sites\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSlights modifications on the order of the topics were performed for 4 groups due to practical reasons - availability of facilitators and of facilities - but no more than two ranks difference in order.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eReactive \u0026amp; unsystematic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTopic sessions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003ePositive factor\u003c/em\u003e: Remuneration of external contractors to be facilitator\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOpen-topic session replaced by a session on the end of pregnancy and the different stages of the maternity ward stay.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eProactive \u0026amp; systematic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEnhanced appropriateness, acceptability and uptake\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSites\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eNegative factor\u003c/em\u003e: obligation to comply with the site managers' organization\u003c/p\u003e \u003cp\u003e\u003cem\u003ePositive factor\u003c/em\u003e: good partnerships with site managers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOnly one group experienced a change of site where interactive learning sessions took place\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eReactive \u0026amp; unsystematic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMore adapted facility\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFacilitator profile\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003cp\u003e(4 out 5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003ePositive factor\u003c/em\u003e:\u003c/p\u003e \u003cp\u003efacilitators are external contractors\u003c/p\u003e \u003cp\u003egood communication between implementers and facilitators\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eConfusion about the goals \u0026amp; approach led to contract termination with one facilitator, after which a new activity was developed collaboratively with co-facilitators.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eReactive \u0026amp; systematic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEnhanced acceptability and appropriateness\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCo-facilitator profile\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOne facilitator without maternity experience nor Haitian origin but could speak Haitian creole and other language and had mediation experience.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eReactive \u0026amp; systematic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTraining of co-facilitators\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003ePositive factor\u003c/em\u003e: recruitment several months in advance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDetails of content\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eReplacement or addition of messages and activities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eProactive \u0026amp; systematic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eIncreased acceptability and efficiency\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eDose\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eRecruitment, coverage and representativity\u003c/h3\u003e\n\u003cp\u003eAs part of this pilot phase, the objective was not good coverage of the target population but to form one group in each of the 4 municipalities during 3 different periods. As planned, twelve groups were created.\u003c/p\u003e \u003cp\u003eThe identification of pregnant women was opened up to independent midwives for the last period in order to achieve a higher headcount per group. For these last groups, a social recruitment criterion was added, namely receiving state medical assistance or being covered by universal health insurance for people without salaried employment or not covered by other specific schemes. Among the difficulties encountered in identifying women, the main reason cited by maternal and child health care center professionals and liberal midwives was \u0026ldquo;\u003cem\u003eforgetting to ask the patient\u003c/em\u003e\u0026rdquo;. The second most cited difficulty for independent midwives was \u0026ldquo;\u003cem\u003elack of time\u003c/em\u003e\u0026rdquo;.\u003c/p\u003e \u003cp\u003eA total of 198 women were identified and their contact details forwarded to the co-facilitators so that they could be invited to take part in the research project and the group sessions.\u003c/p\u003e \u003cp\u003eOf the 40 women not included, the reason was documented for 33, as shown in the Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, among whom, 27% were not reached at all.\u003c/p\u003e \u003cp\u003eAmong the 155 women included, 122 participated in at least one group session, the characteristics of which are presented in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. The majority of women was born in Haiti, foreigners without residence permit, homemakers without allowance, and lived in a household with no source of declared income at the end of pregnancy.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe characteristics of the pregnant women who participated in at least one group session (n\u0026thinsp;=\u0026thinsp;122)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategories\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eWoman\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;20\u0026nbsp;year.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (6.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u0026ndash;35\u0026nbsp;year.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79 (64.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;=35\u0026nbsp;year.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (28.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eAdministrative status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrench Citizen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (7.