Barriers and enablers for iron folic acid (IFA) supplementation in pregnant women

Maternal and Child Nutrition, Volume 14, Year 2018

Interprétation

In order to inform large scale supplementation programme design, we review and summarize the barriers and enablers for improved coverage and utilization of iron and folic acid (IFA) supplements by pregnant women in 7 countries in Africa and Asia. Mixed methods were used to analyse IFA supplementation programmes in Afghanistan, Bangladesh, Indonesia, Ethiopia, Kenya, Nigeria, and Senegal based on formative research conducted in 2012–2013. Qualitative data from focus-group discussions and interviews with women and service providers were used for content analysis to elicit common themes on barriers and enablers at internal, external, and relational levels. Anaemia symptoms in pregnancy are well known among women and health care providers in all countries, yet many women do not feel personally at risk. Broad awareness and increased coverage of facility-based antenatal care (ANC) make it an efficient delivery channel for IFA; however, first trimester access to IFA is hindered by beliefs about when to first attend ANC and preferences for disclosing pregnancy status. Variable access and poor quality ANC services, including insufficient IFA supplies and inadequate counselling to encourage consumption, are barriers to both coverage and adherence. Community-based delivery of IFA and referral to ANC provides earlier and more frequent access and opportunities for follow-up. Improving ANC access and quality is needed to facilitate IFA supplementation during pregnancy. Community-based delivery and counselling can address problems of timely and continuous access to supplements. Renewed investment in training for service providers and effective behaviour change designs are urgently needed to achieve the desired impact. Formative research was conducted with mixed qualitative and quantitative methods in selected districts or areas of Afghanistan, Bangladesh, Ethiopia, Indonesia, Kenya, Nigeria, and Senegal between 2012 and 2013 to better understand IFA supplementation knowledge, attitudes, and practices among pregnant women, health care providers, and social influencers, identifying the barriers and enablers associated with coverage and adherence. Local research teams were recruited to carry out the fieldwork in each country and developed and pretested their own adapted versions of the study tools, with technical guidance and quality assurance provided by MI on overall study objectives, study design, sampling, questionnaire development, and reporting of key indicators and themes. Minimum standards for study implementation were assured across contexts, including qualifications of researchers, training duration and content, pretesting of questionnaires, and approval of local adaptations to study protocols. The studies used a variety of qualitative methods, including focus‐group discussions and key informant or in‐depth interviews, see Table 1 for a description of the methods and respondents in each country. The study instruments were developed in coordination with regional technical advisors and local government, academic and non‐governmental organization partners. In most cases, the formative research studies were designed to address data gaps and deepen the understanding of programme implementation issues in the specific context. Focus group discussions were held with pregnant women or mothers who already had one child. In some countries, focus‐group discussions were also held with husbands and mothers or mothers‐in‐law who were considered key influencers in household decision‐making processes. In‐depth interviews were conducted with women, key influencers, and health care providers, including community health workers. Purposive sampling was used to represent the diversity of target beneficiaries and health providers. Overview of formative research studies by region and data collection method FGD: PW (n = 9 groups), husbands (n = 3 groups), mothers‐in‐law (n = 3 groups), fathers‐in‐law (n = 3 groups) IDI: health managers (n = 9), health workers (3 doctors, 3 midwives, 3 female nurses, 3 community health supervisors), CHWs (n = 12), PW (n = 18), husbands (n = 6), mother‐in‐law (n = 6), father‐in‐law (n = 6), member of Shura Sehi (n = 6) FGD: PW and PPW (n = 12 groups), key influential persons (n = 4 groups) IDI: PW and PPW (n = 20), key influential persons (n = 12), health service providers (n = 28), health supervisors (n = 8), local leaders (n = 12) FGD: PW or PPW (n = 6 groups), influential persons (n = 6 groups) IDI: PW or PPW (n = 24), key influencers (n = 24), village health workers—midwives or nurses (n = 6), facility health workers (n = 12), TBA (n = 8), cadres or CHWs (n = 8), community leaders (n = 12), district and provincial level (n = 18) FGD: PW attending ANC (n = 16 groups), PW not attending ANC (n = 16 groups), influential community members (n = 8 groups) IDI: health coordinator or supervisors (n = 16), HEWs (n = 16); MCH clinic nurses (n = 8), VCHPs (n = 16) FGD: mothers (3 groups per district), fathers and grandmothers (1 group per district), CHWs (1 group per district) IDI: health workers at selected health facilities (4 per district), national health staff FGD: PPW (gave birth to a child in past year), PW attending ANC, PW not attending ANC, MNCH coordinators, health care providers, influential community members and opinion leaders (n = 23) HFS: health workers (n = 139 from 93 facilities); health managers (n = 29 LGA and 4 managers) FGD: PW and WRA (n = 35 groups) IDI: PW (n = 83); WRA or mothers‐in‐law (n = 39); husbands (n = 27); community volunteers (n = 52); health care providers (n = 56 from 36 health facilities); managers (n = 8) Note. ANC = antenatal care; CHW = community health worker; FGD = focus group discussion; HEW = health extension worker; HFS = health facility survey; HWS = health worker survey; IDI = in‐depth interview; LGA = local government area; MCH = maternal child health; MNCH = maternal, newborn and child health; PPW = post‐partum women; PW = pregnant women; TBA = traditional birth attendant; WRA = women of reproductive age. Ethical approval was sought by each local partner agency. Informed consent (verbal or written) was obtained from all participants as per recommendation and acceptable standards of each local review board. Voluntary participation and confidentiality were ensured in each of the studies. No remuneration was given. Management of and access to data files followed guidelines from local ethics review boards in each case. Key features of each country’s IFA programme were summarized using the WHO/Centers for Disease Control (CDC) logic model for micronutrient interventions in public health (WHO/CDC, 2011). Where necessary, additional document review (e.g., national policy) and consultation with country representatives helped to fill information gaps. The review and synthesis of the formative research results were guided by a socioecological framework blended with an adapted version of the Theory of Triadic influence (Flay, Snyder, & Petraitis, 2009) to identify internal, external, and relational barriers and enablers that impact pregnant women and health providers with regard to target behaviours associated with improved IFA coverage and adherence in the programme impact pathway (see Figure 1). Increasing coverage (defined as receiving any amount of IFA during pregnancy) and adherence (defined as regularly consuming IFA throughout pregnancy as recommended by provider) were considered as two essential outcomes that would contribute to optimal IFA supplementation. Analysis of barriers and enablers to increased coverage focused on the target behaviour of accessing any IFA during pregnancy either through attending ANC services or through community‐based delivery. Target behaviours considered for barriers and enablers to increased adherence included (a) timely access to IFA supplements (starting in first trimester); (b) continued access to IFA supplements throughout pregnancy, requiring regular refills of IFA supplements either through repeat ANC visits or other sources; and (c) daily consumption of IFA supplements. Theoretical framework for IFA supplementation programme impact pathway. IFA = iron folic acid; ANC = antenatal care

