Mary de Boer

All Publications

• Exploring the interplay of family dynamics and pregnancy supplement adherence among married women of reproductive age: a qualitative study from rural Bangladesh BMJ OPEN Mondal, P., de Boer, M., Rahman, A., Khaled, N., Zavala, E., Haque, R., Ali, H., Siddiqua, T., Afsana, K., Christian, P., Thorne-Lyman, A. L., Kalbarczyk, A. 2026; 16 (5): e115088

  Abstract

  To examine how household members, community health research workers (CHRWs) and broader social networks influenced pregnant women's capabilities, opportunities and motivations to consume a daily balanced-energy protein (BEP) supplement or a multiple micronutrient supplement (MMS) in the context of an effectiveness trial in rural Bangladesh.In-depth interviews, group interviews, focus group discussions, thematic analysis using the Capability, Opportunity, Motivation-Behaviour (COM-B) framework.Gaibandha, Bangladesh.Women (n=32) who had completed participation in the TARGET-BEP randomised trial, their husbands (n=13) and mothers-in-law (n=13), who participated in 13 group interviews, and CHRWs (n=39) who participated in six focus group discussions.Capability to adhere to BEP and MMS was strengthened when family members understood the value of supplements and actively supported supplementation. Children emerged as unexpected facilitators, reminding mothers to consume supplements and tracking intake. Opportunity to use supplements consistently was enhanced by women's educational attainment and the availability of household resources. Finally, motivation to take the supplements was influenced by many actors including neighbours, who could offer support but also often transmitted rumours and taboos, and CHRWs, who adeptly adapted adherence messages to the local context and to women's specific concerns.To improve antenatal supplement adherence and maternal-infant health in Bangladesh and similar contexts, pregnancy nutrition programmes should move beyond the woman-as-sole-agent paradigm by: (1) co-designing messages for husbands, mothers-in-law, children and neighbours in conversation with effective community health workers, such as those working in the TARGET-BEP trial; (2) equipping community health workers with flexible, family-engaging counselling strategies; and (3) complementing women's education gains with gender-transformative and family-inclusive interventions.ClinicalTrials.gov NCT05576207.

  View details for DOI 10.1136/bmjopen-2025-115088

  View details for Web of Science ID 001769603600001

  View details for PubMedID 42129982

  View details for PubMedCentralID PMC13182426

• Bridging Gender Gaps in Global Health: Insights from the Gender and Health Applied Learning Institute. Annals of global health de Boer, M., Banchoff, K., Morgan, R., Kalbarczyk, A. 2025; 91 (1): 57

  Abstract

  Background: Gender's influence on health outcomes is well-documented, yet gaps in gender expertise persist within the global health workforce. Simultaneously, accessible and interactive gender training opportunities are limited. The Johns Hopkins Bloomberg School of Public Health Gender and Health Summer Institute (GHSI), launched in 2023, aims to address these gaps by advancing the gender integration and analysis skills of health professionals. Methods: Using Stake's Countenance Model for educational evaluations, we explored whether the Institute was meeting its objective of providing applied knowledge and experience of gender integration and analysis for health research, programs, and policy. The evaluation focused on intended and actual program outcomes. We examined proposal documents and held discussions with the GHSI team. All students receive pre-course surveys one week prior to each course. Post-course surveys focused on changes in knowledge, skills, and abilities and overall experience. Two focus-group discussions were held with students. Survey data were analyzed descriptively in R, and qualitative data were analyzed thematically. Results: The pre-course survey received 137 unique responses; the post-course survey received 78 responses. Results indicate that the GHSI successfully met many of its intended goals, for example, by increasing participants' knowledge and skills in gender analysis and integration as well as confidence in applying new skills. Learning was enhanced through creating safe and inclusive spaces. However, the courses' short duration and lack of a sustained community of practice were identified as areas for improvement. Conclusion: Findings underscore the importance of applied skills training and the need for ongoing support to fully equip professionals to address gender disparities in health. The GHSI's virtual format also demonstrates a scalable, innovative approach other programs may consider. Finally, recommendations are provided for enhancing the GHSI and similar programs to better serve working professionals and foster a more equitable global health landscape.

  View details for DOI 10.5334/aogh.4811

  View details for PubMedID 40919333

  View details for PubMedCentralID PMC12412444

• Dietary diversity as a modifier of the effect of supplementation with multiple micronutrients during pregnancy on low birth weight in a randomized controlled trial in Bangladesh. The American journal of clinical nutrition de Boer, M., Thorne-Lyman, A. L., Shamim, A. A., Wu, L. S., Shaikh, S., Ali, H., West, K. P., Christian, P. 2025; 122 (3): 762-769