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eForeign national with residence permit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48 (39.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eForeign national without residence permit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57 (46.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (6.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eHealth coverage\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon or AME\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75 (\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePUMA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eBirth country\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHaiti\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86 (70.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36 (29.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eEducation level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBefore high school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43 (35.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOver high school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71 (58.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (6.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003e\u003cb\u003eProfessional situation at the beginning of pregnancy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDeclared work\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (6.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUndeclared job\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (14.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-paid training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (4.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePaid training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (1.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWorkless with allowance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (3.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHomemaker without allowance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75 (61.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (7.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eLives with child's father (at the end of pregnancy)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71 (58.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (33.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (8.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eTerm in weeks of pregnancy for the 1st group session\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u0026ndash;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e104 (85.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (14.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003e\u003cb\u003eBMI before pregnancy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnderweight (\u0026lt;\u0026thinsp;18.5 kg/m\u0026sup2;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (4.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNormal weight (18.5\u0026ndash;24.9 kg/m\u0026sup2;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (33.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOverweight (25.0\u0026ndash;29.9 kg/m\u0026sup2;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (22.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eObese (more than 30.0\u0026ndash;39,9 kg/m\u0026sup2;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (19.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMorbidly obese (\u0026gt;\u0026thinsp;40 kg/m\u0026sup2;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (2.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (16.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eNulliparous\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (21.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e93 (76.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (2.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eHousehold\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eAt least 1 member with a declared source of income at the end of pregnancy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (17.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90 (73.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (9.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eRunning water at home\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWithout\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47 (38.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWith\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64 (52.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (9.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eNumber of children in the household\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (17.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (23.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45 (36.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u0026ndash;11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (13.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (9.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eAt least one child under 3 years of age\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (18.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88 (72.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (9.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eHousehold with no other adult (single-parent)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (13.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95 (77.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (9.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIdentified or declared reasons for non-participation are also displayed in flow chart.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e \u003cb\u003eshould be here.\u003c/b\u003e\u003c/p\u003e\n\u003ch3\u003eExposure\u003c/h3\u003e\n\u003cp\u003eTen of the twelve groups created were offered all twelve planned group sessions. One group in the first period was offered 11 group and one group was offered 10 group sessions.