Résumé de l’IA

Study Justification:

The study aims to identify the barriers and enablers for improved coverage and utilization of iron and folic acid (IFA) supplements by pregnant women in 7 countries in Africa and Asia. This information is crucial for designing large-scale supplementation programs and improving the health outcomes of pregnant women and their babies.

Highlights:

1. Anaemia symptoms in pregnancy are well known among women and health care providers in all countries, but many women do not feel personally at risk. This perception needs to be addressed to increase the uptake of IFA supplements.
2. Broad awareness and increased coverage of facility-based antenatal care (ANC) make it an efficient delivery channel for IFA. However, first trimester access to IFA is hindered by beliefs about when to first attend ANC and preferences for disclosing pregnancy status.
3. Variable access and poor quality ANC services, including insufficient IFA supplies and inadequate counseling, are barriers to both coverage and adherence. Improving ANC access and quality is crucial for facilitating IFA supplementation during pregnancy.
4. Community-based delivery of IFA and referral to ANC provide earlier and more frequent access to supplements. Community-based counseling can address problems of timely and continuous access to supplements.
5. Renewed investment in training for service providers and effective behavior change designs are urgently needed to achieve the desired impact.

Recommendations:

1. Improve awareness among pregnant women about the risks of anaemia during pregnancy and the benefits of IFA supplementation.
2. Strengthen ANC services to ensure consistent and high-quality access to IFA supplements throughout pregnancy.
3. Implement community-based delivery of IFA supplements and counseling to enhance timely and continuous access.
4. Invest in training programs for service providers to improve their knowledge and skills in promoting IFA supplementation.
5. Develop effective behavior change strategies to encourage pregnant women to adhere to IFA supplementation guidelines.

Key Role Players:

1. Local research teams: Responsible for conducting the formative research and data collection in each country.
2. Health care providers: Involved in delivering ANC services and counseling pregnant women on IFA supplementation.
3. Community health workers: Play a crucial role in community-based delivery of IFA supplements and counseling.
4. Health managers: Responsible for overseeing the implementation of ANC services and ensuring the availability of IFA supplies.
5. National government agencies: Provide policy guidance and support for implementing IFA supplementation programs.

