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
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