\u003c/p\u003e \u003cp\u003eAmong the 122 participants, 110 were in capacity to attend at least 10 group sessions (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWhile 61% of nutrition group sessions had between 8 and 13 participants, only 24% of other thematic group sessions reached the minimum number of 8 participants.\u003c/p\u003e \u003cp\u003eThe duration of the group sessions was 1,5 to 2 hours as expected. At least one woman was late for 65% of the sessions.\u003c/p\u003e \u003cp\u003eThe median number of food baskets received by participants was 5.\u003c/p\u003e \u003cp\u003eParticipant responsiveness\u003c/p\u003e \u003cp\u003eRecipients responsiveness\u003c/p\u003e\n\u003ch3\u003eAttendance\u003c/h3\u003e\n\u003cp\u003eThe median number of sessions attended was 8; 77% of participants attended at least half of the sessions, and 31% attended 10 to 12 sessions. Considering only the sessions devoted to nutrition, 88% of participants attended at least half of them.\u003c/p\u003e \u003cp\u003eAmong participants, only 3,3% (n\u0026thinsp;=\u0026thinsp;4) came to a single session, for reasons other than early pregnancy termination or medical contra-indication to move.\u003c/p\u003e\n\u003ch3\u003eMotives for attending sessions\u003c/h3\u003e\n\u003cp\u003eLearning new things or specifically learning things about food or cooking emerged as the main declared motive for participation (63.7%, n\u0026thinsp;=\u0026thinsp;65). More than a third of participants (36.3%, n\u0026thinsp;=\u0026thinsp;37) said that they participated because their midwife asked them to. Meeting other women and/or feeling less lonely were quoted by 22.5% (n\u0026thinsp;=\u0026thinsp;23). Whilst the provision of fresh food was cited by only 2.9% of participants as a reason for participating, the attendance rate was higher for nutrition sessions with fresh food baskets (78%) than for sessions without (51%). Some participants confessed during interviews that it was more than a little compensation for coming.\u003c/p\u003e \u003cp\u003eParticipant-F-05: \u0026ldquo;\u003cem\u003eThey gave me fruits and vegetables, and it even became a source of income for me\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003cp\u003eThe reassuring routine associated with the facilitator's consistency during these nutrition sessions could also be a factor in this difference.\u003c/p\u003e \u003cp\u003eParticipant-F-004: \u0026ldquo;\u003cem\u003eIt was really good, they taught me a lot, (even though I forgot some things), especially how to eat a balanced diet. I liked their little programs; sitting there made me feel comfortable\u0026rdquo;\u003c/em\u003e.\u003c/p\u003e \u003cp\u003eCo-facilitator-01: \u003cem\u003e\u0026ldquo;There really are some for whom the (food) baskets are very important, but there are others for whom it's about getting out, comfort, feeling comfortable in a different environment, conviviality, soulfulness, happiness\u0026mdash;that's what interests them.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eBarriers to attendance\u003c/h2\u003e \u003cp\u003eAlthough the reason for absence could not be systematically collated, the two main reasons given at least once for an absence were 1) medical appointment by 43 participants, and 2) fatigue or other medical reasons by 42 participants.\u003c/p\u003e \u003cp\u003eThe qualitative assessment revealed another obstacle, namely the fear of being arrested by local authorities in the event of an irregular administrative situation.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eFactors of assiduity\u003c/h3\u003e\n\u003cp\u003eAssiduity was calculated as the proportion of sessions attended in relation to those in which the participant was able to take part, considering the group (between 10 to 12 sessions), the date of recruitment (in case it was after the start of the sessions) and the date of pregnancy termination (in case it was before the last session). The factors of assiduity were compared between the highest tercile and the two lowest terciles, for nutrition sessions (including the handing of a fresh food basket) on one side, and for non-nutrition sessions (without food basket) - such as physical activity, breastfeeding or budget management - on the other side.\u003c/p\u003e \u003cp\u003eMultivariate analysis showed that being born in Haiti, living in a household with at least three children, and having a higher education level were all positively and significantly linked to high assiduity for nutrition sessions. Conversely, living in a household with no other adults and currently enrolled in a course or training were both associated with lower levels of assiduity.\u003c/p\u003e \u003cp\u003eFor non-nutrition sessions, the only variable associated with high assiduity was mentioning \"\u003cem\u003eto take care of myself and the baby\u003c/em\u003e\" as a reason for participating. It is noteworthy that feeling isolated was positively linked with high assiduity for both nutrition and non-nutrition sessions in bivariate analysis, although significance disappeared after adjustment (See Additional file 3 for the details).\u003c/p\u003e\n\u003ch3\u003eSatisfaction of intervention recipients\u003c/h3\u003e\n\u003cp\u003eTo the question \u0026ldquo;What do you think of this program?\u0026rdquo;, no negative comments were registered and 83 out of 87 were positive to highly positive. Again, learning new things was the most valuable aspect cited (18 out of 87 respondents), and was also discussed during interviews. Information transmission appeared to be valued, both vertically (from facilitators) and horizontally (from peers).\u003c/p\u003e \u003cp\u003eParticipant-B-13: \u0026ldquo;\u003cem\u003eThat's it, that's it, I like the group sessions too, the discussion groups, talking, exchanging, you give and you take too, that's it\u003c/em\u003e.