Cost Items for Planning Recommendations:

1. Training programs for service providers: Budget for developing and implementing training modules, conducting training sessions, and monitoring the effectiveness of the training.
2. IFA supplies: Allocate funds for procuring an adequate supply of IFA supplements to meet the demand during pregnancy.
3. Community-based delivery: Budget for establishing and maintaining community-based delivery systems, including transportation, storage, and distribution of IFA supplements.
4. Behavior change communication: Allocate funds for developing and implementing behavior change strategies, including materials, media campaigns, and community outreach activities.
5. Monitoring and evaluation: Set aside a budget for monitoring the implementation of the recommendations and evaluating the impact of the IFA supplementation programs.

Force de la preuve

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong because it is based on mixed methods research conducted in 7 countries in Africa and Asia. The research used qualitative data from focus-group discussions and interviews with women and service providers to identify common themes on barriers and enablers for iron folic acid (IFA) supplementation in pregnant women. The study also involved formative research with local research teams in each country, ensuring minimum standards for study implementation. To improve the evidence, it would be beneficial to include more details on the sample sizes and demographics of the participants, as well as the specific findings and recommendations from the research.

Abstrait

Formative research was conducted with mixed qualitative and quantitative methods in selected districts or areas of Afghanistan, Bangladesh, Ethiopia, Indonesia, Kenya, Nigeria, and Senegal between 2012 and 2013 to better understand IFA supplementation knowledge, attitudes, and practices among pregnant women, health care providers, and social influencers, identifying the barriers and enablers associated with coverage and adherence. Local research teams were recruited to carry out the fieldwork in each country and developed and pretested their own adapted versions of the study tools, with technical guidance and quality assurance provided by MI on overall study objectives, study design, sampling, questionnaire development, and reporting of key indicators and themes. Minimum standards for study implementation were assured across contexts, including qualifications of researchers, training duration and content, pretesting of questionnaires, and approval of local adaptations to study protocols. The studies used a variety of qualitative methods, including focus‐group discussions and key informant or in‐depth interviews, see Table 1 for a description of the methods and respondents in each country. The study instruments were developed in coordination with regional technical advisors and local government, academic and non‐governmental organization partners. In most cases, the formative research studies were designed to address data gaps and deepen the understanding of programme implementation issues in the specific context. Focus group discussions were held with pregnant women or mothers who already had one child. In some countries, focus‐group discussions were also held with husbands and mothers or mothers‐in‐law who were considered key influencers in household decision‐making processes. In‐depth interviews were conducted with women, key influencers, and health care providers, including community health workers. Purposive sampling was used to represent the diversity of target beneficiaries and health providers. Overview of formative research studies by region and data collection method FGD: PW (n = 9 groups), husbands (n = 3 groups), mothers‐in‐law (n = 3 groups), fathers‐in‐law (n = 3 groups) IDI: health managers (n = 9), health workers (3 doctors, 3 midwives, 3 female nurses, 3 community health supervisors), CHWs (n = 12), PW (n = 18), husbands (n = 6), mother‐in‐law (n = 6), father‐in‐law (n = 6), member of Shura Sehi (n = 6) FGD: PW and PPW (n = 12 groups), key influential persons (n = 4 groups) IDI: PW and PPW (n = 20), key influential persons (n = 12), health service providers (n = 28), health supervisors (n = 8), local leaders (n = 12) FGD: PW or PPW (n = 6 groups), influential persons (n = 6 groups) IDI: PW or PPW (n = 24), key influencers (n = 24), village health workers—midwives or nurses (n = 6), facility health workers (n = 12), TBA (n = 8), cadres or CHWs (n = 8), community leaders (n = 12), district and provincial level (n = 18) FGD: PW attending ANC (n = 16 groups), PW not attending ANC (n = 16 groups), influential community members (n = 8 groups) IDI: health coordinator or supervisors (n = 16), HEWs (n = 16); MCH clinic nurses (n = 8), VCHPs (n = 16) FGD: mothers (3 groups per district), fathers and grandmothers (1 group per district), CHWs (1 group per district) IDI: health workers at selected health facilities (4 per district), national health staff FGD: PPW (gave birth to a child in past year), PW attending ANC, PW not attending ANC, MNCH coordinators, health care providers, influential community members and opinion leaders (n = 23) HFS: health workers (n = 139 from 93 facilities); health managers (n = 29 LGA and 4 managers) FGD: PW and WRA (n = 35 groups) IDI: PW (n = 83); WRA or mothers‐in‐law (n = 39); husbands (n = 27); community volunteers (n = 52); health care providers (n = 56 from 36 health facilities); managers (n = 8) Note. ANC = antenatal care; CHW = community health worker; FGD = focus group discussion; HEW = health extension worker; HFS = health facility survey; HWS = health worker survey; IDI = in‐depth interview; LGA = local government area; MCH = maternal child health; MNCH = maternal, newborn and child health; PPW = post‐partum women; PW = pregnant women; TBA = traditional birth attendant; WRA = women of reproductive age. Ethical approval was sought by each local partner agency. Informed consent (verbal or written) was obtained from all participants as per recommendation and acceptable standards of each local review board. Voluntary participation and confidentiality were ensured in each of the studies. No remuneration was given. Management of and access to data files followed guidelines from local ethics review boards in each case. Key features of each country’s IFA programme were summarized using the WHO/Centers for Disease Control (CDC) logic model for micronutrient interventions in public health (WHO/CDC, 2011). Where necessary, additional document review (e.g., national policy) and consultation with country representatives helped to fill information gaps. The review and synthesis of the formative research results were guided by a socioecological framework blended with an adapted version of the Theory of Triadic influence (Flay, Snyder, & Petraitis, 2009) to identify internal, external, and relational barriers and enablers that impact pregnant women and health providers with regard to target behaviours associated with improved IFA coverage and adherence in the programme impact pathway (see Figure 1). Increasing coverage (defined as receiving any amount of IFA during pregnancy) and adherence (defined as regularly consuming IFA throughout pregnancy as recommended by provider) were considered as two essential outcomes that would contribute to optimal IFA supplementation. Analysis of barriers and enablers to increased coverage focused on the target behaviour of accessing any IFA during pregnancy either through attending ANC services or through community‐based delivery. Target behaviours considered for barriers and enablers to increased adherence included (a) timely access to IFA supplements (starting in first trimester); (b) continued access to IFA supplements throughout pregnancy, requiring regular refills of IFA supplements either through repeat ANC visits or other sources; and (c) daily consumption of IFA supplements. Theoretical framework for IFA supplementation programme impact pathway. IFA = iron folic acid; ANC = antenatal care