  Abstract

  Meta-analysis of trials of multiple micronutrient supplements (MMS) compared with iron-folic acid (IFA) suggests an overall benefit of 12% on low birth weight (LBW).Building on prior work showing that MMS is more effective in anemic and higher body mass index females; this paper explores whether dietary quality modifies the effect of MMS on birth weight.A 7-day food frequency questionnaire was administered in late pregnancy to 19,160 pregnant participants in the JiVitA-3 cluster-randomized controlled trial of MMS compared with IFA supplementation in Bangladesh. A 10-item dietary diversity score (DDS) was created by summing the number of food groups consumed ≥4 times per week. Risk ratios (RRs) and 95% confidence intervals (CIs) for the effect of MMS compared with IFA on LBW were estimated by DDS. The interaction between DDS and MMS was tested using a generalized estimating equations log-binomial regression model to account for the cluster randomization. Point estimates and 95% CI for the effect of MMS on LBW were estimated at each DDS. Models were adjusted for confounders. We used P < 0.1 to determine the statistical significance of the interaction.The median DDS was 3 (interquartile range: 2, 4), and 18.6% of pregnant women had a score ≥ 5. The fully adjusted protective effect of MMS on LBW was inversely associated with dietary diversity [MMS×DDS RR: 1.02 (95% CI: 1.00, 1.04), P-interaction = 0.05]. The effect was greatest at the lowest DDS [DDS= 1, RR LBW: 0.86 (0.81, 0.91)] and decreased at higher scores [DDS = 7, RR: 0.92 (0.84, 1.00)].In rural Bangladesh, where maternal dietary diversity was generally low, MMS (compared with IFA) supplementation had the strongest effect on reducing low birth weight among pregnant females with the least diverse diet, possibly reflecting the additional benefit of supplementation in this vulnerable group. This trial was registered at clinicaltrials.gov as NCT00860470.

  View details for DOI 10.1016/j.ajcnut.2025.07.007

  View details for PubMedID 40653272

• Measuring feasibility: complex questions need complex tools. BMJ global health de Boer, M., Kalbarczyk, A., Islam, M. N., Rodríguez, D. C., Sarker, M., Christian, P., Lyman, A. T. 2025; 10 (6)

  Abstract

  We sought to assess the feasibility of mainstreaming balanced energy protein supplementation, a maternal nutrition intervention, into Bangladesh's routine antenatal care system in tandem with an ongoing effectiveness trial in northwestern Bangladesh. Feasibility is an implementation science outcome defined as the extent to which a new intervention can be implemented successfully in a given context. We found feasibility difficult to measure using existing Anglophone quantitative tools translated into Bangla and identified particular challenges with using Likert scales. We also found it challenging to measure feasibility early in implementation, as recommended in the implementation science literature, due to potential respondents' unfamiliarity with the intervention and what implementation would look like. To address these issues, we explored alternative assessment methods, such as focus groups and workshops. These formats presented additional difficulties, including identifying the correct participants and moderating participant power dynamics. In conclusion, we question whether existing feasibility assessment tools, developed in English, are suitable for use in non-Anglophone contexts as well as whether Likert scales are appropriate for use in low-income and middle-income countries more broadly. We also question current recommendations on the timing of feasibility assessments. We feel that-particularly with new, difficult-to-conceptualise interventions-feasibility must be assessed later in implementation or only after providing detailed explanations of the intervention to respondents.

  View details for DOI 10.1136/bmjgh-2024-017331

  View details for PubMedID 40461057

  View details for PubMedCentralID PMC12142074

• Developing cadres of gender specialists in global public health to meet increasing demand. Frontiers in sociology Kalbarczyk, A., Banchoff, K., Perry, K., de Boer, M., Morgan, R. 2025; 10: 1501764

  Abstract

  Gender is increasingly prioritized in global health and embedded across the Sustainable Development Goals. This shift has created a demand for gender specialists with skills to integrate gender into research and programs. Most global health professionals lack formal training in gender analysis or integration. Gender is often misunderstood-conflated with sex, focused only on women, or limited to maternal health. Training can equip professionals to address these gaps, improve outcomes, and reduce inequities. We developed the Gender and Health Summer Institute at Johns Hopkins Bloomberg School of Public Health to grow this capacity. Using universal design, the Institute enhances accessibility, inclusivity, and engagement. Our goal: build a global cadre of gender specialists driving more gender-responsive and equitable health programs.

  View details for DOI 10.3389/fsoc.2025.1501764

  View details for PubMedID 40510843

  View details for PubMedCentralID PMC12160082

• A formative study of the sociocultural influences on dietary behaviours during pregnancy in rural Bangladesh. Maternal & child nutrition Khaled, N., Kalbarczyk, A., Zavala, E., Rahman, A., de Boer, M., Chakraborty, B., Rahman, H., Ali, H., Haque, R., Ayesha, K., Siddiqua, T. J., Afsana, K., Christian, P., Thorne-Lyman, A. L. 2024; 20 Suppl 6 (Suppl 6): e13713

