Enabling Environments for Non-communicable Disease Risk Reduction in Ethiopia

The ENABLE study is a two-arm, parallel-group, cluster-randomized controlled trial (cRCT) designed to address the rising burden of NCDs in Ethiopia by integrating NCD risk reduction counseling into routine ANC.

The investigators will evaluate the effectiveness and implementation of an integrated ANC-based intervention for reducing NCD risk factors during pregnancy in urban Ethiopia. The trial follows a Hybrid Type II effectiveness-implementation design, simultaneously assessing effectiveness on improving birth outcomes, specifically birth weight, and evaluating implementation processes under routine primary health care conditions.

The study will be conducted in 77 public urban health centers in four Ethiopian cities: Addis Ababa, Adama, Harar, and Jimma. Health centers and their catchment areas constitute the unit of randomization (clusters)," and are allocated in a 1:1 ratio to the intervention or control arm using covariate-constrained randomization to ensure balance by facility size and baseline ANC caseload. The trial will enroll 1,268 pregnant women (approximately 19 per cluster) who are attending their first routine ANC visit at ≤20 weeks of gestation. The women will be followed up through delivery.

The ENABLE intervention integrates structured counselling on three modifiable NCD risk factors, namely unhealthy diet, physical inactivity, and exposure to air pollution, into routine ANC services. The intervention is designed to be delivered within existing health care delivery systems by health workers and UHEPs within routine service workflows. Counseling follows the WHO 5As behavior change model (Ask, Advise, Assess, Assist, Arrange) which is based on WHO's brief intervention ("BRIEF project"), national ANC guidelines, and other relevant national recommendations and has been adapted to the local context.

Based on previous knowledge and formative work, the intervention is implemented through three tailored implementation strategies:

i) Facilitation: Trained facilitators provide ongoing support and collaborative problem-solving around intervention delivery to health workers and UHEPs to strengthen counseling skills and ensure fidelity to the intervention.

ii) Digital ANC eRegistry: A digital tool, adapted from the WHO Digital Adaptation Kit, supports standardized screening, clinical decision support, documentation, automates SMS reminders for patients, and routine monitoring of service quality and outcomes at the point of care.

iii) Training: Health workers in intervention facilities receive targeted training on NCD risk screening, counseling delivery, and use of the digital ANC eRegistry to promote sustainable integration of NCD prevention within routine maternal health services.

Health centers randomized to the control arm continue to provide standard routine ANC according to national guidelines, without access to ENABLE training, facilitation or the digital ANC eRegistry.

The primary effectiveness outcome is newborn birth weight. Other outcomes include maternal dietary quality, physical activity, behaviors related to indoor air pollution exposure, and quality of ANC service delivery and NCD-related screening and counseling practices. Implementation outcomes include feasibility, acceptability, appropriateness, fidelity, and contextual determinants of implementation. Data are collected using structured surveys, routine digital records, and qualitative methods (focus group discussions and interviews).

Additionally, a biomarker sub-study will examine early-life biological pathways associated with early NCD risks by analyzing maternal and newborn blood and urine samples from a subset of participants.

• Dietary Behavior [Time frame: Baseline (enrollment) and third trimester of pregnancy (≥28 weeks of gestation)]
• Physical activity [Time frame: Baseline (enrollment) and third trimester of pregnancy (≥28 weeks of gestation)]
• Air pollution exposure-related behaviors [Time frame: Baseline (enrollment) and third trimester of pregnancy (≥28 weeks of gestation)]
• Quality of NCD counseling during ANC [Time frame: Three occasions, i.e., baseline, and at 12 and 18 months after facilitation has commenced. The last measurement includes a 6-month follow-up after completing the facilitation component.]
• Quality of ANC related to NCDs [Time frame: Baseline, and at 12 months after implementation has commenced]