\u0026rdquo;\u003c/p\u003e \u003cp\u003eThe vocabulary of well-being and stress relief was frequently used in the questionnaires when opinions were asked for (\u0026ldquo;brings joy to the heart\u0026rdquo;, \u0026ldquo;pleasure\u0026rdquo;, \u0026ldquo;pleasant\u0026rdquo;, \u0026ldquo;nice\u0026rdquo;, \u0026ldquo;happiness\u0026rdquo;, \u0026ldquo;living better in pregnancy\u0026rdquo;, \u0026ldquo;feel good\u0026rdquo;, \u0026ldquo;stress decrease\u0026rdquo;) and was often associated with breaking isolation or social bonding during interviews.\u003c/p\u003e \u003cp\u003eParticipant-F-18: \u0026ldquo;\u003cem\u003eThe sessions helped me a lot. There were things I didn't know that I ended up learning. [...] We became like a family. We were happy and fulfilled... it was really great\u003c/em\u003e.\u0026rdquo;\u003c/p\u003e \u003cp\u003eParticipant-F-03: \u0026ldquo;\u003cem\u003eWhen we went to the sessions, it was as if we left all our problems behind, as if we had no worries. We also made new friends thanks to the workshop.\u003c/em\u003e\u0026rdquo;\u003c/p\u003e \u003cp\u003eHealthcare providers who were able to follow up with patients who participated in the program responded that the feedback from these patients was generally \u0026ldquo;somewhat positive\u0026rdquo; or \u0026ldquo;positive.\u0026rdquo;\u003c/p\u003e \u003cp\u003eDeliverers responsiveness and its influence on the quality of delivery\u003c/p\u003e \u003cp\u003eQuality of program delivery has been defined differently in the literature. It can be measured quantitatively through observation or self-report (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). In the case of this pilot intervention, normative evaluation was not appropriate, as no criteria or standards exist for assessing how the content has been delivered. However, observation of more than a third of the sessions by 4 observers and self-reporting by, and debriefings with, facilitators and co-facilitators provide qualitative information on the way the sessions were conducted, which can moderate fidelity.\u003c/p\u003e \u003cp\u003eTo the question \u0026ldquo;how was the group dynamic\u0026rdquo;, facilitators and co-facilitators responses were very similar with respectively 78% and 76% of sessions appraised as \u0026ldquo;good\u0026rdquo;. Facilitators' satisfaction with the facilitator-co-facilitator pairing\u0026mdash;rated as \u0026ldquo;very good\u0026rdquo; for 78% of sessions\u0026mdash;was also associated with their positive feelings about group dynamics (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). To the question \u0026ldquo;did you feel you had found your place during the session in relation to the facilitator?\u0026rdquo; the co-facilitators answered \u0026ldquo;yes, a lot\u0026rdquo; for 61% of the sessions, but there was no link with their perceived group dynamics.\u003c/p\u003e \u003cp\u003e For 47% of sessions, facilitators replied that co-facilitators did help to make participants feel secure and mentioned it during interviews.\u003c/p\u003e \u003cp\u003eFacilitator-02: \"\u003cem\u003eWhat I also found super important in these groups was the presence of the co-facilitators. [...] The way they were present in the group had an impact on the whole group. [...] And in the groups where they were really there and present, we were able to talk about things very freely\u003c/em\u003e.\"\u003c/p\u003e \u003cp\u003eFor one municipality, two co-facilitators were equally in charge of the group. The consequence of this dilution of responsibility was less involvement of each co-facilitator during the sessions according to observers and one facilitator.\u003c/p\u003e \u003cp\u003eIn the meantime, although this was not quantifiable and might have been anecdotic, some deliverers, including healthcare professionals, mentioned the transmission or fear of transmission of misleading or false information.\u003c/p\u003e \u003cp\u003eMidwife-01: \u0026ldquo;\u003cem\u003eBeware also of co-facilitators who are not health professionals and who use their personal experience as an example. Recommendations and advice are sometimes erroneous\u003c/em\u003e.\u0026rdquo;\u003c/p\u003e \u003cp\u003eIn addition to that, all respondents, including the co-facilitators themselves, acknowledged that they had been assigned too many tasks, including logistics.\u003c/p\u003e \u003cp\u003eThe commitment of these co-facilitators to help some of the participants in difficulty went sometimes beyond what was asked of them.\u003c/p\u003e \u003cp\u003eFacilitator-01: \"\u003cem\u003eThey went a bit overboard and weren't recognized. [...] The project team kept saying, \u0026lsquo;Yes, but you don't have to do that.\u0026rsquo;... Except that when you're in contact with people, you clearly can't. Even I found myself taking a lady home once. Because it's difficult. It's difficult sometimes, even if you set limits\u003c/em\u003e.\"\u003c/p\u003e \u003cp\u003eHowever, the right boundaries of this engagement were different according to the various people interviewed, which shows how complex it was for these co-facilitators to find the right balance.\u003c/p\u003e \u003cp\u003eA lack of preparation to deal with difficult situations was reported, despite attempts to put in place an effective system for referring people to the appropriate facilities.\u003c/p\u003e \u003cp\u003eCo-facilitator-02: \u0026ldquo;\u003cem\u003eI see myself supporting a woman who has lost her baby. I haven't been trained for that\u003c/em\u003e.\u0026rdquo;\u003c/p\u003e \u003cp\u003eFinally, despite the difficulties mentioned, the co-facilitators had a positive attitude toward the project and were convinced of its usefulness in improving the participants' nutrition, social life, and health.\u003c/p\u003e \u003cp\u003eCo-facilitator-02: \u003cem\u003e\u0026ldquo;They eat better with very little money. So, what more could you ask for?\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eCo-facilitator-03: \u0026ldquo;\u003cem\u003eIt also helped them break out of their isolation. They learned a lot. They really did. No, they\u0026rsquo;re happy about it.