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src="/corehtml/pmc/pmcgifs/bookshelf/thumbs/th-niceng247er5-lrg.png" alt="Cover of Evidence reviews for interventions to increase uptake of vitamin supplements (including Healthy Start vitamins) in line with government advice" /></a></div><div class="bkr_bib"><h1 id="_NBK612337_"><span itemprop="name">Evidence reviews for interventions to increase uptake of vitamin supplements (including Healthy Start vitamins) in line with government advice</span></h1><div class="subtitle">Maternal and child nutrition</div><p><b>Evidence review E</b></p><p><i>NICE Guideline, No. 247</i></p><div class="half_rhythm">London: <a href="https://www.nice.org.uk" ref="pagearea=meta&targetsite=external&targetcat=link&targettype=publisher"><span itemprop="publisher">National Institute for Health and Care Excellence (NICE)</span></a>; <span itemprop="datePublished">2025 Jan</span>.<div class="small">ISBN-13: <span itemprop="isbn">978-1-4731-6747-6</span></div></div><div><a href="/books/about/copyright/">Copyright</a> © NICE 2025.</div></div><div class="bkr_clear"></div></div><div id="niceng247er5.s1"><h2 id="_niceng247er5_s1_">Interventions to increase uptake of vitamin supplements (including Healthy Start vitamins) in line with government advice</h2><div id="niceng247er5.s1.1"><h3>Review question</h3><p>What interventions are effective to increase uptake of vitamin supplements (including Healthy Start vitamins) in line with government advice for pregnant women, breastfeeding women, babies and children up to 5 years?</p><div id="niceng247er5.s1.1.1"><h4>Introduction</h4><p>The UK government recommend that women who are pregnant or breastfeeding, and babies and children under 5 years of age, take appropriate vitamin supplements to meet heightened nutritional requirements during these periods of rapid growth and development. For pregnant women the necessary supplements are folic acid and vitamin D, and breastfeeding women should take vitamin D. Vitamin D supplementation is recommended particularly during winter months, unless there are other risk factors. Under 5s should be given vitamin D from birth, and vitamins A and C from 6 months (with the exception of babies drinking more than 500ml of infant formula a day, given that this already contains vitamins). The government provides free vitamins to eligible women, babies and children under the Healthy Start scheme; including pregnant teenagers under 18 and those on very low incomes. These individuals are more likely to have poor quality diets which do not provide all the nutrients they need, and the vitamin supplements are intended to help address this. However, vitamin supplement use in line with government recommendations is generally low, including for those eligible for the Healthy Start scheme.</p><p>Understanding what interventions may be effective to increase uptake of government guidance on vitamin supplement use, including the supplements provided via Healthy Start, would enable healthcare professionals to give appropriate advice to parents and carers. The aim of this review is to find out what interventions are effective in increasing the uptake of vitamin supplements in line with government advice.</p></div><div id="niceng247er5.s1.1.2"><h4>Summary of the protocol</h4><p>See <a href="/books/NBK612337/table/niceng247er5.tab1/?report=objectonly" target="object" rid-ob="figobniceng247er5tab1">Table 1</a> for a summary of the Population, Intervention, Comparison and Outcome (PICO) characteristics of this review.</p><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng247er5tab1"><a href="/books/NBK612337/table/niceng247er5.tab1/?report=objectonly" target="object" title="Table 1" class="img_link icnblk_img" rid-ob="figobniceng247er5tab1"><img class="small-thumb" src="/corehtml/pmc/css/bookshelf/2.26/img/table-icon.gif" alt="Table Icon" /></a><div class="icnblk_cntnt"><h4 id="niceng247er5.tab1"><a href="/books/NBK612337/table/niceng247er5.tab1/?report=objectonly" target="object" rid-ob="figobniceng247er5tab1">Table 1</a></h4><p class="float-caption no_bottom_margin">Summary of the protocol (PICO table). </p></div></div><p>For further details see the review protocol in <a href="#niceng247er5.appa">appendix A</a>.</p></div><div id="niceng247er5.s1.1.3"><h4>Methods and process</h4><p>This evidence review was developed using the methods and process described in <a href="https://www.nice.org.uk/process/pmg20/chapter/introduction" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Developing NICE guidelines: the manual</a>. Methods specific to this review question are described in the review protocol in <a href="#niceng247er5.appa">appendix A</a> and the <a href="/books/NBK612337/bin/NG247-Supp1-methods.pdf">methods</a> document (supplementary document 1).</p><p>Declarations of interest were recorded according to <a href="https://www.nice.org.uk/about/who-we-are/policies-and-procedures" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">NICE’s conflicts of interest policy</a>.</p></div><div id="niceng247er5.s1.1.4"><h4>Effectiveness evidence</h4><div id="niceng247er5.s1.1.4.1"><h5>Included studies</h5><p>Four studies were included for this review, 2 randomised controlled trials (RCTs; <a class="bibr" href="#niceng247er5.s1.ref2" rid="niceng247er5.s1.ref2">de Nooijer 2012</a> and <a class="bibr" href="#niceng247er5.s1.ref3" rid="niceng247er5.s1.ref3">Evans 2014</a>), 1 cluster randomised trial (<a class="bibr" href="#niceng247er5.s1.ref4" rid="niceng247er5.s1.ref4">Madar 2009</a>), and 1 retrospective cohort study (<a class="bibr" href="#niceng247er5.s1.ref1" rid="niceng247er5.s1.ref1">Cawley 2020</a>).</p><p>As per protocol studies were from high-income countries and were conducted in the USA, The Netherlands or Norway.</p><p>The included studies are summarised in <a href="/books/NBK612337/table/niceng247er5.tab2/?report=objectonly" target="object" rid-ob="figobniceng247er5tab2">Table 2</a>.</p><p>Two studies compared interventions using information/education provision to status quo treatment (<a class="bibr" href="#niceng247er5.s1.ref1" rid="niceng247er5.s1.ref1">Cawley 2020</a> and <a class="bibr" href="#niceng247er5.s1.ref3" rid="niceng247er5.s1.ref3">Evans 2014</a>), 1 study compared multicomponent interventions of information/education provision and vitamin D drops supply to status quo (<a class="bibr" href="#niceng247er5.s1.ref4" rid="niceng247er5.s1.ref4">Madar 2009</a>) and 1 study compared multicomponent interventions of information/education provision and psychological or behavioural technique (implementation intention instruction) to information/education provision only (<a class="bibr" href="#niceng247er5.s1.ref2" rid="niceng247er5.s1.ref2">de Nooijer 2012</a>).</p><p>One study included a population of pregnant and postpartum women (<a class="bibr" href="#niceng247er5.s1.ref1" rid="niceng247er5.s1.ref1">Cawley 2020</a>), 1 study included pregnant women only (<a class="bibr" href="#niceng247er5.s1.ref3" rid="niceng247er5.s1.ref3">Evans 2014</a>), 1 study examined outcomes in children aged between 1 and 5 years (<a class="bibr" href="#niceng247er5.s1.ref2" rid="niceng247er5.s1.ref2">de Nooijer 2012</a>) and 1 study examined outcomes in babies from birth to 1 year (<a class="bibr" href="#niceng247er5.s1.ref4" rid="niceng247er5.s1.ref4">Madar 2009</a>).</p><p>Three studies reported on the critical outcome changes in vitamin supplementation uptake rate (<a class="bibr" href="#niceng247er5.s1.ref1" rid="niceng247er5.s1.ref1">Cawley 2020</a>, <a class="bibr" href="#niceng247er5.s1.ref2" rid="niceng247er5.s1.ref2">de Nooijer 2012</a> and <a class="bibr" href="#niceng247er5.s1.ref4" rid="niceng247er5.s1.ref4">Madar 2009</a>) and 1 study reported on the important outcome changes in attitudes, confidence and knowledge as part of people’s intention to change behaviour (with a focus on attitudes) (<a class="bibr" href="#niceng247er5.s1.ref3" rid="niceng247er5.s1.ref3">Evans 2014</a>). No evidence was found that reported on the important outcome unintended consequences as it relates to increase in inequalities and supplementation wastage.</p><p>Meta-analysis was not performed as the studies had different interventions/comparisons or they did not report the same outcome of interest.</p><p>Sensitivity analysis on the following component domains along with the interventions were planned if there was enough data available: component 1 mode of delivery, component 2 intervention aimed at individuals or groups, component 3, individualised/tailored interventions or general, component 4 who delivers the intervention, component 5 where the intervention is delivered, component 6 behaviour change models, techniques and theories. However, sensitivity analysis could not to be performed by component as there were not more than two studies per analysis.</p><p>None of the studies reported information on any of the subgroups prespecified in our protocol: Women and parents with disabilities, including learning disabilities and other physical and mental health conditions; women going through assisted conception; LGBTQ+ women and parents; children with developmental problems; geographical variation, for example, places without adequate provision of primary care (outside cities).</p><p>See the literature search strategy in <a href="#niceng247er5.appb">appendix B</a> and study selection flow chart in <a href="#niceng247er5.appc">appendix C</a>.</p></div><div id="niceng247er5.s1.1.4.2"><h5>Excluded studies</h5><p>Studies not included in this review are listed, and reasons for their exclusion are provided in <a href="#niceng247er5.appj">appendix J</a>.</p></div></div><div id="niceng247er5.s1.1.5"><h4>Summary of included studies</h4><p>Summaries of the studies that were included in this review are presented in <a href="/books/NBK612337/table/niceng247er5.tab2/?report=objectonly" target="object" rid-ob="figobniceng247er5tab2">Table 2</a>.</p><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng247er5tab2"><a href="/books/NBK612337/table/niceng247er5.tab2/?report=objectonly" target="object" title="Table 2" class="img_link icnblk_img" rid-ob="figobniceng247er5tab2"><img class="small-thumb" src="/corehtml/pmc/css/bookshelf/2.26/img/table-icon.gif" alt="Table Icon" /></a><div class="icnblk_cntnt"><h4 id="niceng247er5.tab2"><a href="/books/NBK612337/table/niceng247er5.tab2/?report=objectonly" target="object" rid-ob="figobniceng247er5tab2">Table 2</a></h4><p class="float-caption no_bottom_margin">Summary of included studies. </p></div></div><p>See the full evidence tables in <a href="#niceng247er5.appd">appendix D</a>. No meta-analysis was conducted (and so there are no forest plots in <a href="#niceng247er5.appe">appendix E</a>).</p></div><div id="niceng247er5.s1.1.6"><h4>Summary of the evidence</h4><div id="niceng247er5.s1.1.6.1"><h5>Comparison 1: Interventions using information/education provision versus status quo (including no treatment) in pregnant women– Combined components</h5><p>Two studies were included in this comparison. Results from 1 study in pregnant women showed that interventions using general information/education provision, delivered using digital/electronic interventions, aimed at individuals, delivered by peer and delivered on mobile devices showed no important difference for prenatal vitamin supplementation uptake in pregnant women when compared with status quo. Results from 1 study in pregnant women showed that interventions using general information/education provision, delivered using face to face and digital/electronic interventions, aimed at individuals, delivered by peer, on mobile devices and based on the health belief model and social cognitive theory showed an important benefit over status quo for change in attitudes towards prenatal vitamins in pregnant women based on the statement "Strongly agree that taking a prenatal vitamin will improve the health of my developing baby". However, there was no evidence of important differences found between the same intervention and comparator group for attitudes reflecting the statement "Strongly agree that taking a prenatal vitamin is important to the health of my developing baby".</p><p>The quality of the evidence was very low.