Factors associated with high compliance/feasibility during iron and folic acid supplementation in a tribal area of Madhya Pradesh, India

The association between social support with compliance of IFA supplement intake among adolescent girls in Sidoarjo, Indonesia

Background: Anemia is a severe nutritional issue affecting people worldwide, including in Indonesia. One of the government's initiatives to alleviate anemia afflicting adolescent Indonesian girls is iron and folic acid supplementation (IFAS). However, this program has shown to be ineffective, which may be due to poor compliance of IFAS. Aim: This study aimed to identify the association of social support (sources of information and reminders) with compliance of IFA supplement intake among adolescent girls in Sidoarjo, Indonesia. Methods: This research was an observational analytic study with the cross-sectional method in three schools in Sidoarjo, Indonesia. A total of 202 high school adolescent girls were randomly selected. Bivariate statistics with the Spearman rank test determined associations and the strength of associations at a significant threshold of p < 0.05. Results: IFA compliance was low (11.4%). However, there was a significant association between the number of sources of information (r = 0.175, p = 0.013) and the number of reminders (r = 0.158; p = 0.025) with compliance of high school adolescent girls to consume IFA supplements regularly in Sidoarjo, Indonesia. Meanwhile, age did not significantly affect compliance of regular IFA supplement consumption. Conclusions: The compliance level was positively related to the number of sources of information and the number of reminders for taking IFA supplements among high school adolescent girls. Involvement from social environments such as teachers, parents, and health workers as a source of information and reminders can help improve high school adolescent girls' compliance.

Public health supply chain for iron and folic acid supplementation in India: Status, bottlenecks and an agenda for corrective action under Anemia Mukt Bharat strategy

PURPOSE

The IFA supplementation program under the Anemia Mukt Bharat (AMB) program is one of the most ambitious nutrient supplementation programs in India. The delivery of services often suffers due to frequent stock outs and shortages. It is critical to understand the bottleneck in the supply chain adversely affecting the performance and coverage of the program. The paper attempts to identify the bottlenecks of the IFA supply chain in key areas of supply chain i.e., forecasting, procurement, warehousing and inventory management, transportation, distribution, logistic information system and suggests a plan of action aimed at ensuring uninterrupted supplies to the end beneficiaries.

DESIGN/METHODOLOGY/APPROACH

The data source for the present paper is the nationwide IFA Supply Chain Assessment (2018-19) conducted across 29 Indian states with a total of 58 districts, 116 blocks, 232 Sub-Centres, 232 Anganwadi centres and 232 schools covered under the assessment as a multi-partner collaborative initiative. Field insights from supply chain strengthening interventions under different public health programs in India and other developing countries were taken to arrive at corrective actions and recommendations. Findings were disseminated to government and an action plan was suggested for connecting service delivery points through an app-based system, developing a micro plan for ensuring fixed distribution schedule, followed by continuous monitoring and review meetings identified for follow up.

FINDINGS

The average lead time across states was 35 weeks with top three performing states being Goa, Sikkim, and Telangana. The average per unit cost of procurement was Rs 0.35 for IFA Red, Rs 0.25 for IFA Blue, Rs 0.31 for IFA Pink and Rs 7.30 for IFA syrup. Out of the 704 districts in India, only 213 has IFA Red, only 140 had IFA Blue, 152 had IFA Pink and 163 had IFA Syrup available in four quarters of 2018-19. The key issues identified in the assessment were-a lack of standardized forecasting process, absence of inventory management techniques, no fixed distribution schedule, inadequate availability of transport vehicles and an absence of an integrated MIS.

ORIGINALITY/VALUE

The identification of bottlenecks in the IFA supply chain and its impact on the performance of the supply chain would provide policy guidelines for the government as well as development partner agencies to design an effective and efficient supply chain. It would also enable the policy planners to understand the challenges associated with managing different components of a supply chain, their interrelation and impact on the overall performance of the supply chain. The suggested recommendations would equip program managers with the tool to devise and implement field level solutions.

