Strong marriages lead to stable families, which are vital building blocks for a healthy society. Optimal health and family wellness during the first 1,000 days of life are essential for unlocking the full potential of the next generation. This crucial period of human development starts from the time a foetus is first formed in the womb, all the way until the child reaches the age of 2 years. Research has shown that due to rapid brain growth and development during these first 1,000 days, the environment and experiences that are provided to a child in order to learn and thrive will have a lasting impact on future health all the way into adulthood[1].
There are several robust initiatives in Singapore that aim to improve health delivery services for mother and child, in line with the Ministry of Health’s Healthier SG plan to keep families healthy. Yet, to date, there are no programmes that look into overall health from the time a family is first built, at the beginning of marriage.
Is there a need for additional programmes in our community?
A needs analysis commissioned by Temasek Foundation and led by KK Women’s and Children’s Hospital (KKH) was conducted on 48 Muslim women of Malay ethnicity aged 16 to 50 years in 2020 (unpublished data). The results revealed significant gaps in the participants’ knowledge of their own health and, for mothers, the health of their own children. In addition, the majority reported experiencing at least one adverse childhood experience (ACE) before the age of 18, such as emotional and/or physical abuse. Religion was noted to be an influencing factor for many of these respondents’ decisions throughout their adult lives. One recommendation from the needs analysis was to extend the social role of mosques beyond being solely a place of worship, and to enhance the capability of religious personnel to better support Malay-Muslim women in the areas of maternal and child health.
Project Achieving Resilient and Inspiring Families (ARIF)
A novel approach was conceptualised to improve maternal and child health in our community; through a multi-faceted programme combining medical and socio-religious support to newlyweds in Singapore. Project Achieving Resilient and Inspiring Families (ARIF) was a collaborative effort between Temasek Foundation, KKH and the Islamic Religious Council of Singapore (MUIS). Project ARIF leveraged on Bersamamu, an existing programme in our community whereby the marriage solemniser, or naib kadi (NK), accompanies each solemnised couple for the first two years of marriage to provide guidance. Through Project ARIF, NKs were further equipped with knowledge on maternal and child health, enabling them to support their couples more holistically.
NKs underwent formal training to deliver basic health advice and identify newlyweds with greater needs. The training and expertise were provided by the KKH team, which included three obstetricians and gynaecologists, one paediatrician, one midwife specialising in lactation services, one paediatric nurse clinician and two medical social workers (MSWs). The NKs risk-stratified couples according to their needs, which included both social factors (such as young marriages, previous incarceration, low-income status or rental public housing) and medical factors (such as a history of chronic medical and/or mental illness(es) or intoxicant use). Couples with greater needs received appropriate and timely interventions, including direct medical and/or social work counselling, as well as referrals to relevant external agencies. Two resource centres were set up in An-Nur Mosque and Assyafaah Mosque for the team to conduct counselling sessions with couples and their families within the community. Print and digital resources were also created (available on www.projectarif.sg), including a guidebook on maternal and child health that weaved health information together with sociocultural and Islamic context, with short summaries translated into Malay. ARIF Bulletins were also developed to keep the public informed on maternal and child topics, such as the safety of fasting during pregnancy and breastfeeding. Pregnancies reported were tracked and expectant women were invited to attend pregnancy health advisory sessions. Babies born to enrolled couples were also monitored for their health and developmental status. This was done through direct engagement with MSWs (inclusive of home visits), and child health advisory sessions conducted by the KKH medical team at the resource centres.
Phase 1 of Project ARIF was conducted from September 2020 to August 2022. We enrolled Muslim newlyweds or soon-to-be-wed couples (of whom at least one had to be a Singapore citizen or Permanent Resident) solemnised from July 2020 onwards by NKs trained under Project ARIF. Written informed consent was obtained from each couple prior to enrolment into the programme.