Matériaux

N/A

Innovations

Based on the information provided, here are some potential innovations that could improve access to maternal health:

1. Mobile Health (mHealth) Applications: Develop mobile applications that provide pregnant women with information and reminders about the importance of iron and folic acid (IFA) supplementation. These apps can also provide access to virtual antenatal care consultations and allow women to track their IFA intake.

2. Community Health Worker Training: Invest in training programs for community health workers (CHWs) to improve their knowledge and counseling skills regarding IFA supplementation. CHWs can play a crucial role in educating pregnant women about the benefits of IFA and ensuring regular supply and consumption.

3. Supply Chain Management: Implement innovative supply chain management systems to ensure a consistent and reliable supply of IFA supplements. This could include using technology to track stock levels, predict demand, and streamline distribution to health facilities and community-based delivery points.

4. Behavior Change Communication: Develop targeted behavior change communication campaigns to address misconceptions and beliefs surrounding IFA supplementation. These campaigns can use various channels such as radio, television, and community engagement to raise awareness and promote the importance of IFA intake during pregnancy.

5. Public-Private Partnerships: Foster collaborations between the public and private sectors to improve access to IFA supplements. This could involve partnering with pharmaceutical companies to increase the availability and affordability of IFA supplements, as well as leveraging private sector distribution networks to reach remote areas.

6. Integration with Existing Services: Integrate IFA supplementation into existing maternal and child health services, such as antenatal care and immunization programs. This can ensure that pregnant women have regular access to IFA supplements during their interactions with the healthcare system.

7. Digital Health Records: Implement electronic health record systems that capture and track IFA supplementation data. This can help healthcare providers monitor and follow up on pregnant women’s IFA intake, identify gaps in coverage, and provide personalized counseling.

8. Financial Incentives: Explore the use of financial incentives, such as conditional cash transfers or vouchers, to encourage pregnant women to attend antenatal care visits and adhere to IFA supplementation. This can help overcome financial barriers and improve access to maternal health services.

9. Peer Support Networks: Establish peer support networks or community groups where pregnant women can share their experiences and knowledge about IFA supplementation. This can create a supportive environment and encourage adherence to IFA intake.