The role of social support and interpersonal trust to improve compliance of iron supplementation amongst adolescent girls: A qualitative approach

Context

Adolescence is a crucial phase in preventing and controlling anaemia. One of the efforts made by the Indonesian government to overcome adolescent girl's anaemia is the iron and folic acid (IFA) supplementation programme. This programme is one of the most effective interventions that various countries have used to overcome anaemia. The key to the success of the supplementation of IFA is the compliance of adolescent girls.

Aims

This study investigates the compliance and its contributing factors of IFA supplementation and the role of social support and interpersonal trust as a source of information and reminder amongst adolescent girls in Sidoarjo, Indonesia.

Methods

This research was a qualitative study using the in-depth interview to collect data. Thirteen adolescent girls from three high schools in Sidoarjo, Indonesia, were recruited using a snowball sampling technique.

Results

Most of the girls did not comply with IFA supplementation. Contributing factors were the influence of peers, influence of teachers, parental influence, risk and benefit of taking IFA tablet and also failure to remember to take IFA tablet. The social environment that provided information and reminder came from teacher, parent, peer and also health worker. Interpersonal trust was needed to have positive perceived social support.

Conclusions

Compliance with the consumption of IFA supplements requires the cooperation of various parties (teachers, parents, peers and health workers) and also interpersonal trust between adolescent girls to their social environment so the programme could be run optimally.

Coverage of Iron and Folic Acid Supplementation in India: Progress Under the Anemia Mukt Bharat Strategy 2017-2020

High prevalence of anemia is a severe public health problem in India. In 2018, India launched the Anemia Mukt Bharat (AMB) strategy that focuses on six beneficiary groups for coverage, six institutional mechanisms for health system strengthening and six programmatic interventions to accelerate reductions in anemia prevalence. This paper uses the Health Management Information System (HMIS) data (2017-18 to 2019-20) to examine gains in IFA coverage across Indian states. A coverage based AMB index is computed to review performance across states. After the launch of AMB strategy, the IFA supplementation coverage between 2017-18 and 2019-20 has increased for all beneficiary groups (pregnant women from 78% to 90%; lactating mothers from 34% to 49%; school going adolescent girls (boys) from 23% to 40% (21% to 42%); out-of-school adolescent girls from 6% to 23%; children 5-9 years from 8% to 3%; and, children 6-59 months from 7% to 15%). Coverage was relatively low for target groups being served through a multi-departmental convergence mechanism (health and other departments such as education department for schools or women and child development department for anganwadi centres) than compared to those served by health department alone. However, no major gender disparities are noted in the coverage of IFA supplementation among school-going girls and boys. Bulk of the variations in coverage is attributable to state-specific differences. Training and sensitization workshops for state and district officials are found to be associated with increased coverage across beneficiary groups. The paper argues that despite following international best practices in the field it is important to harness synergy in program implementation across line departments to eliminate coverage inefficiencies.

Effect of direct monitoring by family members and counseling by health professionals on iron-folic acid supplementation: A cross-sectional study among pregnant women in Puducherry, India

BACKGROUND:

The prevalence of iron-deficiency anemia in pregnant Indian women is reportedly quite high. Despite the sustained efforts of the current national control program and undisputed efficacy of iron-folic acid supplementation (IFAS), the onslaught of anemia has not been curtailed, probably as a result of noncompliance to IFAS. The objective of this study was to assess the effect of direct monitoring of pregnant women by family members, counseling by health professionals, and other variables on adherence to IFAS in Puducherry, India.

MATERIALS AND METHODS:

A cross-sectional study was conducted among 250 pregnant women visiting Outpatient Clinic, Obstetrics and Gynecology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry. Missing ≥2 doses of IFAS in the preceding 7 days was considered as nonadherence. The Pearson Chi-square test was applied to identify the association between the different variables. Bivariate and multivariate logistic regressions revealed variables affecting adherence.

RESULTS:

Around 34.4% of respondents reported nonadherence to IFAS. Direct monitoring by family members (Adjusted Odds Ratio [aOR] = 7.04; P < 0.001), counseling by health professionals (aOR = 2.97; P = 0.002), and improvement in hemoglobin (Hb) levels (aOR = 2.4; P = 0.01) were associated with better adherence. Vomiting, abdominal pain, and diarrhea were common ADRs. The distance to hospital, improvement in Hb levels, counseling by health professionals, and direct monitoring by family members significantly reduced the odds of ADRs.