Results from Project ARIF Phase 1
43 NKs and mosque personnel were trained in Phase 1. A total of 2,188 newlyweds were solemnised and given access to all educational resources. All couples were also invited to attend regular public educational forums conducted by Project ARIF. These forums covered topics such as maternal and child health, family wellness, and relevant Islamic teachings and values. A total of 1,416 newlyweds (64.7%) enrolled into Project ARIF and underwent needs assessment conducted by the NKs. Among the participants, 276 individuals (19.5%) were identified to have greater needs, and all received additional support. Some of the support rendered included tailored health advisory sessions conducted by the doctors and/or nurses, featuring personalised counselling on sexual health, family planning, pregnancy, mental wellness, and parenting. 20 individuals were referred to external agencies such as family service centres, the Early Childhood Development Agency’s KidSTART programme and INSPIRASI (Centre for Early Marriage Support for Minor and Young Muslim Couples). Additionally, 56 participants attended at least one public educational forum.
There were 39 reported pregnancies during Phase 1 of Project ARIF. All women complied with recommended antenatal vaccinations and follow-up. 16 expectant or post-natal women were counselled on pregnancy-related concerns, breastfeeding, and post-natal care. A total of 18 live babies were born during this period. All children monitored were up to date with the National Childhood Immunisation Schedule and well-baby checks, at the time of reporting. 12 children and their parents/caregivers benefitted from health advisory sessions, including a child development and parenting workshop.
The drop-out rate for Project ARIF was low at 0.85% (12 individuals) and participants’ feedback was generally positive. For health advisory sessions and public educational forums, participants were asked to rate their satisfaction scores on a scale of 1 to 5. The mean satisfaction score obtained was 4.89. When asked to rate their increased knowledge and confidence in parenting after accessing ARIF’s resources, the mean score was 3.72. This mean score increased to 4.27 when evaluating their willingness and knowledge of where to seek help if faced with challenges pertaining to maternal and child health. Some open-ended written responses revealed that the participants found Project ARIF sessions to be “personalised”, “insightful” and “truly beneficial”, and that the guidebook was “concise yet very informative”. One interesting comment reflected that the respondent’s partner had started reading a few chapters from the guidebook, even though he did not usually like to read. Several individuals with high needs expressed gratitude for the individualised support rendered during difficult periods of their early marriage lives. The NKs also gave positive feedback, noting that Project ARIF allowed them to upskill and provide more holistic mentoring for their couples’ benefit, as they journeyed with them in the first two years of marriage.
Case vignettes of Project ARIF Beneficiaries (Phase 1)
Case 1
M and F met through mutual friends and got married a year later. Both individuals were in their late twenties and were the youngest children in their families. They decided to stay with F’s family after the solemnisation while working on getting a matrimonial home. They were blessed with a daughter a year after their wedding.
Cracks in their marital relationship began to appear when M had a change of job with higher pay. Due to his longer working hours, F often felt alone, especially during the first few months of caring for their newborn. On the other hand, M felt that he was already doing his part as the family’s provider.
During a home visit by the MSW and paediatric nurse clinician, their baby was assessed to be doing well, showing normal growth and meeting developmental milestones. Although F was exhausted from caring for her baby, thankfully her mother was available to provide additional support and caregiving. Both received anticipatory guidance on the child’s needs as well as advice on managing common paediatric ailments.
F disclosed that she was keen to work on her marital relationship. Her MSW assessed that F’s mother served as a protective factor, helping to avoid unnecessary tension and escalation during interactions with her husband. M and F agreed to attend a counselling session with their MSW and NK at the neighbourhood mosque. Their NK reminded them of their roles and responsibilities, while the MSW facilitated a discussion, allowing the couple to express how each other’s decisions and actions had affected and impacted them. During the session, M and F were invited to revisit their marital goals and renegotiate their expectations of each other.
Case 2
A was a new mother who had given birth to a baby girl and was excited to breastfeed her baby exclusively. She couldn’t wait to put all the theory and knowledge that she had acquired from lactation education into practice. Unfortunately, her breastfeeding journey became daunting as her milk production was unable to match the baby’s demands. Feeling sorrowful, she started displaying depressive symptoms. Her relationship with her husband became unstable due to reduced interaction and communication. As her husband struggled to provide adequate support and turned to unsavoury activities to cope with his situation, A refused to allow him to care for their baby. There was gradual estrangement and even quarrels in the presence of the baby. Eventually, with support from their MSW, the couple recognised that this would be detrimental to their daughter’s emotional and psychological well-being and decided to seek further help and counselling.
