Magnitude and factors associated with adherence to Iron-folic acid supplementation among pregnant women in Eritrean refugee camps, northern Ethiopia

Background: Globally, anemia is a public health problem affecting the life of more than two billion people. Pregnant women are at high risk of iron deficiency anemia due to increased nutrient requirement during pregnancy. Iron-folic acid supplementation is the main strategy for prevention and control of iron deficiency anemia and its effectiveness depends on adherence to Iron-Folic Acid tablets. In the refugee camps of Ethiopia, despite the efforts made to reduce iron deficiency anemia during pregnancy, information about adherence to iron-folic acid supplementation and its associated factors are lacking. The objective of this study was to assess magnitude and factors associated with adherence to iron-folic acid supplementation, among pregnant women, in Shire refugee camps. Methods: Institution based cross-sectional study with mixed design (quantitative and qualitative) was carried out among pregnant women in Shire refugee camps from September to November 2015. For quantitative data, a sample of 320 pregnant women was systematically selected and data were collected via interview administered structured questionnaire. Quantitative data were coded and entered into Epi-info version 3.5.1 and exported into a statistical package for social sciences (SPSS) Version 19.0 software for analysis. Bivariable and multivariable logistic regressions were employed to identify the predictors at p-value <0.2 and 0.05 respectively. For the qualitative part, six focus group discussions and three key informant interviews were conducted on purposely-selected individuals. Open-Code version 3.6.2.0 was used for analysis. Identified themes were arranged into coherent groupings and triangulated with quantitative findings. Results: The adherence rate was found to be 64.7% [95% CI (59.7%, 70.0%)]. Women who were having lower knowledge about anemia [AOR; 0.23 95% CI (0.14, 0.38)] and not receiving information about importance of iron-folic acid supplementation [AOR; 0.43 95% CI (0.25, 0.74)] were negatively associated with adherence to iron and folic acid., Having four or more antenatal care visits [AOR; 2.83 95% CI (1.46, 5.48)] were positively significantly associated with adherence to iron-folic acid supplementation. Conclusions: Adherence rate of iron-folic acid supplementation during pregnancy in the study area is relatively low. Proper counseling and health promotion about Iron-Folic Acid tablet intake, promoting the benefits of early and frequent ANC visit, health promotion on anemia prevention and health benefits of the importance of iron-folic acid supplements are recommended to increase adherence with iron-folic acid supplementation. Health facility-based cross-sectional study was carried out in four Shire refugee camps, named as “Shimelba”, “May-Aini”, “Adi-Harush”, and“Hitsats”, located in the Tigray regional state, Northern Ethiopia whereby Eritrean refugees are residing in. According to the UNHCR monthly population data, the Eritrean refugee population in the four camps was 60,119 as of 31 December 2013, of which 28.1% were females. Data were collected from 03, November to 29, December 2015, and 1036 pregnant women were residing during the data collection period in all refugee camps. Each refugee camp had one health center, which is administered by the Administration for Refugees and Returnees Affairs (ARRA). Comprehensive health services and nutrition programs are running in the four camps supported by UNHCR and WFP. Maternal health services have been implemented in each refugee camp. Pregnant women who came to the health centers had an access to all components of ANC services including IFA supplementation by health social workers regularly. The source population was pregnant women residing in all of the four Shire refugee camps. The pregnant women visiting Shire refugee camps’ health centers at least for a second antenatal visit and received IFA tablets for at least one month prior to the date of interview were selected as the study population. Women who were critically ill during the data collection period were excluded from the study. The interview was made just before receiving the ANC service. A total of 320 pregnant women were included in the study. The sample size was calculated using a single population proportion formula with the proportion of adherence (P = 37%) from a study conducted in North West Tigray [14]. During the sample size calculation, the assumptions of 95% confidence interval, 5% of marginal error and 10% non-response rate were considered. To determine the number of women to be interviewed, an average of 12 months’ flow of pregnant women in each camp was obtained from UNHCR and ARRA Health Information System (HIS) report. The average number of pregnant women attending second ANC visit in each health center was; 267 in “Shimelba”, 214 in “May-Aini”, 161 in “Adi-Harush” and 394 in “Hitsats”. Considering the client flow in the health center, the total sample size determined (320) was allocated proportionally to each health center in the camps (Fig. 1). The final sample from each camp was done consecutively until we reach the required sample. Sampling procedure for the quantitative data among pregnant women in Eritrean refugee camps, northern Ethiopia A total of six Focus Group Discussions (FGDs) among pregnant women and three Key Informant Interviews (KIIs) among midwives who give ANC service for the pregnant women in the four refugee camps were conducted using purposive sampling technique until enough information is gained. A total of 56 participants were involved in the six FGDs. The average number of participants in the FGDs was 10 individuals with a range of 8 to 12 individuals. One