CONCLUSION:

Direct monitoring of intake by family members and counseling by health professionals improved adherence to IFAS. Further in-depth formative research studies are recommended for strategies to improve adherence to IFAS in the vulnerable pregnant population of Puducherry and streamline the implementation of anemia national control program in a specific context.

Compliance with Weekly Iron and Folic Acid Supplementation and Its Associated Factors among Adolescent Girls in Tamale Metropolis of Ghana

Background

In Ghana, anaemia is a severe public health problem among adolescent girls. In an attempt to deal with this phenomenon, Ghana Ministry of Health in collaboration with other development partners developed and launched weekly iron and folic acid supplementation program for adolescent girls in Ghanaian junior high schools. Therefore, the main aim of this study was to determine the level of compliance with iron and folic acid supplementation (IFAS) and its associated factors among adolescent girls in the Tamale Metropolis of Ghana.

Methods

A cross-sectional study was conducted among 424 randomly sampled adolescent girls in the Tamale Metropolis of Ghana from April to July 2019 using an interviewer-administered structured questionnaire. Twenty school health coordinators were purposively selected to answer questions on the challenges they face in implementing the IFAS program at the school level. Bivariate logistic regression and multivariate logistic regression were used to determine associations and strength of associations, respectively, at a significant threshold of p < 0.05.

Results

Compliance with the IFAS was low (26.2%). Adolescent girls who were aware of anaemia (AOR = 3.57 (95% CI: 1.96, 6.51) p < 0.01), had good knowledge of anaemia (AOR = 1.82 (95% CI: 1.17, 2.81) p=0.01), and had good knowledge of the IFAS program (AOR = 2.29 (95% CI: 1.47, 3.57) p < 0.01) were significantly associated with compliance with the IFAS. The majority (60%) of the adolescent girls have ever missed taking the iron and folic acid (IFA) tablet because it was not issued to them by the teacher's concern while about 48.3% (169) of the adolescent girls are taking the tablet because it prevents anaemia. Adolescent girls perceiving the tablet as family planning medicine (88.8%) and unavailability of water in classrooms (18.8%) were cited as the major challenges by school health coordinators.

Conclusion

Compliance with the IFAS among adolescent girls was low. Level of education and occupation of mothers of adolescent girls, awareness on anaemia, and good knowledge of anaemia and of the IFAS program were significant predictors of compliance with the IFAS. Educating the adolescent girls on anaemia and benefits of the IFAS, constant supply of the IFA tablet, and engaging parents of the adolescent girls on the program will help improve the compliance level of the adolescent girls with the IFAS.

Magnitude and factors associated with adherence to Iron and folic acid supplementation among pregnant women in Aykel town, Northwest Ethiopia

INTRODUCTION

Physiological changes during pregnancy, foetal growth and development increase the requirement for Iron and Folic Acid. The increased demand of these nutrients is not meet through diet alone due to decreased bioavailability of nutrients during pregnancy. In 2004, Ethiopia adopted the global Iron and Folic Acid supplementation strategy targeting to reduce the prevalence of Iron deficiency anemia in women of reproductive age and children under five, by one third. However, the prevalence of anemia remains high and only 5% of pregnant women took Iron and Folic Acid tablets for 90 days or more during their most recent pregnancy in Ethiopia. Therefore, we conducted this study to assess the magnitude and associated factors of adherence to Iron and Folic Acid supplementation during pregnancy.

METHODS

A facility based cross sectional study was conducted from February to May, 2018 among pregnant women in Northwest Ethiopia. Systematic random sampling technique was used to select 418 study subjects. Bivariable and multivariable logistic regression analyses were computed to identify predictor variables.

RESULTS

Rate of adherence to Iron and Folic Acid supplementation among pregnant women was 47.6%. Pregnant women who had a past history of abortion, knowledge of anemia and received health education were more likely to be adherent with Iron and Folic Acid supplementation. Furthermore, knowledge about benefits of the supplement and not facing any problem in the health facilities during Iron and Folic Acid tablet collection were factors associated with Iron and Folic Acid supplementation adherence.