</p></div><div id="niceng247er5.s1.1.6.2"><h5>Comparison 2: Multicomponent interventions (information/education provision and Vitamin D drops supply) versus status quo (including no treatment) in babies aged 3 months– Combined components</h5><p>One study in babies aged 3 months was included in this comparison. Multicomponent interventions involving general information/education provision and supply of vitamin D drops delivered using face to face and printed interventions, aimed at individuals and delivered by public health nurses in child health clinics showed an important benefit over status quo for vitamin D supplementation uptake rate in babies aged 3 months.</p><p>The quality of the evidence was very low.</p></div><div id="niceng247er5.s1.1.6.3"><h5>Comparison 3: Multicomponent interventions (information/education provision and psychological or behavioural technique) versus control (information/education provision only) in children 1 to 3.5 years– Combined components</h5><p>One study in children 1 to 3.5 years was included in this comparison. Multicomponent interventions involving general information/education provision and psychological or behavioural technique, delivered using face to face and printed interventions, aimed at individuals and delivered on an internet panel showed no evidence of important difference over information/education provision only for vitamin D supplementation uptake rate in children aged 1 to 3.5 years.</p><p>The quality of the evidence was low.</p><p>See <a href="#niceng247er5.appf">appendix F</a> for full GRADE tables.</p></div></div><div id="niceng247er5.s1.1.7"><h4>Economic evidence</h4><div id="niceng247er5.s1.1.7.1"><h5>Included studies</h5><p>Three economic studies were identified which were relevant to this question (<a class="bibr" href="#niceng247er5.s1.ref6" rid="niceng247er5.s1.ref6">Filby 2014</a>, <a class="bibr" href="#niceng247er5.s1.ref7" rid="niceng247er5.s1.ref7">Filby 2015</a>, <a class="bibr" href="#niceng247er5.s1.ref8" rid="niceng247er5.s1.ref8">Floreskul 2020</a>). There was also one study reporting utility data that was identified in this review (<a class="bibr" href="#niceng247er5.s1.ref5" rid="niceng247er5.s1.ref5">Aguiar 2020</a>), which could be used in economic modelling.</p><p>See the literature search strategy in <a href="#niceng247er5.appb">appendix B</a> and economic study selection flow chart in <a href="#niceng247er5.appg">appendix G</a>.</p></div><div id="niceng247er5.s1.1.7.2"><h5>Excluded studies</h5><p>Economic studies not included in this review are listed, and reasons for their exclusion are provided in <a href="#niceng247er5.appj">appendix J</a>.</p></div></div><div id="niceng247er5.s1.1.8"><h4>Summary of included economic evidence</h4><p>See <a href="/books/NBK612337/table/niceng247er5.tab3/?report=objectonly" target="object" rid-ob="figobniceng247er5tab3">Table 3</a> and <a href="/books/NBK612337/table/niceng247er5.tab4/?report=objectonly" target="object" rid-ob="figobniceng247er5tab4">Table 4</a> for the economic evidence profiles of the included studies.</p><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng247er5tab3"><a href="/books/NBK612337/table/niceng247er5.tab3/?report=objectonly" target="object" title="Table 3" class="img_link icnblk_img" rid-ob="figobniceng247er5tab3"><img class="small-thumb" src="/corehtml/pmc/css/bookshelf/2.26/img/table-icon.gif" alt="Table Icon" /></a><div class="icnblk_cntnt"><h4 id="niceng247er5.tab3"><a href="/books/NBK612337/table/niceng247er5.tab3/?report=objectonly" target="object" rid-ob="figobniceng247er5tab3">Table 3</a></h4><p class="float-caption no_bottom_margin">Economic evidence profile for interventions aiming to increase uptake of vitamin D in pregnant women, infants and children up to 5 years of age. </p></div></div><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng247er5tab4"><a href="/books/NBK612337/table/niceng247er5.tab4/?report=objectonly" target="object" title="Table 4" class="img_link icnblk_img" rid-ob="figobniceng247er5tab4"><img class="small-thumb" src="/corehtml/pmc/css/bookshelf/2.26/img/table-icon.gif" alt="Table Icon" /></a><div class="icnblk_cntnt"><h4 id="niceng247er5.tab4"><a href="/books/NBK612337/table/niceng247er5.tab4/?report=objectonly" target="object" rid-ob="figobniceng247er5tab4">Table 4</a></h4><p class="float-caption no_bottom_margin">Economic evidence profile for intervention aiming to increase uptake of Healthy Start vitamin programme in women planning a pregnancy, pregnant women, infants and children up to 5 years of age. </p></div></div></div><div id="niceng247er5.s1.1.9"><h4>Economic model</h4><p>This area was prioritised for de novo economic modelling. The committee selected to assess the cost-effectiveness of health technologies (such as apps), because these are the only interventions they considered for a recommendation which have promising evidence but are not currently in routine use in England. However, there was no adequate effectiveness evidence on health technologies to allow a meaningful and informative economic analysis to be carried out. Therefore, no economic model was developed for this review question.</p></div><div id="niceng247er5.s1.1.10"><h4>Economic evidence statement</h4><ul><li class="half_rhythm"><div>Evidence from 1 UK modelling study was unclear as to whether free vitamin D supplementation and information aiming to increase uptake of vitamin D to pregnant women up to 12 months post-partum and children aged <5 years was cost-effective versus no intervention, as the study did not use the QALY as the measure of outcome, so it was difficult to assess whether additional benefits (number of people taking vitamin D supplements and number of people with symptomatic vitamin D deficiency averted) were worth the extra costs incurred. The evidence is partially applicable to the NICE decision-making context as the study it did not use the QALY as the measure of outcome, and is characterised by potentially serious limitations.</div></li><li class="half_rhythm"><div>Evidence from 1 UK modelling study suggests that, compared with no intervention, free vitamin D supplementation to pregnant women and children <4 years of age is likely to be cost-effective if the study population has dark skin tone, may be cost-effective if the study population has medium skin tone, but is highly unlikely to be cost-effective if the study population has light skin tone. The evidence is directly applicable to the UK context and is characterised by potentially serious limitations.</div></li><li class="half_rhythm"><div>Evidence from 1 UK modelling study suggests that universal offering of the Healthy Start Vitamin programme to pregnant women from 10 weeks, women with a child aged <12 months, and children aged 6 months - 4 years is not cost-effective compared with the current offering of Healthy Start Vitamin programme (which involves pregnant women from 10 weeks aged <18 years, low-income adult pregnant women from 10 weeks, low-income women with a child aged <12 months, and children from low-income families aged 6 months - 4 years). On the other hand, universal offering of the Healthy Start Vitamin programme and extension to all women planning a pregnancy, all pregnant women regardless of month in pregnancy, women with a child aged <12 months, infants aged 0-6 months and children aged 6 months – 5 years is likely to be cost effective compared with the current offering of Healthy Start Vitamin programme. Universal offering of the Healthy Start Vitamin programme is particularly cost-effective when it is focused to all women planning a pregnancy and pregnant women within 10 weeks into pregnancy. The evidence is directly applicable to the UK context but is characterised by potentially serious limitations.</div></li></ul></div><div id="niceng247er5.s1.1.11"><h4>The committee’s discussion and interpretation of the evidence</h4><div id="niceng247er5.s1.1.11.1"><h5>The outcomes that matter most</h5><p>Changes in vitamin supplementation uptake rate was prioritised as the critical outcome by the committee because it is the most appropriate measure that directly answers the review question. The committee considered that both subjective and objective measures of vitamin supplementation uptake will be useful to determine the effectiveness of interventions aimed at improving uptake of vitamins in line with government advice.</p><p>The committee agreed that changes in attitude, confidence and knowledge as part of people’s intention to change behaviour and unintended consequences such as supplementation wastage and increase in inequalities should be important outcomes. This was because they are common factors to measure and target in an intervention and can ultimately impact on behaviour. In addition, inequalities are reported as part of the studies on Healthy Start in England.</p><p>No evidence was found that reported on the outcome unintended consequences.</p></div><div id="niceng247er5.s1.1.11.2"><h5>The quality of the evidence</h5><p>The quality of the evidence for outcomes was assessed using GRADE and the majority of the evidence was very low in quality. The main issues with the quality were due to bias arising from the methodological quality of the studies, indirect interventions due to broader intervention aims than the protocol for this review and imprecision.</p><p>Individual studies were assessed for methodological quality based on their study design. Randomised controlled trials were assessed using the Cochrane RoB 2.0 tool, cluster randomised studies were assessed using the Cochrane RoB 2.0 tool for cluster randomised trials and retrospective cohort studies were assessed using the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool. Concerns towards risk of bias for randomised control trials related to attrition, randomisation process, concealment of allocation, outcome measurement and analysis method. Concerns towards risk of bias for the cluster randomised trial related to measurement of outcome and missing outcome data. Concerns towards risk of bias for the retrospective cohort studies primarily related to retrospective classification of intervention groups, unclear details on initiation, adherence and deviations from intended interventions and unclear bias in selection of reported results.</p></div><div id="niceng247er5.s1.1.11.3"><h5>Benefits and harms</h5><p>The committee considered the current government advice from the Scientific Advisory Committee on Nutrition (SACN) for vitamins uptake in the different populations included in the review – pregnant women, breastfeeding women, babies <1 year and children between 1 and 5 years and agreed that all health professionals working with any of these populations should provide the key messages from the government advice on vitamins intake during pregnancy, breastfeeding and in children from birth to 5 years (<a class="bibr" href="#niceng247er5.s1.ref9" rid="niceng247er5.s1.ref9">SACN 2016</a>). The committee discussed that it is crucial to increase awareness on the importance of vitamin supplements in various settings as all these contacts would provide opportunities to counsel women about the benefits of vitamins for themselves and their babies and young children. In the evidence, this information was discussed during antenatal care, appointments or checks or at baby development check. The committee agreed that this setting and time point was appropriate for providing information and also used the qualitative evidence (see evidence report P) to suggest additional timepoints and settings for this to occur such as during antenatal and postnatal care appointments or checks, vaccination appointments (during pregnancy and after birth), at pharmacies, appointments in specialist clinics for pre-existing medical conditions (such as diabetes or epilepsy), within multi-agency health and social care hubs, at visits to young people’s services and at breastfeeding support group sessions.</p><p>The committee discussed that the available evidence did not show much benefit towards the use of digital or electronic means for providing information to pregnant women. While the committee noted from their experience that there is an increased use of digital technology for providing information, they did not make any recommendations towards digital technologies based on the limited low quality evidence. The committee agreed not to prioritise this topic for a research recommendation but made a related research recommendation on digital technologies to increase uptake of folic acid before and during pregnancy, see evidence review C for more details. The evidence showed that there was an important benefit in improving uptake of vitamin D in children with the use of face-to-face information provision/education and provision of leaflets when compared with status quo treatment. As there was no robust evidence on different modes of delivery, the committee agreed that the information could be delivered in different formats depending on feasibility and the person’s preference.