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eFacilitation strategies to improve deliverers responsiveness\u003c/p\u003e \u003cp\u003eIn order to improve working conditions for co-facilitators, two strategies were implemented. The first consisted of providing mentoring by the association responsible for health education training, and the second of offering the opportunity to meet individually or in groups with a psychologist to help them better manage the stress induced by their role. However, neither of these strategies improved the situation, probably because they came too late and did not resolve the issue of workload.\u003c/p\u003e \u003cp\u003eResponsiveness of people who \u0026ldquo;have influence and/or power over the outcome of implementation efforts\u0026rdquo;\u003c/p\u003e \u003cp\u003eBoth health professionals and external partners believed that the issues addressed by the project were priorities, based on their observations in their practice and because they had been identified as public health policy priorities, i.e. perinatal health, food security and care access for the most vulnerable.\u003c/p\u003e \u003cp\u003ePartner-02: \"\u003cem\u003eThere have also been favorable winds at national level, with women's roadmaps, (\u0026hellip;), and a national roadmap for the first 1000 days. [...] It's a choice that was made here, [...] it's the food priority [...] this project is coming, in fact, in due course\u003c/em\u003e.\"\u003c/p\u003e \u003cp\u003eDuring the interviews, the notion of a transdisciplinary approach was cited by several interviewees as one of the added values of this program:\u003c/p\u003e \u003cp\u003eCoordinator-02: \u0026ldquo;\u003cem\u003eThe fact of grafting around nutrition and a nutritional journey around it, really this kind of cross-cutting approach, I think that's what makes \u0026lsquo;Nutri\u0026rsquo; (short name of the project) what it is, with the idea of mediation\u003c/em\u003e.\u0026rdquo;\u003c/p\u003e \u003cp\u003eSix out of eight healthcare providers said that, in their opinion, the program had a positive impact on the overall health of their patients. Two of them believed that there was no effect.\u003c/p\u003e \u003cp\u003eHealthcare provider: \u0026ldquo;\u003cem\u003eI saw a very positive effect on the people I was treating, who suddenly became very diligent about their appointments, never canceled, and were very concerned about monitoring their pregnancy, diabetes screening, etc. It's extremely positive\u003c/em\u003e.\u0026rdquo;\u003c/p\u003e \u003cp\u003eSome doubts were raised about the sustainability of such a strategy as it stands by different stakeholders.\u003c/p\u003e \u003cp\u003eFirstly, the food aid component, frequently mentioned as very useful in this particular context, was also seen as complex to implement routinely as part of a scale-up strategy in terms of cost and logistics.\u003c/p\u003e \u003cp\u003ePartner-01: \u0026ldquo;\u003cem\u003eThe basket was too big for the ladies; I said, instead, it's 35 euros, [...] why not a 25 euros basket? That would be enough for each person, or even to multiply, to be able to reach more ladies\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e \u003cp\u003eSecondly, the implementation team was divided on the issue of whether to use external service providers to facilitate the sessions. Some members saw this as an obstacle to durability, while others saw the contractual relationship as a guarantee of fidelity.\u003c/p\u003e \u003cp\u003eComprehensiveness of intervention description\u003c/p\u003e \u003cp\u003eResponses to the quantitative questionnaire completed by healthcare providers showed that the program objectives were \u0026ldquo;fairly clear\u0026rdquo; for half of them, \u0026ldquo;clear\u0026rdquo; for one-third, and \u0026ldquo;moderately clear\u0026rdquo; for one in ten. However, the components of the intervention were \u0026ldquo;rather poorly known\u0026rdquo; or \u0026ldquo;moderately known\u0026rdquo; by healthcare providers for two-thirds of them.\u003c/p\u003e \u003cp\u003eRegarding the development of messages to be conveyed during the sessions, some implementers and facilitators regret the lack of co-construction and visibility of the content of the various sessions despite the organization of several multidisciplinary working groups during the design phase, as well as four newsletters throughout the project.\u003c/p\u003e \u003cp\u003eFacilitation strategies to improve comprehensiveness of intervention description\u003c/p\u003e \u003cp\u003eAfter the first period, facilitators, co-facilitators, intervention designers, implementation managers, evaluators, and close partners were invited to a meeting during which the initial results of the implementation were presented. A second similar meeting was organized at the end of the pilot phase, during which workshops were added to discuss opportunities for improvement.\u003c/p\u003e \u003cp\u003eSetting\u003c/p\u003e \u003cp\u003eIn terms of inner settings, interviews with the team and partners revealed that most felt that stronger and clearer coordination were needed. As two different structures were responsible for coordinating the intervention, the organizational chart was ambiguous to some people. Some of the deliverers mentioned problems such as an unclear distribution of tasks and responsibilities, and communication difficulties.:\u003c/p\u003e \u003cp\u003eCo-facilitator-02: \"\u003cem\u003eWe can't have five people managing the same thing. Each person must have their place and recognize their place\u003c/em\u003e.\"\u003c/p\u003e \u003cp\u003eCoordinator-01: \u0026ldquo;\u003cem\u003eThere are two teams. And that's already complicated (\u0026hellip;). That didn't make things any easier. So that was one of the big obstacles, one of the big problems, I think, throughout. (\u0026hellip;) having two teams where it wasn't always clear who was doing what.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe overall analysis of data reveals that the fidelity of this intervention compared to what was initially planned was high.