to two FGDs were conducted in each of the four refugee camps, and pregnant women were selected purposefully based on their length of pregnancy period. To get sufficient information pregnant women with longer duration of pregnancy, usually in their third trimester, were selected. Structured questionnaires were used for the interview. The questionnaire was adopted and modified from Ethiopian Health and Nutrition Research Institute, micronutrient initiative effective modalities to improve pregnant women’s adherence to daily iron supplementation survey questionnaire, WHO guideline for anemia prevention and other literature [15, 16]. First, the questionnaire was written in English and then translated to the local language, Tigrigna, peer-reviewed and translated back to English to ensure consistency. The Tigrigna version of the questionnaire was pretested among 16 women (5% of the total sample size) who visit May-Tsebri government health center Maternal and Child Health (MCH) clinic. The principal investigator and data collectors undertook the pretest. Based on the findings of the pretest, necessary corrections and amendments were made on the questionnaire before the actual data collection was started. Four refugee diploma holder midwife data collectors (one for each camp) and two supervisors (one for two camps) who have a Bachelor of Science in nursing were recruited. Supervisors and data collectors had previous experience of data collection and were trained for one day (See Additional file 1 for details of the quantitative data collection tool). FGD interview guide note was used to understand the perceptions of participants about the use of antenatal IFA supplementation. Furthermore, the behavioral and cultural issues in terms of facilitating factors and barriers to utilization of antenatal IFA supplementation were assessed through KII guiding questions. First, the FGD guiding questions were written in English and then translated to the local language, Tigrigna, and peer-reviewed and then translated back to English before administration. Two bachelor degree holders in nursing and sociology with experiences in collecting qualitative data were assigned in each FGD to collect data as modulator and note taker. A tape recorder was used to capture the qualitative data during FGD and KII. Key informant interview was administered by the principal investigator and one bachelor holder in nursing was a note taker (see Additional file 2 for details of the qualitative data collection tool). The dependent variable is adherence to iron-folic acid supplementation and the independent variables are socio-demographic, obstetric, personal/individual and health service related factors of the pregnant women. Pregnant women who reported that they took at least 70% of the expected dose of the IFA tablets in the previous two weeks before the data collection, which is equivalent to consuming at least five tablets per week, were considered as adhered to IFA supplementation, and the opposite is true for non-adherence [15, 17, 18]. All women had given sufficient IFA tablets during their first and second ANC visit. Regarding the monthly income of the respondents, a tertile classification is applied to categorize it into three levels, as low, medium and higher income categories. To assess the level of knowledge about anemia during pregnancy, respondents were asked 18 questions on major causes, symptoms, and consequences during pregnancy. Those who scored > the mean value were considered as somehow knowledgeable and those who scored ≤the mean value were considered as less knowledgeable. Data were coded and entered into Epi-info version 3.5.1 and exported into statistical package for social sciences (SPSS) Version 21.0 software for analyses. Descriptive statistics were employed to describe the study population in relation to socio-demographic and other relevant variables and to display findings in mean, median, percentage and 95% confidence intervals. A composite scale was constructed for maternal knowledge about anemia. To identify factors associated with adherence to IFA supplementation, first a bivariable logistic regression was performed for each independent variable with adherence to IFA supplementation and crude odds ratio with 95% confidence intervals was obtained. Subsequently, significant variables in the bivariable analysis (p-value < 0.2) were incorporated into the multivariable logistic regression to determine independent predictors of adherence to IFA supplementation among pregnant women. To control the effect of the four different health facilities (camps), a random effect was estimated using Generalized Estimating Equation (GEE) model. Results were summarized using tables, figures and graphs. The goodness of fit of the final logistic model was tested using Hosmer and Lemeshow test. For the knowledge-related questions, reliability was checked during pretest using Cronbach’s Alpha, which was 0.746. Open code version 3.6.2.0 software was used for analysis. Data were recorded by tape recorders from six FGDs and three KIIs were transcribed word-by-word into plain text and translated into English. After codes were developed, issues discussed and themes developed. The codes developed from the texts were coded into the following terms: availability of tablets, knowledge about IFA supplementation, attitude about IFAs, information from health professionals, and the perception of women, as they are healthy, parity and gravidity. The themes developed from the codes were personal factors, health facility-related factors, and pregnancy-related factors. All authors together develop the codes and themes of the qualitative data. An MSc expert in Health Education assisted how to analyze the qualitative data. Finally, the themes were triangulated with quantitative findings.