</p><p>The committee discussed the low-quality evidence on behavioural intervention combined with providing information or education materials in relation to formulating an implementation intention for increasing uptake of vitamins in children. This showed no evidence of important difference and the committee agreed that no specific recommendation can be made in relation to behavioural interventions. The committee discussed techniques in the evidence that served as a helpful reminder to take vitamins. These included pairing a behaviour with a routine activity such as bedtime story or reminder through apps and in combination with the evidence from the qualitative report (evidence report P) came to the consensus that the health care provider should discuss ways to remember taking vitamin supplements each day.</p><p>The committee discussed current government advice on vitamin D supplementation. All pregnant or breastfeeding people are advised to take vitamin D supplement during the autumn and winter months when sunlight is not sufficient in the UK setting to provide enough vitamin D. However, vitamin D supplementation throughout the year is advised for people with reduced sun exposure, such as those who are not outdoors often or frequently cover their skin and people who are at a higher risk of not making sufficient vitamin D from sunlight, such as people with darker or medium skin tones. The committee wanted to highlight in the recommendations that the risk of vitamin D insufficiency during pregnancy may be increased in these populations. All young children are advised to take vitamin D supplementation throughout the year, except for infants who receive at least 500ml of formula milk per day.</p><p>There was very low-quality evidence on giving information along with supply of vitamin D drops for children that showed an important benefit. There was no clinical evidence found for interventions aimed at improving access to vitamin supplementation for pregnant or breastfeeding women or children. Evidence from an economic study among pregnant and breastfeeding women and their children showed free vitamin D provision to those with medium to dark skin to be cost-effective in preventing vitamin D deficiency and rickets. Based on the evidence the committee agreed that services should offer free vitamin D supplements for children under 5 years, pregnant and breastfeeding women if they are at increased risk of vitamin D deficiency because of their skin tone or because of lack of exposure to sunlight.</p><p>The committee discussed the free vitamin supplements that are offered to pregnant or breastfeeding people or children through the Healthy Start Scheme and agreed it is important that healthcare professionals discuss and provide information about the scheme, what the supplements contain, and refer people to the scheme if appropriate.</p><p>The committee also discussed eligibility in relation to free Healthy Start vitamins. The committee noted that Healthy Start scheme is income derived for those over 18 years of age (while all pregnant and/or breastfeeding teenagers under 18 are eligible) such that an individual needs to be in receipt of specific benefits to be eligible. However, the committee were aware that Healthy Start vitamins were already available free of charge in some areas regardless of the family’s income or their risk of vitamin D deficiency.</p><p>The committee came to the consensus that for households not eligible for free Healthy Start vitamins, advice should be provided in line with government advice. In addition, the committee came to the consensus that pregnant and breastfeeding people who are eligible for Healthy start vitamins should follow government advice on dosage, products or supplements to avoid (<a href="https://www.healthystart.nhs.uk/getting-vitamins/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Healthy Start vitamins</a> and <a href="https://www.nhs.uk/pregnancy/keeping-well/vitamins-supplements-and-nutrition/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">NHS advice on vitamins, supplements and nutrition in pregnancy</a>). The committee also discussed the needs of individuals who may be following a restricted diet, such as vegan or gluten-free diet, and came to the consensus that, following government advice, this population may also need to take a vitamin B12 supplement (<a href="https://www.nice.org.uk/guidance/indevelopment/gid-ng10176" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">NICE guideline on vitamin B12 deficiency in over 16s</a>, <a href="https://www.nhs.uk/pregnancy/keeping-well/vegetarian-or-vegan-and-pregnant/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">NHS advice on being vegetarian or vegan and pregnant</a> and <a href="https://www.nhs.uk/conditions/vitamins-and-minerals/vitamin-b/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">NHS advice on B vitamins</a>).</p><p>The committee discussed that in line with government advice (<a href="https://www.nhs.uk/start-for-life/baby/baby-vitamins/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">UK government advice about vitamins for babies</a> and <a href="https://www.nhs.uk/conditions/baby/weaning-and-feeding/vitamins-for-children/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">vitamins for children</a>), health care professionals should provide information and advice to parents and carers on vitamin supplementation such as which vitamins should be given and at what age, and how that is impacted if the baby is formula fed, and where to get the supplements.</p><p>All available evidence was in those with single pregnancies. There was no evidence for women with multiple pregnancies, hence the committee did not make any specific recommendations for this group. The committee referred to the section on diet, lifestyle and nutritional supplements in the NICE guideline on <a href="https://www.nice.org.uk/guidance/ng137/chapter/Recommendations#general-care" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Twin and triplet pregnancy</a>, as this provides advice on nutritional supplements for multiple pregnancies.</p></div><div id="niceng247er5.s1.1.11.4"><h5>Cost effectiveness and resource use</h5><p>There was UK evidence that offering Healthy Start supplements universally to the current target group (pregnant women from 10 weeks, women with a child aged under 12 months and children over 6 months and under 4 years) was not cost-effective; however, if universal offering was extended to women who are planning a pregnancy, women less than 10 weeks pregnant, infants aged 0–6 months and children aged from 4 to 5 years, then it became cost-effective as it increased vitamin uptake, but only if the cost per head of including women planning a pregnancy and those who are less than 10 weeks pregnant was not considerably higher than the cost per head for women already in the scheme. However, a mechanism would need to be identified to deliver a universal scheme to these 2 groups, which would require a new route to target women this early on.</p><p>There was evidence from a recent UK study that free vitamin D supplementation to pregnant women and children up to 4 years of age with darker or medium tone skin (who are at higher risk for vitamin D deficiency) is cost-effective, by reducing the risk of vitamin D deficiency and, consequently, reducing the risk of developing rickets in children. In contrast, free vitamin D supplementation to a respective population with light tone skin was not cost-effective. The review question was originally prioritised for economic modelling, as the committee wished to assess the cost-effectiveness of health technologies in enhancing uptake of vitamins. However, clinical evidence around health technologies was too limited and uncertain to inform an economic model. The recommendations made overall reflect current practice and aim to reiterate government advice and harmonise practice across settings, by providing advice during routine or other planned appointments. Moderate resource implications (in terms of health professionals’ time) are expected in settings where optimal advice on vitamin supplementation is currently not offered or is limited. The recommendation to offer free vitamin D supplements for women and people who are pregnant or breastfeeding, and for children under 5 years of age, if they have darker skin or limited exposure to sun, may also have small to moderate resource implications to settings where this is not current practice, comprising the acquisition cost of the vitamin supplements. However, as reported above, offering free vitamin D supplementation to a population of pregnant women and children up to 4 years of age who have darker skin (and are thus at a higher risk for vitamin D deficiency) was found to be cost-effective in the UK, as it reduced the risk of rickets in children and therefore led to clinical benefits for the children and future cost-savings to the NHS. The recommendation was not expanded to the respective population with light skin tone because evidence suggested that this was highly unlikely to be cost-effective, due to this population’s lower risk of vitamin D deficiency and, subsequently, for development of rickets in children.</p></div><div id="niceng247er5.s1.1.11.5"><h5>Other factors the committee took into account</h5><p>For this review question, in relation to vitamin supplementation during or after pregnancy, the population in the evidence was women and no evidence was identified or reviewed for trans men or non-binary people. The protocol and literature searches were not designed to specifically look for evidence on trans men or non-binary people but they were also not excluded. However, there is a small chance evidence on them may not have been captured, if such evidence exists. In discussing the evidence, the committee considered whether the recommendations could apply to a broader population, and used gender inclusive language to promote equity, respect and effective communication with everyone. Healthcare professionals should use their clinical judgement when implementing the recommendations, taking into account each person’s circumstances, needs and preferences, and ensuring all people are treated with dignity and respect throughout their care.</p></div></div><div id="niceng247er5.s1.1.12"><h4>Recommendations supported by this evidence review</h4><p>This evidence review supports recommendations 1.1.10 to 1.1.14. Other evidence supporting these recommendations can be found in the evidence review P on facilitators and barriers to increase the uptake of government advice on folic acid and vitamin supplements.</p></div></div><div id="niceng247er5.s1.rl.r1"><h3>References – included studies</h3><ul class="simple-list"><div id="niceng247er5.s1.rl.r1.1"><h4>Effectiveness</h4><ul class="simple-list"><li class="half_rhythm"><p><div class="bk_ref" id="niceng247er5.s1.ref1"><p id="p-211">
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<strong>Cawley 2020</strong>
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</p>Cawley, Caroline, Buckenmeyer, Hannelore, Jellison, Trina
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et al. Effect of a Health System-Sponsored Mobile App on Perinatal Health Behaviors: Retrospective Cohort Study. JMIR mHealth and uHealth
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8(7): e17183, 2020
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[<a href="/pmc/articles/PMC7380997/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC7380997</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/32628123" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 32628123</span></a>]</div></p></li><li class="half_rhythm"><p><div class="bk_ref" id="niceng247er5.s1.ref2"><p id="p-212">
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<strong>de Nooijer 2012</strong>
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</p>de Nooiier, J.; Jansen, R.; van Assema, P.