\u003c/p\u003e \u003cp\u003eIn terms of representativeness in relation to the target population identified through logical modelling, the question was whether the intervention reached the individuals with the greatest need (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Indeed, given that the identified barriers included transportation, irregular administrative situations (due to administrative appointments and/or fear of arrest by the police) and competing survival priorities, there was a risk of failing to reach those most in need (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). Although the recruitment criteria tended to exclude the most privileged women, the possibility of \u0026ldquo;marginal exclusion\u0026rdquo; could not be ruled out (\u003cspan additionalcitationids=\"CR47\" citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). The characteristics of the participants did reveal that more than half of them lived in severe financial and administrative precarity. More than a third did not attend school until high school, and more than a third declared living in accommodations without running water, suggesting informal housing.\u003c/p\u003e \u003cp\u003eThe analysis of assiduity levels showed no significant differences linked to administrative situation, health coverage, housing (with or without running water), or absence of declared source of income. The number of participants experiencing social isolation, was even higher in the last tercile of assiduity for both nutrition and non-nutrition sessions with the bivariate analysis. In addition to being associated with food insecurity in this context, social isolation during pregnancy has also been found to be related to several poor health outcomes, including mental health issues, as documented in the literature (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan additionalcitationids=\"CR50\" citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e). The qualitative assessment also confirmed that the search for social bonding was a moderator of engagement.\u003c/p\u003e \u003cp\u003eOn the opposite, the relationship between high assiduity and living with other adults suggested that being a single-parent, in addition to be factor of poverty and food insecurity, could also be a barrier to attendance (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). In other settings, being a single-mother was also found to be a negative factor of compliance to prenatal care, and non-single-parenthood family were more likely to meet children health-care needs or engage in Child Mental Health Programs (\u003cspan additionalcitationids=\"CR53\" citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe high association between education level and high assiduity for nutrition group sessions, also tends to support the Inverse Equity Hypothesis (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). Women's education attainment is well known to be a positive determinant of maternal health and dietary diversity (\u003cspan additionalcitationids=\"CR56\" citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e). This relationship is partially mediated through better access to maternal care and better exposure to and utilization of health information or promotion by more educated women (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan additionalcitationids=\"CR59\" citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e). In this particular context, this result suggested that provision of fresh food is not the only factor of participation to these sessions. Further adaptation of the format and content of the sessions to different levels of education and health literacy, could increase uptake among less educated women, thereby reducing inequalities.\u003c/p\u003e \u003cp\u003eLogically, women born in Haiti were overrepresented among those identified and who participated, given that the recruitment criteria included the ability to speak French or Haitian Creole. However, it was also a positive factor for assiduity levels for nutrition sessions. The fact that two of the three co-facilitators were of Haitian origin and all spoke Haitian Creole may have contributed to facilitate retainment in the program. Similarly, mingling with women who have common culture may have fostered cohesion and encouraged participants to return more often to the next sessions. Having similar sociocultural background for nutrition group counselling or other group therapy has been identified as a factor of effectiveness (\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e). The activities offered during nutrition sessions related to recipes, culinary habits, or valuing knowledge about plants and spices, which are culturally influenced, may also explain why this phenomenon was specifically observed during nutrition sessions.\u003c/p\u003e \u003cp\u003eFor non-nutritional sessions where no fresh food was provided, citing \u0026ldquo;\u003cem\u003etaking care of oneself and the baby\u003c/em\u003e\u0026rdquo; as the reason for participation was associated with high assiduity. Awareness of that prenatal care would improve the health of both mother and baby has been identified as a motivator that facilitates compliance (\u003cspan additionalcitationids=\"CR64\" citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e). This result aligns with several conceptual models of healthcare utilization, such the modified Gelberg-Anderson behavioral model for vulnerable populations, which identifies health beliefs, in particular the expected benefits of health services, as a predisposing factor for service use (\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e). In this context, this suggests that prior trust and trust built throughout the program may have influenced participation and assiduity, respectively.