10. Telemedicine Services: Develop telemedicine services that allow pregnant women in remote areas to consult with healthcare providers and receive guidance on IFA supplementation. This can help overcome geographical barriers and ensure access to quality maternal healthcare.

It is important to note that the implementation of these innovations should be context-specific and tailored to the needs and resources of each country or region.

AI Innovations Description

Based on the description provided, the following recommendation can be developed into an innovation to improve access to maternal health:

1. Strengthening Antenatal Care (ANC) Services: Improve access and quality of ANC services to ensure that pregnant women have timely and continuous access to iron and folic acid (IFA) supplements. This can be done by increasing the coverage of facility-based ANC services and addressing barriers such as beliefs about when to first attend ANC and preferences for disclosing pregnancy status.

2. Community-Based Delivery of IFA: Implement community-based delivery of IFA supplements to provide earlier and more frequent access to pregnant women. This can be done through trained community health workers who can distribute IFA supplements and provide counseling on the importance of IFA supplementation during pregnancy.

3. Behavior Change Communication: Develop effective behavior change communication strategies to increase awareness and knowledge about the benefits of IFA supplementation among pregnant women, their families, and health care providers. This can include targeted messaging and education campaigns to address misconceptions and promote the importance of timely and continuous IFA supplementation.

4. Training for Service Providers: Invest in training programs for health care providers to ensure they have the knowledge and skills to provide adequate counseling and support for IFA supplementation during pregnancy. This can include training on the importance of IFA supplementation, proper counseling techniques, and monitoring and evaluation of IFA adherence.

5. Supply Chain Management: Improve the supply chain management of IFA supplements to ensure consistent availability and adequate supply at health facilities and community distribution points. This can include strengthening procurement and distribution systems, as well as monitoring and forecasting IFA supply needs.

By implementing these recommendations, it is expected that access to maternal health, specifically access to IFA supplementation, can be improved, leading to better maternal and child health outcomes.

AI Innovations Methodology

Based on the provided information, here are some potential recommendations to improve access to maternal health:

1. Strengthening Antenatal Care (ANC) Services: Improve the quality and availability of ANC services, including ensuring an adequate supply of iron and folic acid (IFA) supplements, and providing comprehensive counseling on the importance of IFA supplementation during pregnancy.

2. Community-Based Delivery of IFA: Implement community-based programs that deliver IFA supplements directly to pregnant women, ensuring timely access and follow-up. This can be done through trained community health workers or other community-based providers.

3. Behavior Change Communication: Develop targeted behavior change communication strategies to increase awareness and knowledge about the benefits of IFA supplementation during pregnancy. This can include educational campaigns, use of mass media, and engagement with key influencers such as husbands, mothers-in-law, and community leaders.

4. Training and Capacity Building: Invest in training programs for healthcare providers to enhance their knowledge and skills in providing quality ANC services, including IFA supplementation. This can help improve the overall delivery and adherence to IFA supplementation.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the indicators: Identify specific indicators that measure access to maternal health, such as ANC attendance rates, IFA supplementation coverage, and adherence rates.

2. Data collection: Collect baseline data on the selected indicators before implementing the recommendations. This can be done through surveys, interviews, or existing data sources.

3. Implement the recommendations: Roll out the recommended interventions, such as strengthening ANC services, community-based delivery of IFA, behavior change communication campaigns, and training programs.

4. Monitor and evaluate: Continuously monitor the implementation of the interventions and collect data on the selected indicators. This can be done through regular surveys, interviews, or monitoring systems.

5. Analyze the data: Analyze the collected data to assess the impact of the interventions on the selected indicators. Compare the post-intervention data with the baseline data to measure the changes in access to maternal health.

6. Interpret the results: Interpret the findings to understand the effectiveness of the recommendations in improving access to maternal health. Identify any gaps or areas for further improvement.

7. Adjust and refine: Based on the findings, make adjustments and refinements to the interventions as needed to optimize their impact on improving access to maternal health.

By following this methodology, stakeholders can gain insights into the potential impact of the recommendations and make informed decisions on how to further improve access to maternal health.

Auteurs et co-auteurs

Statistics:

Citations: 36

Authors: 5

Identifiers:

DOI: 10.1111/mcn.12532

ISSN: 17408695

Research Areas:

Community Interventions, Disparities, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Workforce

Study Countries:

Ethiopia, Kenya, Multi-Countries, Nigeria, Senegal

Study Design:

Cohort Study, Cross Sectional Study, Exploratory Study, Grounded Theory

Study Approach:

Mixed-methods, Qualitative, Quantitative

Participants Gender:

Female

Partagez ceci :