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The use of implementation intentions to promote vitamin D supplementation in young children. Nutrients
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4(10): 1454–1463, 2012
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[<a href="/pmc/articles/PMC3497004/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC3497004</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/23201764" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 23201764</span></a>]</div></p></li><li class="half_rhythm"><p><div class="bk_ref" id="niceng247er5.s1.ref3"><p id="p-213">
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<strong>Evans 2014</strong>
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</p>Evans, WD, Wallace Bihm, J, Szekely, D
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et al. Initial outcomes from a 4-week follow-up study of the Text4baby program in the military women’s population: randomized controlled trial. Journal of medical Internet research
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16(5): e131, 2014
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[<a href="/pmc/articles/PMC4051747/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC4051747</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/24846909" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 24846909</span></a>]</div></p></li><li class="half_rhythm"><p><div class="bk_ref" id="niceng247er5.s1.ref4"><p id="p-214">
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<strong>Madar 2009</strong>
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</p>Madar
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AA; Klepp
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K; Meyer
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HE. Effect of free vitamin D(2) drops on serum 25-hydroxyvitamin D in infants with immigrant origin: a cluster randomized controlled trial. Eur J Clin Nutr
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63(4): 478–84, 2009
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[<a href="https://pubmed.ncbi.nlm.nih.gov/18231120" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 18231120</span></a>]</div></p></li></ul></div><div id="niceng247er5.s1.rl.r1.2"><h4>Economic</h4><ul class="simple-list"><li class="half_rhythm"><p><div class="bk_ref" id="niceng247er5.s1.ref5"><p id="p-215">
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<strong>Aguiar 2020</strong>
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</p>Aguiar
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M, Andronis
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L, Pallan
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M, Högler
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W, Frew
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E (2020). Micronutrient deficiencies and health-related quality of life: the case of children with vitamin D deficiency. Public Health Nutr, 23(7), 1165–1172.
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[<a href="/pmc/articles/PMC10200666/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC10200666</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/30744725" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 30744725</span></a>]</div></p></li><li class="half_rhythm"><p><div class="bk_ref" id="niceng247er5.s1.ref6"><p id="p-216">
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<strong>Filby 2014</strong>
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</p>Filby
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A, Lewis
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L, Taylor
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M. National Institute for Health and Care Excellence. An Economic Evaluation of Interventions to Improve the Uptake of Vitamin D Supplements in England and Wales. Report. York Health Economics Consortium, 2014.</div></p></li><li class="half_rhythm"><p><div class="bk_ref" id="niceng247er5.s1.ref7"><p id="p-217">
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<strong>Filby 2015</strong>
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</p>Filby
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A, Taylor
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M, Jenks
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M, Burley
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V. National Institute for Health and Care Excellence. Examining the cost-effectiveness of moving the Healthy Start Vitamin Programme from a targeted to a universal offering. Final report. York Health Economics Consortium, 2015.</div></p></li><li class="half_rhythm"><p><div class="bk_ref" id="niceng247er5.s1.ref8"><p id="p-218">
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<strong>Floreskul 2020</strong>
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</p>Floreskul
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V, Juma
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FZ, Daniel
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AB, Zamir
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I, Rawdin
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A, Stevenson
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M, Mughal
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Z, Padidela
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R (2020). Cost-Effectiveness of Vitamin D Supplementation in Pregnant Woman and Young Children in Preventing Rickets: A Modeling Study. Front Public Health, 8:439.
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[<a href="/pmc/articles/PMC7498641/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC7498641</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/33014962" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 33014962</span></a>]</div></p></li></ul></div><div id="niceng247er5.s1.rl.r1.3"><h4>Other</h4><ul class="simple-list"><li class="half_rhythm"><p><div class="bk_ref" id="niceng247er5.s1.ref9"><p id="p-219">
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<strong>SACN 2016</strong>
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</p>Scientific Advisory Committee on Nutrition (SACN). Vitamin D and health. 2016. Available from: <a href="https://www.gov.uk/government/publications/sacn-vitamin-d-and-health-report" ref="pagearea=cite-ref&targetsite=external&targetcat=link&targettype=uri">https://www<wbr style="display:inline-block"></wbr>​.gov.uk/government<wbr style="display:inline-block"></wbr>​/publications<wbr style="display:inline-block"></wbr>​/sacn-vitamin-d-and-health-report</a> [accessed 13 March 2024]</div></p></li></ul></div></ul></div></div><div id="appendixesappgroup1"><h2 id="_appendixesappgroup1_">Appendices</h2><div id="niceng247er5.appa"><h3>Appendix A. Review protocols</h3><p id="niceng247er5.appa.et1"><a href="/books/NBK612337/bin/niceng247er5-appa-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Review protocol for review question: What interventions are effective to increase uptake of vitamin supplements (including Healthy Start vitamins) in line with government advice for pregnant women, breastfeeding women, babies and children up to 5 years?</a><span class="small"> (PDF, 286K)</span></p></div><div id="niceng247er5.appb"><h3>Appendix B. Literature search strategies</h3><p id="niceng247er5.appb.et1"><a href="/books/NBK612337/bin/niceng247er5-appb-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Literature search strategies for review question: What interventions are effective to increase uptake of vitamin supplements (including Healthy Start vitamins) in line with government advice for pregnant women, breastfeeding women, babies and children up to 5 years?</a><span class="small"> (PDF, 390K)</span></p></div><div id="niceng247er5.appc"><h3>Appendix C. Effectiveness evidence study selection</h3><p id="niceng247er5.appc.et1"><a href="/books/NBK612337/bin/niceng247er5-appc-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Study selection for: What interventions are effective to increase uptake of vitamin supplements (including Healthy Start vitamins) in line with government advice for pregnant women, breastfeeding women, babies and children up to 5 years?</a><span class="small"> (PDF, 180K)</span></p></div><div id="niceng247er5.appd"><h3>Appendix D. Evidence tables</h3><p id="niceng247er5.appd.et1"><a href="/books/NBK612337/bin/niceng247er5-appd-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Evidence tables for review question: What interventions are effective to increase uptake of vitamin supplements (including Healthy Start vitamins) in line with government advice for pregnant women, breastfeeding women, babies and children up to 5 years?</a><span class="small"> (PDF, 287K)</span></p></div><div id="niceng247er5.appe"><h3>Appendix E. Forest plots</h3><div id="niceng247er5.appe.s1"><h4>Forest plots for review question: What interventions are effective to increase uptake of vitamin supplements (including Healthy Start vitamins) in line with government advice for pregnant women, breastfeeding women, babies and children up to 5 years?</h4><p>No meta-analysis was conducted for this review question and so there are no forest plots.</p></div></div><div id="niceng247er5.appf"><h3>Appendix F. GRADE tables</h3><p id="niceng247er5.appf.et1"><a href="/books/NBK612337/bin/niceng247er5-appf-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">GRADE tables for review question: What interventions are effective to increase uptake of vitamin supplements (including Healthy Start vitamins) in line with government advice for pregnant women, breastfeeding women, babies and children up to 5 years?</a><span class="small"> (PDF, 192K)</span></p></div><div id="niceng247er5.appg"><h3>Appendix G. Economic evidence study selection</h3><p id="niceng247er5.appg.et1"><a href="/books/NBK612337/bin/niceng247er5-appg-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Study selection for: What interventions are effective to increase uptake of vitamin supplements (including Healthy Start vitamins) in line with government advice for pregnant women, breastfeeding women, babies and children up to 5 years?</a><span class="small"> (PDF, 114K)</span></p></div><div id="niceng247er5.apph"><h3>Appendix H. Economic evidence tables</h3><p id="niceng247er5.apph.et1"><a href="/books/NBK612337/bin/niceng247er5-apph-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Economic evidence tables for review question: What interventions are effective to increase uptake of vitamin supplements (including Healthy Start vitamins) in line with government advice for pregnant women, breastfeeding women, babies and children up to 5 years?</a><span class="small"> (PDF, 173K)</span></p></div><div id="niceng247er5.appi"><h3>Appendix I. Economic model</h3><div id="niceng247er5.appi.s1"><h4>Economic model for review question: What interventions are effective to increase uptake of vitamin supplements (including Healthy Start vitamins) in line with government advice for pregnant women, breastfeeding women, babies and children up to 5 years?</h4><p>This area was prioritised for de novo economic modelling. The committee selected to assess the cost-effectiveness of health technologies (such as apps), because these are the only interventions they considered for a recommendation which have promising evidence but are not currently in routine use in England. However, there was no adequate effectiveness evidence on health technologies to allow a meaningful and informative economic analysis to be carried out. Therefore, no economic model was developed for this review question.