The potential impact of Project ARIF
The outcomes from the first phase of Project ARIF are promising and suggest that early support and intervention from the start of marriage give couples more confidence to build their families and may directly or indirectly affect subsequent outcomes including pregnancy wellness and child health and development. The inclusion of NKs as influencing partners in preventive health may increase the receptivity of the couples to health advice and motivate behaviour change. A large study conducted by Guthrie et al in Ethiopia emphasised the influential role that faith leaders can play in community health. The study revealed that partnering Orthodox priests with community health workers significantly increased utilisation of antenatal care and facility delivery services for pregnant women[2].
The use of newly created resources that incorporate health information within a socio-cultural and Islamic context may better resonate with our community and drive further behaviour change. A formal analysis is in progress to objectively assess the outcomes of Project ARIF and determine how such a programme can be made sustainable for our community.
The future of Project ARIF
Project ARIF is currently in its second phase, and the team has expanded to include an additional MSW and a dedicated research coordinator. Two lead NKs who are under the umbrella of AMP have joined the team as master trainers to continue the work of training the growing pool of Project ARIF NKs. With this “train the trainer” model and established curriculum, we hope to eventually equip NKs in Singapore to support all Muslim newlyweds. To further ensure the sustainability of our efforts, there has been a gradual shift towards group sessions and workshops for couples, replacing direct counselling and health advisory sessions led by doctors, nurses and/or MSWs. By building a self-sustaining community to share knowledge and resources, more experienced couples who have previously benefitted from our programmes are continuously encouraged to guide newer couples. Furthermore, the team also aims to continue hosting mass health talks and engagement sessions to reach out to even more families and members of the public.
It is hoped that this pilot model of religious-based community support, designed to address the health literacy and psychosocial needs of newlyweds, can be expanded nationwide and adapted for other faiths. This would aim to improve future child health and developmental outcomes and achieve a new generation of resilient and inspiring families in Singapore.
1McDonald, C. M., & Thorne-Lyman, A. L. (2017). The importance of the first 1,000 days: An epidemiological perspective. In The biology of the first 1,000 days (pp. 3-14). CRC Press.
2Guthrie, B. L., Tsegaye, A. T., Rankin, K. C., Walson, J. L., & Alemie, G. A. (2021). Partnering faith leaders with community health workers increases utilization of antenatal care and facility delivery services in Ethiopia: a cluster randomized trial. Journal of Global Health, 11.
Acknowledgements
The authors wish to thank the following individuals from the Project ARIF team: Zul Ikmal Bin Zulkefle, Mohamad Azri Bin Ahmad, Dr Muhammad Fairuz Bin Abdul Rahman, Dr Dhilshad Qadir, Shakira Khaliq, Nazimah Binte Mohamed Sani, Siti Nurzakiah Binte Zaran, Siti Munawarah Binte Maaroof, A’bidah Binte Yahya, Fatin Insyirah Bte Fadil, Ustaz Ahmad Khushairi Abidin, Ustaz Mohamed Tajuddin Noor, Husain Abdul Rahim and Nur Syarfeena Mohd Fauzi. Project ARIF is supported by Temasek Foundation.
Dr Nur Adila Ahmad Hatib is a consultant paediatrician with the Department of Paediatrics in KKH. She is currently co-leading KKH Project ARIF. She has a keen interest in the development of community paediatrics in Singapore and works closely with the community and primary healthcare sector to advance child health for all.
Assoc Prof Suzanna Sulaiman is Deputy Division Chairman for Division of Obstetrics and Gynaecology. She is also the Head of Department for Department of Obstetrics and Gynaecology. She leads KKH Project ARIF. She spends her free time creating content for public education inclusive of ARIF Times for Project ARIF. She is passionate in education for medical students, junior doctors and the community.