\u003c/p\u003e \u003cp\u003eResponsiveness of co-facilitators was an important moderator of quality of delivery. Their role - outside of sessions - of informing, mobilizing, reminding sessions and responding to individual needs was also a crucial moderator for participants responsiveness. However, their heavy workload and the lack of a clear written framework defining the boundaries of their responsibilities could undermine the fidelity of implementation over time, thereby compromising the sustainability of the intervention. Kangovi \u003cem\u003eet.al\u003c/em\u003e also mentioned the risk of burnout and even adverse effects on patients in the absence of program-specific guidelines or protocols for community health workers (\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e). Richard \u003cem\u003eet.al\u003c/em\u003e identified the development of a clear action plan as a condition of feasibility and success of health mediation implementation (\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e). More training, such as mental health first aid course, intensification of accompaniment and better networking among the actors for referring participants to the appropriate structures according to their needs, could also help to improve their working conditions and response to participants needs.\u003c/p\u003e \u003cp\u003eSoliciting healthcare professionals in the right way, without taking up too much of their limited time, could help improve their responsiveness, even if appropriateness (or perceived relevance) and acceptability were already high. This would also probably improve the clarity of the program, i.c. the comprehensiveness of an intervention description, thereby moderating the fidelity as described in Carroll's framework (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePrenatal care in France combines medical consultations for pregnancy follow-up or preventive care, with elective appointments, up to seven of which are completely free of charge for patients. These latter collective or individual classes are called \u0026ldquo;childbirth and parenting preparation\u0026rdquo;. Women without health coverage in French Guiana have less access to these as the majority are offered by independent midwives. Some themes of the non-nutrition sessions i.e. physical activity, breastfeeding and \u0026ldquo;maternity ward journey\u0026rdquo; are common with childbirth and parenting preparation classes. Providing the \u003cem\u003eNPTM 2\u003c/em\u003e program to pregnant women who do not usually engage in such classes (not only due to health coverage absence), is complementing the existing offer for the general population. Therefore, it aligns more closely with proportionate universalism than with a strictly targeted approach. Similarly to the group-care strategy, the intervention aimed to reduce the social gradient of health, by seeking cultural relevance, trust-building, empowerment and peer support (\u003cspan additionalcitationids=\"CR71\" citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eLimitations\u003c/p\u003e \u003cp\u003eIt was not possible to obtain the number of individuals eligible for the intervention who could have been approached, making it impossible to estimate coverage and analyze participation factors. Furthermore, the small number of participants limited the analysis of assiduity factors.\u003c/p\u003e \u003cp\u003eThe data on prenatal consultations were insufficient to assess whether the intervention could be a\u003c/p\u003e \u003cp\u003ebarrier, a facilitator, or a neutral factor for adherence to antenatal care.\u003c/p\u003e \u003cp\u003eFinally, this paper did not extensively explore aspects of viable validity (\u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e) or scalability (\u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e), all of which will be the subject of future research.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eCarroll et al.\u0026rsquo;s modified framework was useful for assessing the fidelity of this nutrition pilot intervention inspired by antenatal centering-based group care, and its moderators. The results showed that the intervention was successful in reaching individuals living in precarious situations and retaining socially isolated women in the program. However, the nutrition sessions prompted greater engagement among the most educated women, and the barrier of being a single mother may not have been fully overcome. This work also highlighted the need for a more comprehensive description of the program and improvements to the quality of delivery, providing co-facilitators with better support and clarifying the scope of their roles. Overall, these results will help with process and effectiveness evaluation and with transferability determination in other settings.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch3\u003eEthics approval and consent to participate\u003c/h3\u003e\n\u003cp\u003eAll subjects and their legal representatives (if they were under 18) provided informed consent before recruitment. The study was approved by the French ethics committee (\u0026ldquo;Comit\u0026eacute; de Protection des Personnes Sud-Est 1\u0026rdquo;) on 11 September 2023 (ID-RCB number: 2023-A01739-36).\u003c/p\u003e\n\u003ch3\u003eConsent for publication\u003c/h3\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch3\u003eAvailability of data and materials\u003c/h3\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003ch3\u003eCompeting interests\u003c/h3\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003ch3\u003eFunding\u003c/h3\u003e\n\u003cp\u003eThis study received public funding from the \u0026ldquo;Agence R\u0026eacute;gionale de Sant\u0026eacute; de Guyane\u0026rdquo; (French Guiana Regional Health Agency), the \u0026ldquo;Centre Hospitalier Universitaire de Guyane\u0026rdquo;, the \u0026ldquo;Dispositif Sp\u0026eacute;cifique R\u0026eacute;gional de P\u0026eacute;rinatalit\u0026eacute; Guyane\u0026rdquo; and the \u0026ldquo;Pr\u0026eacute;fecture de Guyane\u0026rdquo;.\u003c/p\u003e\n\u003ch3\u003eAuthors\u0026apos; contributions\u003c/h3\u003e\n\u003cp\u003eMSG, CB and CG conceptualised the study, OD conceptualised the external evaluation, NT and MSG implemented the study, MSG and CB analysed the data, MSG, CB, CG, OD, AD and MN contributed to interpretation and MG drafted the manuscript.\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final version of the manuscript.