</p></div></div><div id="niceng247er5.appj"><h3>Appendix J. Excluded studies</h3><div id="niceng247er5.appj.s1"><h4>Excluded studies for review question: What interventions are effective to increase uptake of vitamin supplements (including Healthy Start vitamins) in line with government advice for pregnant women, breastfeeding women, babies and children up to 5 years?</h4><div id="niceng247er5.appj.s1.1"><h5>Excluded effectiveness studies</h5><p>The excluded studies table only lists the studies that were considered and then excluded at the full-text stage for this review (N=17) and not studies (N=42) that were considered and then excluded from the search at the full-text stage as per the PRISMA diagram in Appendix C for the other review question in the same search (see evidence review C).</p><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng247er5appjtab1"><a href="/books/NBK612337/table/niceng247er5.appj.tab1/?report=objectonly" target="object" title="Table 11" class="img_link icnblk_img" rid-ob="figobniceng247er5appjtab1"><img class="small-thumb" src="/corehtml/pmc/css/bookshelf/2.26/img/table-icon.gif" alt="Table Icon" /></a><div class="icnblk_cntnt"><h4 id="niceng247er5.appj.tab1"><a href="/books/NBK612337/table/niceng247er5.appj.tab1/?report=objectonly" target="object" rid-ob="figobniceng247er5appjtab1">Table 11</a></h4><p class="float-caption no_bottom_margin">Excluded studies and reasons for their exclusion. </p></div></div></div><div id="niceng247er5.appj.s1.2"><h5>Excluded economic studies</h5><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng247er5appjtab2"><a href="/books/NBK612337/table/niceng247er5.appj.tab2/?report=objectonly" target="object" title="Table" class="img_link icnblk_img" rid-ob="figobniceng247er5appjtab2"><img class="small-thumb" src="/corehtml/pmc/css/bookshelf/2.26/img/table-icon.gif" alt="Table Icon" /></a><div class="icnblk_cntnt"><h4 id="niceng247er5.appj.tab2"><a href="/books/NBK612337/table/niceng247er5.appj.tab2/?report=objectonly" target="object" rid-ob="figobniceng247er5appjtab2">Table</a></h4></div></div></div></div></div><div id="niceng247er5.appk"><h3>Appendix K. Research recommendations – full details</h3><div id="niceng247er5.appk.s1"><h4>Research recommendations for review question: What interventions are effective to increase uptake of vitamin supplements (including Healthy Start vitamins) in line with government advice for pregnant women, breastfeeding women, babies and children up to 5 years?</h4><p>No research recommendations were made for this review question.</p></div></div></div></div><div class="fm-sec"><div><p>Final</p></div><div><p>Evidence reviews underpinning recommendations 1.1.10 to 1.1.14 in the NICE guideline</p><p>These evidence reviews were developed by NICE</p></div><div><p><b>Disclaimer</b>: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.</p><p>Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.</p><p>NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the <a href="https://www.gov.wales/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Welsh Government</a>, <a href="http://www.scotland.gov.uk/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Scottish Government</a>, and <a href="http://www.northernireland.gov.uk/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Northern Ireland Executive</a>. All NICE guidance is subject to regular review and may be updated or withdrawn.</p></div><div class="half_rhythm"><a href="/books/about/copyright/">Copyright</a> © NICE 2025.</div><div class="small"><span class="label">Bookshelf ID: NBK612337</span><span class="label">PMID: <a href="https://pubmed.ncbi.nlm.nih.gov/39993052" title="PubMed record of this title" ref="pagearea=meta&targetsite=entrez&targetcat=link&targettype=pubmed">39993052</a></span></div></div><div class="small-screen-prev"></div><div class="small-screen-next"></div></article><article data-type="table-wrap" id="figobniceng247er5tab1"><div id="niceng247er5.tab1" class="table"><h3><span class="label">Table 1</span><span class="title">Summary of the protocol (PICO table)</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK612337/table/niceng247er5.tab1/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng247er5.tab1_lrgtbl__"><table><tbody><tr><th id="hd_b_niceng247er5.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Population</th><td headers="hd_b_niceng247er5.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<ul><li class="half_rhythm"><div>women in a single or multiple pregnancy</div></li><li class="half_rhythm"><div>breastfeeding women</div></li><li class="half_rhythm"><div>babies ≤1 year</div></li><li class="half_rhythm"><div>children between 1 year and 5 years</div></li></ul></td></tr><tr><th id="hd_b_niceng247er5.tab1_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Intervention</th><td headers="hd_b_niceng247er5.tab1_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<ul><li class="half_rhythm"><div><b>intervention group 1:</b> Interventions using information provision and/or education</div></li><li class="half_rhythm"><div><b>intervention group 2:</b> Interventions using alternative forms of vitamin supplementation (drops or tablets)</div></li><li class="half_rhythm"><div><b>intervention group 3:</b> Interventions aimed at improving access to vitamin supplementation (that is, provision of vitamin supplementation in different settings or incorporation of vitamin in welfare schemes)</div></li><li class="half_rhythm"><div><b>intervention group 4:</b> Interventions using psychological or behavioural techniques</div></li><li class="half_rhythm"><div><b>intervention group 5:</b> Multicomponent interventions (interventions that combine more than 1 intervention listed above).</div></li></ul>
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The committee anticipated that, along with the intervention, studies would report at least 1 component of each of the groups noted below. Sensitivity analyses will be done according to these if enough data is available.
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<ul><li class="half_rhythm"><div><b>component 1:</b> Mode of delivery</div></li><li class="half_rhythm"><div><b>component 2:</b> Intervention aimed at individuals or groups</div></li><li class="half_rhythm"><div><b>component 3:</b> Individualised or tailored interventions</div></li><li class="half_rhythm"><div><b>component 4:</b> Who delivers the intervention</div></li><li class="half_rhythm"><div><b>component 5:</b> Where is the intervention delivered</div></li><li class="half_rhythm"><div><b>component 6</b>: Behaviour change models, techniques and theories</div></li></ul></td></tr><tr><th id="hd_b_niceng247er5.tab1_1_1_3_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Comparison</th><td headers="hd_b_niceng247er5.tab1_1_1_3_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<ul><li class="half_rhythm"><div>one of the above interventions (within the same group or different group interventions will be considered)</div></li><li class="half_rhythm"><div>status quo/treatment as usual (as defined by study authors, includes no treatment)</div></li><li class="half_rhythm"><div>time (before and after)</div></li></ul></td></tr><tr><th id="hd_b_niceng247er5.tab1_1_1_4_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Outcome</th><td headers="hd_b_niceng247er5.tab1_1_1_4_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p><b>Critical</b>
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<ul><li class="half_rhythm"><div>changes in vitamin supplementation uptake rate (self-reported or objective measured)</div></li></ul></p>
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<p><b>Important</b>
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<ul><li class="half_rhythm"><div>changes in attitude, confidence, and knowledge as part of people’s intention to change behaviour.</div></li><li class="half_rhythm"><div>unintended consequences:
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<ul class="circle"><li class="half_rhythm"><div>increase in inequalities</div></li><li class="half_rhythm"><div>supplementation wastage</div></li></ul></div></li></ul></p>
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</td></tr></tbody></table></div></div></article><article data-type="table-wrap" id="figobniceng247er5tab2"><div id="niceng247er5.tab2" class="table"><h3><span class="label">Table 2</span><span class="title">Summary of included studies</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK612337/table/niceng247er5.tab2/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng247er5.tab2_lrgtbl__"><table class="no_bottom_margin"><thead><tr><th id="hd_h_niceng247er5.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Study</th><th id="hd_h_niceng247er5.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Population</th><th id="hd_h_niceng247er5.tab2_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Intervention</th><th id="hd_h_niceng247er5.tab2_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Comparison</th><th id="hd_h_niceng247er5.tab2_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Outcomes</th></tr></thead><tbody><tr><td headers="hd_h_niceng247er5.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p><a class="bibr" href="#niceng247er5.s1.ref1" rid="niceng247er5.s1.ref1">Cawley 2020</a></p>
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<p>Retrospective cohort study</p>
|
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<p>USA</p></td><td headers="hd_h_niceng247er5.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>N=567</p>
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<p>Women who gave birth to a live infant in the previous 4 – 6 months</p>
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<p>Mean age in years (SD): Not reported, but age >18</p>
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</td><td headers="hd_h_niceng247er5.tab2_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p><u>Information/education provision</u></p>
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<p>Circle app: Personalised health information for prenatal and postpartum care and paediatric care up to 18 years</p></td><td headers="hd_h_niceng247er5.tab2_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p><u>Status quo treatment</u></p>
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<p>No Circle app</p></td><td headers="hd_h_niceng247er5.tab2_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<ul><li class="half_rhythm"><div>vitamin supplementation uptake in pregnant and postpartum women (Follow-up unclear)</div></li></ul></td></tr><tr><td headers="hd_h_niceng247er5.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p><a class="bibr" href="#niceng247er5.s1.ref2" rid="niceng247er5.s1.ref2">de Nooijer 2012</a></p>
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<p>RCT</p>
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<p>The Netherlands</p>
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</td><td headers="hd_h_niceng247er5.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p>N = 171</p>
|
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<p>Parents of children aged 1 to 3½ years</p>
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<p>Child mean age in years (SD): 2.3 (0.8)</p></td><td headers="hd_h_niceng247er5.tab2_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p><u>Multicomponent intervention (information/education provision and behavioural intervention)</u></p>
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<p>Implementation intention instruction: Parents were asked to formulate an implementation intention toward giving their child 10µg vitamin D daily. In addition, parents were provided with written information on vitamin D supplementation, why it is important in children and the required amount.</p></td><td headers="hd_h_niceng247er5.tab2_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p><u>Information provision only</u></p>