  Abstract

  Balanced energy protein supplementation (BEP) is recommended for contexts of high maternal undernutrition by the World Health Organization. Despite recent improvements in undernutrition, Bangladesh remains a context where BEP could help accelerate progress towards nutrition goals. In preparation for an effective trial testing a fortified BEP, a qualitative study was undertaken to better understand sociocultural factors influencing dietary behaviours in pregnancy. Married women of reproductive age (n = 23), their husbands (n = 6) and mothers-in-law (n = 6) were interviewed, and focus group discussions were conducted with women (n = 4). Women had a clear understanding of which nutritious foods are important to consume during pregnancy, including green leafy vegetables, dairy and other animal-source foods. Many explained affordability as a barrier to consuming those foods with the desired frequency. Women acquired information about diet and nutrition in pregnancy from community health workers as well as other women in the community. Most preferred to seek information from their own networks before formal health care providers. Women and husbands generally had positive views about micronutrient supplements, although some mothers-in-law were more hesitant. Some food taboos relating to the consumption of certain foods like duck and pigeon meat persist, mainly stemming from concerns for the unborn child. Opportunities exist to build on existing perceptions of healthy diets, potentially framing food or nutrient supplements as a beneficial 'add-on' to promote a healthy pregnancy. There is a scope to strengthen nutrition counselling, especially for the family members, to dispel myths and misconceptions and promote dietary and other support for pregnant women.

  View details for DOI 10.1111/mcn.13713

  View details for PubMedID 39212336

  View details for PubMedCentralID PMC11439735

• Acceptability of a balanced energy protein (BEP) supplement for pregnant women in Bangladesh. Maternal & child nutrition Zavala, E., Rahman, A., Kalbarczyk, A., de Boer, M., Khaled, N., Chakraborty, B., Rahman, H., Ali, H., Haque, R., Ayesha, K., Siddiqua, T. J., Afsana, K., Christian, P., Thorne-Lyman, A. L. 2024; 20 Suppl 6 (Suppl 6): e13587

  Abstract

  Balanced energy protein (BEP) supplementation in pregnancy is recommended in the context of undernutrition for the reduction of small-for-gestational age neonates and stillbirths. To inform an effectiveness trial, we evaluated the acceptability of a packaged, ready-to-eat fortified BEP product among women of reproductive age and their health care providers (HCPs) in rural Bangladesh and explored the feasibility of adhering to daily supplementation. We implemented a formative study using focus groups discussions with women (n = 29) and HCPs (n = 17) to introduce the product and investigate components of acceptability. A "trials of improved practice" activity was conducted in subset of women (n = 16) to evaluate adherence to BEP over a 2-week period, followed by focus group discussions to identify challenges with adherence and strategies employed. Contributors to BEP acceptability included the product's sensory attributes, such as taste, smell and texture; the attractive packaging and informative labelling; and the perceived benefits of use. Participants also identified household and community level factors influencing the adoption of BEP, such as trust in the provider, cultural beliefs on supplement use in pregnancy, and family member tasting and approval. Over the 2-week period, women consumed over 80% of the supplements provided to them and identified strategies for adherence, including visual aids and reminders from family members or providers. HCPs recommended targeted communication messages for mothers-in-law to foster a supportive home environment. Findings informed changes to the BEP product to improve acceptability and shaped the content of communication messages to optimise adherence in a forthcoming effectiveness trial.

  View details for DOI 10.1111/mcn.13587

  View details for PubMedID 37991138

  View details for PubMedCentralID PMC11439734

• Assessing implementation outcomes for launching balanced energy protein supplementation: A formative study in rural Bangladesh. Maternal & child nutrition Kalbarczyk, A., de Boer, M., Khaled, N., Chakraborty, B., Rahman, A., Zavala, E., Rahman, H., Ali, H., Haque, R., Ayesha, K., Siddiqua, T. J., Afsana, K., Christian, P., Thorne-Lyman, A. 2024; 20 Suppl 6 (Suppl 6): e13606

  Abstract

  Balanced energy protein (BEP) supplementation is an efficacious intervention in pregnancy for improving birthweight and is recommended by World Health Organization (WHO) in countries with high maternal undernutrition. Few countries have implemented BEP programmes due in part to high cost, lack of data on acceptability and feasibility, and complexity of delivery. We sought to address implementation gaps in BEP interventions through a formative study designed to understand implementation outcomes. We conducted 52 in-depth interviews and 8 focus-group discussions with married women of reproductive age, family members, health care providers and pharmacists in three unions of the Gaibandha district in rural Bangladesh. Interviews were translated and transcribed in English and analysed using an analytic framework for implementation science in nutrition. BEP was viewed as an acceptable and appropriate intervention to combat undernutrition in this setting. There was a lack of clarity on who should or could be responsible for providing/distributing BEP in a way convenient to mothers. Many participants preferred door-to-door delivery and thought this approach could address social and gender inequities, but providers mentioned already being overworked and worried about adding new tasks. Participants were concerned about the affordability of BEP and opportunity costs associated with travel to proposed distribution sites such as ANC or pharmacies. Women in these communities do not always have the agency to travel without supervision or make purchasing decisions. BEP supplementation is a complex intervention; future trials seek to assess ways to overcome these implementation challenges and inform a long-term systems-owned BEP intervention.

  View details for DOI 10.1111/mcn.13606

  View details for PubMedID 38087927

  View details for PubMedCentralID PMC11439744