\u003c/p\u003e\n\n\u003ch3\u003eAcknowledgements\u003c/h3\u003e\n\u003cp\u003eThe authors thank all the study participants; the surveyors: Guerline Jean, Yslande Buissereth, Jovany Mac-Intosch and Ruth Alphonse; members of the research support team: Sonia Martin, Mayka Mergeay-Fabre, Christelle Elfort, Estelle Thomas, Linda Matignon, Li Marian and Charlotte Duborgel, as well as close partners: Vanessa Izeros and Jean-Luc Bauza.\u003c/p\u003e\n\n\u003ch3\u003eAuthors\u0026apos; information (optional)\u003c/h3\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBarrientos G, Ronchi F, Conrad ML. 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Health Promot Int 1 sept. 2013;28(3):285\u0026ndash;98. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/heapro/dar097\u003c/span\u003e\u003cspan address=\"10.1093/heapro/dar097\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-9023020/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9023020/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the context of an overseas territory of a high-income country characterized by high fertility rates, cultural diversity, and food insecurity, a small-scale collective intervention with a focus on nutrition was implemented among pregnant women. Inspired by centering-based group care, without the health care component and with a food aid component, the interactive group sessions were co-facilitated by an expert on the session's topic and a peer-facilitator. This paper describes the intervention, its underlying theory and presents the fidelity of the intervention following the Conceptual Framework for Implementation Fidelity developed by Carroll et al. (2007) and its modified versions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQuantitative data among the study participants were collected internally through questionnaires (pre- and post-intervention), intervention worksheets and medical records. Two ancillary studies provided qualitative information about the intervention participants' experience. Data among deliverers and “people who have influence over the outcome of implementation efforts” were collected quantitatively through self-questionnaires and qualitatively through semi-structured interviews. Descriptive, bivariate, and multivariate analyses were performed using Stata 19.5 software to determine the sociodemographic characteristics of participants and the determinants of assiduity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOverall, implementation was aligned with the original plan, with only a few minor adaptations. Despite contextual barriers and competing survival priorities, 77% of the 122 participants attended at least half of the sessions, indicating a satisfactory participation rate. The profile of participants showed that marginal exclusion of the most socioeconomically disadvantaged women appears to have been limited, and bivariate analysis revealed that women who reported suffering from social isolation actually showed greater commitment. Conversely, educational attainment was associated with higher assiduity in nutrition-focused sessions, and living in a single-adult household was negatively associated with overall assiduity, even after adjustment. Although the intervention demonstrated high appropriateness and was well-received from participants and all stakeholders, opportunities for improvement were identified regarding intervention clarity, organizational processes, and the scope of the mediation role.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThese findings inform the subsequent impact evaluation and its mechanisms of action. They also shed light on the potential transferability of a group-based intervention that addresses determinants of food insecurity during the first 1,000 days.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eclinicaltrials.gov number: NCT06528535. Release date: 07/23/2024.\u003c/p\u003e","manuscriptTitle":"Implementation fidelity of a pilot group-based nutrition intervention for pregnant women (Nutri Pou Ti Moun 2): a mixed method assessment","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-04 08:20:52","doi":"10.21203/rs.3.rs-9023020/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"330357396211527957665578346958127146940","date":"2026-05-14T07:52:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"48654079245773804360683619148152743740","date":"2026-05-13T00:16:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"166744793558530318851986316382619573230","date":"2026-05-12T08:03:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"312674921242704324826316196117476921906","date":"2026-05-11T08:19:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"1058161812235230579424974871224197919","date":"2026-05-11T02:50:31+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-21T16:27:17+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-11T13:01:17+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-11T13:01:06+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2026-03-03T18:16:37+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1fe2a0d1-ea15-4bc6-a599-15b5d51ceee6","owner":[],"postedDate":"May 4th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"330357396211527957665578346958127146940","date":"2026-05-14T07:52:20+00:00","index":87,"fulltext":""},{"type":"reviewerAgreed","content":"48654079245773804360683619148152743740","date":"2026-05-13T00:16:12+00:00","index":86,"fulltext":""},{"type":"reviewerAgreed","content":"166744793558530318851986316382619573230","date":"2026-05-12T08:03:59+00:00","index":85,"fulltext":""},{"type":"reviewerAgreed","content":"312674921242704324826316196117476921906","date":"2026-05-11T08:19:12+00:00","index":82,"fulltext":""},{"type":"reviewerAgreed","content":"1058161812235230579424974871224197919","date":"2026-05-11T02:50:31+00:00","index":80,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-04T08:20:58+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-04 08:20:52","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9023020","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9023020","identity":"rs-9023020","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}