|
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<p>No implementation intention instruction: Parents were provided with written information on vitamin D supplementation, why it is important in children and the required amount, but with no request to formulate an implementation intention.</p></td><td headers="hd_h_niceng247er5.tab2_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
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<ul><li class="half_rhythm"><div>vitamin supplementation uptake in children (4 weeks follow-up)</div></li></ul></td></tr><tr><td headers="hd_h_niceng247er5.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p><a class="bibr" href="#niceng247er5.s1.ref3" rid="niceng247er5.s1.ref3">Evans 2014</a></p>
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<p>RCT</p>
|
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<p>USA</p></td><td headers="hd_h_niceng247er5.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p>N = 943</p>
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<p>Women who presented for prenatal care prior to 14 weeks gestation</p>
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<p>Mean age in years (SD): Not reported, but age 18-45</p>
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</td><td headers="hd_h_niceng247er5.tab2_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p><u>Information/education provision</u></p>
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<p>Text4baby: Receipt of distinct prenatal information via text messaging</p></td><td headers="hd_h_niceng247er5.tab2_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p><u>Status quo</u></p>
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<p>Usual care</p></td><td headers="hd_h_niceng247er5.tab2_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<ul><li class="half_rhythm"><div>attitudes towards prenatal vitamins in pregnant women (4 weeks follow-up)</div></li></ul></td></tr><tr><td headers="hd_h_niceng247er5.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p><a class="bibr" href="#niceng247er5.s1.ref4" rid="niceng247er5.s1.ref4">Madar 2009</a></p>
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<p>Cluster RCT</p>
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<p>Norway</p></td><td headers="hd_h_niceng247er5.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p>N = 51</p>
|
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<p>Number of clusters = 8</p>
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<p>Women who attended 6-week check of their infants</p>
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<p>Infants’ age, mean (SD), weeks</p>
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<p>Intervention = 7 (1.7)</p>
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<p>Control = 6.9 (1.8)</p></td><td headers="hd_h_niceng247er5.tab2_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p><u>Multicomponent interventions (information/education provision and vitamin D drops supply)</u></p>
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<p>Free Vitamin D2 drops: Free vitamin drops in addition to brochure describing importance of vitamin D and instructions on how to administer the drops</p></td><td headers="hd_h_niceng247er5.tab2_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p><u>Status quo</u></p>
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<p>Usual care: Oral information about vitamin D and recommendation of vitamin D supplementation to the infants</p></td><td headers="hd_h_niceng247er5.tab2_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<ul><li class="half_rhythm"><div>vitamin D supplementation uptake (Approximately 6 weeks follow-up)</div></li></ul></td></tr></tbody></table></div><div class="tblwrap-foot"><div><dl class="temp-labeled-list small"><dl class="bkr_refwrap"><dt></dt><dd><div><p class="no_margin">RCT: randomised controlled trial; USA: United States of America</p></div></dd></dl></dl></div></div></div></article><article data-type="table-wrap" id="figobniceng247er5tab3"><div id="niceng247er5.tab3" class="table"><h3><span class="label">Table 3</span><span class="title">Economic evidence profile for interventions aiming to increase uptake of vitamin D in pregnant women, infants and children up to 5 years of age</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK612337/table/niceng247er5.tab3/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng247er5.tab3_lrgtbl__"><table class="no_bottom_margin"><thead><tr><th id="hd_h_niceng247er5.tab3_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Study and country</th><th id="hd_h_niceng247er5.tab3_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Limitations</th><th id="hd_h_niceng247er5.tab3_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Applicability</th><th id="hd_h_niceng247er5.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Other comments</th><th id="hd_h_niceng247er5.tab3_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Incremental costs<sup>1</sup></th><th id="hd_h_niceng247er5.tab3_1_1_1_6" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Incremental effects</th><th id="hd_h_niceng247er5.tab3_1_1_1_7" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">ICER</th><th id="hd_h_niceng247er5.tab3_1_1_1_8" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Uncertainty</th></tr></thead><tbody><tr><td headers="hd_h_niceng247er5.tab3_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>
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<a class="bibr" href="#niceng247er5.s1.ref6" rid="niceng247er5.s1.ref6">Filby 2014</a>
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</p>
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<p>UK</p>
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</td><td headers="hd_h_niceng247er5.tab3_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Potentially serious<sup>1</sup></td><td headers="hd_h_niceng247er5.tab3_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Partially applicable<sup>2</sup></td><td headers="hd_h_niceng247er5.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p>Population: Pregnant women up to 12 months post-partum and children aged <5 years</p><p>Free vitamin D supplementation and information aiming to increase uptake of vitamin D, vs. no intervention</p>
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<p>Outcomes: (a) number of people taking vitamin D supplements; (b) number of people with symptomatic vitamin D deficiency</p><p>Time horizon NR</p><p>Cost year: 2012-13</p><p>In the estimation of ICER, only respective costs for each sub-population were considered</p></td><td headers="hd_h_niceng247er5.tab3_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£0.99</td><td headers="hd_h_niceng247er5.tab3_1_1_1_6" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p>(a):</p>
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<p>20/100 women 17/100 children</p>
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<p>(b):</p>
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<p>-0.07/100 women -0.06/100 children</p></td><td headers="hd_h_niceng247er5.tab3_1_1_1_7" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p>£10.15/extra woman taking vitamin D</p>
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<p>£2,859/deficiency averted in women</p>
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<p>£4.62/extra child taking vitamin D</p>
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<p>£1,229/deficiency averted in children</p></td><td headers="hd_h_niceng247er5.tab3_1_1_1_8" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p>Intervention not cost-saving even at 0%</p>
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<p>supplementation without intervention or 50%</p>
|
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<p>supplementation following intervention</p></td></tr><tr><td headers="hd_h_niceng247er5.tab3_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>
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<a class="bibr" href="#niceng247er5.s1.ref8" rid="niceng247er5.s1.ref8">Floreskul 2020</a>
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</p>
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<p>UK</p>
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</td><td headers="hd_h_niceng247er5.tab3_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Potentially serious<sup>3</sup></td><td headers="hd_h_niceng247er5.tab3_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Directly applicable<sup>4</sup></td><td headers="hd_h_niceng247er5.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p>Population: pregnant women and children <4 years of age, stratified by skin tone: dark, medium, light</p>
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<p>Intervention: free vitamin D supplementation vs no intervention</p>
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<p>Outcome: QALY</p>
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<p>Time horizon: 4 years</p>
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<p>Cost year: 2016-17</p></td><td headers="hd_h_niceng247er5.tab3_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p>Dark: -£1.23</p>
|
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<p>Medium: £9.33</p>
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<p>Light: £10.87</p></td><td headers="hd_h_niceng247er5.tab3_1_1_1_6" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p>Dark: 0.001</p>
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<p>Medium: 0.0005</p>
|
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<p>Light: 0.00003</p></td><td headers="hd_h_niceng247er5.tab3_1_1_1_7" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p>Dark: intervention dominant</p>
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<p>Medium: £20,222/QALY</p>
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<p>Light: £423,340/QALY</p></td><td headers="hd_h_niceng247er5.tab3_1_1_1_8" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p>Probability of intervention being cost-effective at £20,000/QALY:</p>
|
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<p>Dark: 0.99</p>
|
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<p>Medium: 0.52</p>
|
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<p>Light: 0.00</p>
|
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<p>Medium results sensitive to the risk of having rickets, rickets duration, intervention costs, supplementation rates.</p>
|
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<p>Assuming life-long consequences did not affect conclusions.</p></td></tr></tbody></table></div><div class="tblwrap-foot"><div><dl class="temp-labeled-list small"><dl class="bkr_refwrap"><dt></dt><dd><div><p class="no_margin">CHU: child health utility; DSA: Deterministic sensitivity analysis; ICER: Incremental cost-effectiveness ratio; NR: not reported; PSA: probabilistic sensitivity analysis</p></div></dd></dl><dl class="bkr_refwrap"><dt>1</dt><dd><div id="niceng247er5.tab3_1"><p class="no_margin">Study based on decision-analytic modelling; effectiveness and costs based on published studies; only intermediate data on vitamin D deficiency modelled; national unit costs used; time horizon not reported; DSA conducted.</p></div></dd></dl><dl class="bkr_refwrap"><dt>2</dt><dd><div id="niceng247er5.tab3_2"><p class="no_margin">UK study, no QALYs used, perspective not reported but likely healthcare (& public sector where relevant for intervention delivery), discounting not reported</p></div></dd></dl><dl class="bkr_refwrap"><dt>3</dt><dd><div id="niceng247er5.tab3_3"><p class="no_margin">Study based on decision-analytic modelling; effectiveness based on published study and trust observational dataset; costs taken from trust administrative data and published evidence; 4-year time horizon; PSA conducted, collection of some data funded by industry.</p></div></dd></dl><dl class="bkr_refwrap"><dt>4</dt><dd><div id="niceng247er5.tab3_4"><p class="no_margin">UK study, QALYs based on EQ-5D and CHU-9D were used (UK values), NHS+PSS perspective, discounting not reported but time horizon fairly short</p></div></dd></dl></dl></div></div></div></article><article data-type="table-wrap" id="figobniceng247er5tab4"><div id="niceng247er5.tab4" class="table"><h3><span class="label">Table 4</span><span class="title">Economic evidence profile for intervention aiming to increase uptake of Healthy Start vitamin programme in women planning a pregnancy, pregnant women, infants and children up to 5 years of age</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK612337/table/niceng247er5.tab4/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng247er5.tab4_lrgtbl__"><table class="no_bottom_margin"><thead><tr><th id="hd_h_niceng247er5.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Study and country</th><th id="hd_h_niceng247er5.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Limitations</th><th id="hd_h_niceng247er5.tab4_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Applicability</th><th id="hd_h_niceng247er5.tab4_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Other comments</th><th id="hd_h_niceng247er5.tab4_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Incremental costs<sup>1</sup></th><th id="hd_h_niceng247er5.tab4_1_1_1_6" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Incremental effects</th><th id="hd_h_niceng247er5.tab4_1_1_1_7" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">ICER<sup>1</sup></th><th id="hd_h_niceng247er5.tab4_1_1_1_8" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Uncertainty</th></tr></thead><tbody><tr><td headers="hd_h_niceng247er5.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>
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<a class="bibr" href="#niceng247er5.s1.ref7" rid="niceng247er5.s1.ref7">Filby 2015</a>
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</p>
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<p>UK</p>
|
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</td><td headers="hd_h_niceng247er5.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Potentially serious<sup>1</sup></td><td headers="hd_h_niceng247er5.tab4_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Directly applicable<sup>2</sup></td><td headers="hd_h_niceng247er5.tab4_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p>Interventions:</p><p>Universal offering of Healthy Start Vitamin programme to</p>
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<p>a. pregnant women from 10 weeks; women with a child aged <12 months; children aged 6 months - 4 years</p>
|
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<p>b. all women planning a pregnancy; pregnant women; women with a child aged <12 months; infants aged 0-6 months; children aged 6 months – 5 years versus</p>
|
|
<p>Comparator:</p>
|
|
<p>Current offering of Healthy Start Vitamin programme to pregnant women from 10 weeks aged <18 years, low-income (in receipt of qualifying income-related benefits or tax credits) adult pregnant women from 10 weeks & low-income women with a child aged <12 months; children from low-income families aged 6 months - 4 years.</p>
|
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<p>Outcome: QALY</p>
|
|
<p>Time horizon: lifetime for NTDs</p>
|
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<p>Cost year: 2014</p>
|
|
</td><td headers="hd_h_niceng247er5.tab4_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p>(a): £2.06</p>
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<p>(b): £0.82</p>
|
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<p>Women planning a pregnancy + <10 weeks pregnant: £0.89</p>
|
|
<p>Pregnant women <10 weeks: £2.35</p></td><td headers="hd_h_niceng247er5.tab4_1_1_1_6" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p>(a): 0.000003</p>
|
|
<p>(b): 0.000126</p>
|
|
<p>Women planning pregnancy + <10 weeks pregnant: 0.000663</p>
|
|
<p>Pregnant women <10 weeks: 0.000320</p></td><td headers="hd_h_niceng247er5.tab4_1_1_1_7" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p>(a): £620,898</p>
|
|
<p>(b): £6,528</p>
|
|
<p>Women planning pregnancy + <10 weeks pregnant: dominant</p>
|
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<p>Pregnant women <10 weeks: £7,126</p></td><td headers="hd_h_niceng247er5.tab4_1_1_1_8" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><p>(b): Intervention not cost-effective if
|
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<ul><li class="half_rhythm"><div>probability NTD in pregnant women >10 weeks is <0.15%</div></li><li class="half_rhythm"><div>probability of vitamin D deficiency in infants and children aged 6 months - 4 years receiving intervention >0.2%</div></li><li class="half_rhythm"><div>uptake of folic acid in women planning a pregnancy + <10 weeks pregnant receiving intervention <30%</div></li><li class="half_rhythm"><div>proportion of NTD-affected terminations >92%</div></li></ul></p>
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</td></tr></tbody></table></div><div class="tblwrap-foot"><div><dl class="temp-labeled-list small"><dl class="bkr_refwrap"><dt></dt><dd><div><p class="no_margin">DSA: Deterministic sensitivity analysis; ICER: Incremental cost-effectiveness ratio; NTD: neural tube defect; QALY: quality-adjusted life year</p></div></dd></dl><dl class="bkr_refwrap"><dt>1</dt><dd><div id="niceng247er5.tab4_1"><p class="no_margin">Study based on decision-analytic modelling; effectiveness and costs based on published study, national surveys and a primary online survey, government and local data, other published evidence; national and local unit costs used; lifetime horizon; DSA conducted.</p></div></dd></dl><dl class="bkr_refwrap"><dt>2</dt><dd><div id="niceng247er5.tab4_2"><p class="no_margin">UK study, QALYs used, perspective NHS and public (local and central government), discounting 3.5%</p></div></dd></dl></dl></div></div></div></article><article data-type="table-wrap" id="figobniceng247er5appjtab1"><div id="niceng247er5.appj.tab1" class="table"><h3><span class="label">Table 11</span><span class="title">Excluded studies and reasons for their exclusion</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK612337/table/niceng247er5.appj.tab1/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng247er5.appj.tab1_lrgtbl__"><table class="no_bottom_margin"><thead><tr><th id="hd_h_niceng247er5.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Study</th><th id="hd_h_niceng247er5.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Reason for exclusion</th></tr></thead><tbody><tr><td headers="hd_h_niceng247er5.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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Akkermans, M.D., Eussen, S.R.B.M., Van Der Horst-Graat, J.M.
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et al. (2017) A micronutrient-fortified young-child formula improves the iron and Vitamin D status of healthy young European children: A randomized, double-blind controlled trial. American Journal of Clinical Nutrition
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105(2): 391–399
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[<a href="https://pubmed.ncbi.nlm.nih.gov/28052885" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 28052885</span></a>]
|
|
</td><td headers="hd_h_niceng247er5.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- No intervention of interest</p>
|
|
<p>
|
|
<i>Study focused on fortification of formula milk with micronutrients</i>
|
|
</p>
|
|
</td></tr><tr><td headers="hd_h_niceng247er5.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Chilukuri, Nymisha, Cheng, Tina L, Psoter, Kevin J
|
|
et al. (2018) Effectiveness of a Pediatric Primary Care Intervention to Increase Maternal Folate Use: Results from a Cluster Randomized Controlled Trial. The Journal of pediatrics
|
|
192: 247–252e1
|
|
[<a href="https://pubmed.ncbi.nlm.nih.gov/29246348" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 29246348</span></a>]
|
|
</td><td headers="hd_h_niceng247er5.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- Does not address condition or domain being studied</p>
|
|
<p><i>Study focused on vitamins containing folate that were not Healthy Start vitamins and only reported on folate outcomes. This study is included in evidence review C</i>.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng247er5.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Corsello, A, Milani, GP, Giannì, ML
|
|
et al. (2022) Different Vitamin D Supplementation Strategies in the First Years of Life: A Systematic Review. Healthcare (Basel, Switzerland)
|
|
10(6) [<a href="/pmc/articles/PMC9222934/" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC9222934</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/35742074" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 35742074</span></a>]
|
|
</td><td headers="hd_h_niceng247er5.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- No intervention of interest</p>
|
|
<p>
|
|
<i>No intervention of interest. Study assessed different doses of vitamin D supplementation and placebo</i>
|
|
</p>
|
|
</td></tr><tr><td headers="hd_h_niceng247er5.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
deRosset, Leslie, Mullenix, Amy, Flores, Alina
|
|
et al. (2014) Promotora de Salud: Promoting Folic Acid Use Among Hispanic Women. Journal of Women’s Health (15409996)
|
|
23(6): 525–531 [<a href="/pmc/articles/PMC4464669/" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC4464669</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/24707879" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 24707879</span></a>]
|
|
</td><td headers="hd_h_niceng247er5.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- No population of interest</p>
|
|
<p>
|
|
<i>Non-pregnant women</i>
|
|
</p>
|
|
</td></tr><tr><td headers="hd_h_niceng247er5.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Flores, Alina L., Isenburg, Jennifer, Hillard, Christina L.
|
|
et al. (2017) Folic Acid Education for Hispanic Women: The Promotora de Salud Model. Journal of Women’s Health (15409996)
|
|
26(2): 186–194 [<a href="/pmc/articles/PMC5299051/" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC5299051</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/28067585" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 28067585</span></a>]
|
|
</td><td headers="hd_h_niceng247er5.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- No population of interest</p>
|
|
<p>
|
|
<i>All women between 18 - 45 years with no indication of being pregnant were included in the study. Results showed that none of the women were pregnant at the start of the study</i>
|
|
</p>
|
|
</td></tr><tr><td headers="hd_h_niceng247er5.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Golley, R, Pearce, J, Nelson, M
|
|
et al. (2011) Children’s lunchtime food choices following the introduction of food-based standards for school meals: observations from six primary schools in Sheffield. Public Health Nutrition
|
|
14(2): 271–278
|
|
[<a href="https://pubmed.ncbi.nlm.nih.gov/20731886" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 20731886</span></a>]
|
|
</td><td headers="hd_h_niceng247er5.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- No population of interest</p>
|
|
<p>
|
|
<i>Children aged 8-10 years</i>
|
|
</p>
|
|
</td></tr><tr><td headers="hd_h_niceng247er5.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Gomes, F., King, S.E., Dallmann, D.
|
|
et al. (2021) Interventions to increase adherence to micronutrient supplementation during pregnancy: a systematic review. Ann. New York Acad. Sci. 1493(1): 41–58
|
|
[<a href="/pmc/articles/PMC8169578/" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC8169578</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/33400303" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 33400303</span></a>]
|
|
</td><td headers="hd_h_niceng247er5.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- Country not of interest</p>
|
|
<p>
|
|
<i>A systematic review with all included studies from low- and middle- income countries and non-OECD countries</i>
|
|
</p>
|
|
</td></tr><tr><td headers="hd_h_niceng247er5.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Molton, JS, Pang, Y, Wang, Z
|
|
et al. (2016) Prospective single-arm interventional pilot study to assess a smartphone-based system for measuring and supporting adherence to medication. BMJ open
|
|
6(12nopagination) [<a href="/pmc/articles/PMC5223626/" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC5223626</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/27998903" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 27998903</span></a>]
|
|
</td><td headers="hd_h_niceng247er5.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- Does not address condition or domain being studied</p>
|
|
<p>
|
|
<i>Study addresses medication adherence for tuberculosis</i>
|
|
</p>
|
|
</td></tr><tr><td headers="hd_h_niceng247er5.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Moonan, May, Maudsley, Gillian, Hanratty, Barbara
|
|
et al. (2022) An exploration of the statutory Healthy Start vitamin supplementation scheme in North West England. BMC Public Health
|
|
22(1): 1–12
|
|
[<a href="/pmc/articles/PMC8869346/" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC8869346</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/35209874" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 35209874</span></a>]
|
|
</td><td headers="hd_h_niceng247er5.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- Inappropriate study design</p>
|
|
<p>
|
|
<i>Not an intervention study. Study had a quantitative element which reported the uptake of healthy start vouchers using quarterly uptake data. The quantitative element informed the qualitative element (the perceptions of women and health professionals about healthy start vitamins) which was the main focus of the study</i>
|
|
</p>
|
|
</td></tr><tr><td headers="hd_h_niceng247er5.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Morgan. LM, Major
|
|
J, Meyer
|
|
R
|
|
et al. (2009) Multivitamin use among non-pregnant females of childbearing age in the Western North Carolina multivitamin distribution program. N C Med J
|
|
5(70): 386–90 [<a href="https://pubmed.ncbi.nlm.nih.gov/19999514" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 19999514</span></a>]
|
|
</td><td headers="hd_h_niceng247er5.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- No population of interest</p>
|
|
<p>
|
|
<i>Women of childbearing age with no indication of being pregnant</i>
|
|
</p>
|
|
</td></tr><tr><td headers="hd_h_niceng247er5.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Moy, RJ, McGee, E, Debelle, GD
|
|
et al. (2012) Successful public health action to reduce the incidence of symptomatic vitamin D deficiency. Archives of Disease in Childhood
|
|
97(11): 952–954
|
|
[<a href="https://pubmed.ncbi.nlm.nih.gov/22913973" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 22913973</span></a>]
|
|
</td><td headers="hd_h_niceng247er5.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- No intervention of interest</p>
|
|
<p>
|
|
<i>Public health intervention: public awareness campaign about vitamin D</i>
|
|
</p>
|
|
</td></tr><tr><td headers="hd_h_niceng247er5.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Murtadha, Z.A.J.; Abdulrahman, M.A.; Saeed, H.D. (2019) Effect of monthly Vitamin D supplementation during pregnancy versus counseling for increased dietary intake on vitamin serological level and development of adverse effects. Research Journal of Pharmaceutical, Biological and Chemical Sciences
|
|
10(1): 386–392
|
|
</td><td headers="hd_h_niceng247er5.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- Country not of interest</p>
|
|
<p>
|
|
<i>The study was not conducted in a high-income country (Iraq)</i>
|
|
</p>
|
|
</td></tr><tr><td headers="hd_h_niceng247er5.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Nguyen, P.; Thomas, M.; Koren, G. (2009) Predictors of prenatal multivitamin adherence in pregnant women. Journal of Clinical Pharmacology
|
|
49(6): 735–742
|
|
[<a href="https://pubmed.ncbi.nlm.nih.gov/19386624" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 19386624</span></a>]
|
|
</td><td headers="hd_h_niceng247er5.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- Inappropriate study design</p>
|
|
<p>
|
|
<i>Not an intervention study. Study assessed predictors of adherence to prenatal vitamin</i>
|
|
</p>
|
|
</td></tr><tr><td headers="hd_h_niceng247er5.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Oza-Frank, Reena, Kachoria, Rashmi, Keim, Sarah A
|
|
et al. (2015) Provision of specific preconception care messages and associated maternal health behaviors before and during pregnancy. American Journal of Obstetrics & Gynecology
|
|
212(3): 372e1–8 [<a href="https://pubmed.ncbi.nlm.nih.gov/25446665" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 25446665</span></a>]
|
|
</td><td headers="hd_h_niceng247er5.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- Does not address condition or domain being studied</p>
|
|
<p>
|
|
<i>Prenatal vitamin use was measured before pregnancy</i>
|
|
</p>
|
|
</td></tr><tr><td headers="hd_h_niceng247er5.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Phelan, S; Abrams, B; Wing, RR (2019) Prenatal Intervention with Partial Meal Replacement Improves Micronutrient Intake of Pregnant Women with Obesity. Nutrients
|
|
11(5) [<a href="/pmc/articles/PMC6567022/" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC6567022</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/31091748" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 31091748</span></a>]
|
|
</td><td headers="hd_h_niceng247er5.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- Does not address condition or domain being studied</p>
|
|
<p>
|
|
<i>Not focused on supplementation. Study focuses on micronutrient intake which includes food, beverages and supplements. Vitamin intake from supplements were not presented separately</i>
|
|
</p>
|
|
</td></tr><tr><td headers="hd_h_niceng247er5.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Tanna, Nuttan K, Alexander, Emma C, Lee, Charlotte
|
|
et al. (2021) Interventions to improve vitamin D status in at-risk ethnic groups during pregnancy and early childhood: a systematic review. Public health nutrition
|
|
24(11): 3498–3519
|
|
[<a href="/pmc/articles/PMC10195367/" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC10195367</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/33593453" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 33593453</span></a>]
|
|
</td><td headers="hd_h_niceng247er5.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- Does not address condition or domain being studied</p>
|
|
<p>
|
|
<i>Included studies have been individually assessed and these do not meet inclusion criteria, either because they are assessing the impact of vitamin D supplementation on 25(OH)D levels; because the age range is above 5 years old or because they were conducted in a low- or middle-income country. We identified 1 relevant study (<a class="bibr" href="#niceng247er5.s1.ref4" rid="niceng247er5.s1.ref4">Madar 2009</a>), which has been individually included in the systematic review</i>
|
|
</p>
|
|
</td></tr><tr><td headers="hd_h_niceng247er5.appj.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Wadia, U, Soon, W, Chivers, P
|
|
et al. (2018) Randomised Controlled Trial Comparing Daily Versus Depot Vitamin D3 Therapy in 0-16-Year-Old Newly Settled Refugees in Western Australia Over a Period of 40 Weeks. Nutrients
|
|
10(3) [<a href="/pmc/articles/PMC5872766/" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC5872766</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/29533998" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 29533998</span></a>]
|
|
</td><td headers="hd_h_niceng247er5.appj.tab1_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>- No outcome of interest</p>
|
|
<p>
|
|
<i>Outcomes included 25(OH)D level and nutritional intake of vitamin D. No outcomes relevant to uptake of vitamin supplements</i>
|
|
</p>
|
|
</td></tr></tbody></table></div><div class="tblwrap-foot"><div><dl class="temp-labeled-list small"><dl class="bkr_refwrap"><dt></dt><dd><div><p class="no_margin">25(OH)D: 25-hydroxy vitamin D</p></div></dd></dl></dl></div></div></div></article><article data-type="table-wrap" id="figobniceng247er5appjtab2"><div id="niceng247er5.appj.tab2" class="table"><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK612337/table/niceng247er5.appj.tab2/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng247er5.appj.tab2_lrgtbl__"><table><thead><tr><th id="hd_h_niceng247er5.appj.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Study</th><th id="hd_h_niceng247er5.appj.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Reason for exclusion</th></tr></thead><tbody><tr><td headers="hd_h_niceng247er5.appj.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Aguiar, M, Andronis, L, Pallan, M
|
|
et al. (2020) The economic case for prevention of population vitamin D deficiency: a modelling study using data from England and Wales. European journal of clinical nutrition
|
|
74(5): 825–833
|
|
[<a href="https://pubmed.ncbi.nlm.nih.gov/31427760" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 31427760</span></a>]
|
|
</td><td headers="hd_h_niceng247er5.appj.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Population wider than population in research question</td></tr><tr><td headers="hd_h_niceng247er5.appj.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
Dundas
|
|
R, Boroujerdi
|
|
M, Browne
|
|
S, Deidda
|
|
M, Bradshaw
|
|
P, Craig
|
|
P, et al. Evaluation of the Healthy Start voucher scheme on maternal vitamin use and child breastfeeding: a natural experiment using data linkage. Public Health Res
|
|
2023;11(11) [<a href="https://pubmed.ncbi.nlm.nih.gov/37953640" ref="pagearea=body&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 37953640</span></a>]
|
|
</td><td headers="hd_h_niceng247er5.appj.tab2_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Economic results not presented</td></tr></tbody></table></div></div></article></div><div id="jr-scripts"><script src="/corehtml/pmc/jatsreader/ptpmc_3.22/js/libs.min.js"> </script><script src="/corehtml/pmc/jatsreader/ptpmc_3.22/js/jr.min.js"> </script></div></div>
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