CONCLUSIONS

Rate of adherence to Iron and Folic Acid supplementation was low in Aykel town. Therefore, strengthening and promoting health education, creating awareness and avoiding discouraging conditions in health facilities during tablet collection are very crucial to improve and increase the low rate of Iron and Folic Acid supplementation adherence in the study area.

Compliance with iron folic acid and associated factors among pregnant women through pill count in Hawassa city, South Ethiopia: a community based cross-sectional study

Background

Iron deficiency anemia during pregnancy is a public health problem across the globe that adversely affects maternal and perinatal outcome. World Health Organization recommends that universal iron folic acid supplementation of pregnant women. Therefore, the aim of this study was to determine compliance and identify factors associated with Iron folic acid among pregnant women.

Methods

Community based cross-sectional study was conducted from November 01–December 30, 2015 on pregnant women from Hawassa city. An Interviewer administered questionnaire was used to collect data from 422 selected study subjects using simple random sampling technique. Data were entered in to Epi-Data version 3.1 and exported to SPSS version 20 for analysis. Bivariate and multivariable analyses were employed to test presence of association between dependent and independent variables. P value < 0.05 was considered as statistically significant.

Result

In this study prevalence of compliance with iron folic acid was reported 38.3% (95%CI: 33.1, 42.5). Women who know the importance of iron folic acid had 6 times higher odds of compliance with iron folic acid than counterpart (AOR = 6.1, 95% CI: 3.53, 10.24).Pregnant women who develop complication during the previous pregnancy had 0.34 times lower odds of compliance with counterpart (AOR = 0.34, 95% CI: 0.16–0.76), experiencing iron folic acid related side effects during the previous pregnancy had 8.5 time higher odds to decrease compliance with than those did not experience iron folic acid related side effects (AOR = 8.5, 95% CI: 4.65.-15.35).

Conclusion

In this study demonstrated that compliance with iron folic acid among pregnant women through pill count is low. Women who know the importance of iron folic acid, women who develop complications during previous pregnancy, experiencing iron folic acid related side effects during the previous pregnancy were independent predictor of compliance with iron folic acid. Health care providers shall strongly counsel the importance and side effect of iron folic acid before prescribing. The responsible bodies avail suitable iron folic acid pill and less side effect brands. Health care providers and health extension workers shall be monitored iron folic acid by pill count during their home to home visits.

Compliance with Iron and folic acid supplementation (IFAS) and associated factors among pregnant women: results from a cross-sectional study in Kiambu County, Kenya

BACKGROUND

Macro and micronutrients including iron and folic acid deficiencies are prevalent in Kenya, particularly during pregnancy resulting in anaemia. Despite efforts to control anaemia in pregnancy by adopting Iron and Folic Acid Supplementation (IFAS), this public health problem has persisted contributing to significant morbidity and mortality. The problem notwithstanding, there is poor IFAS compliance, whose reasons remain poorly understood, calling for their investigations. We sought to determine compliance status with IFAS and associated factors among pregnant women.

METHODS

This was a cross-sectional study involving 364 pregnant women aged 15-49 years. Using two stage cluster sampling, one Sub-County and five public health facilities in Kiambu County were selected. All pregnant women attending antenatal clinics who met inclusion criteria and consented to participate in the study were recruited. Compliance with IFAS was defined as taking supplements at least 5 out of 7 days per week. A structured interviewer-administered questionnaire consisting of sociodemographic data, IFAS maternal knowledge and compliance practices was pretested and administered. Descriptive and inferential statistics were computed using STATA.

RESULTS

Of the 364 respondents interviewed, 32.7% were IFAS compliant and 40.9% scored high on its knowledge. Of those with high IFAS knowledge, 48.3% were compliant compared to those with low knowledge (21.4%, n = 46, PR = 2.25;95%CI = 1.59-3.17, p < 0.001). Women who were multigravid (30.4%) were less likely to comply compared to primigravid (37.2%, n = 45, PR = 0.68;95%CI = 0.47-0.99, p = 0.004). Multivariate analysis revealed that respondents counselled on management of IFAS side effects (100%, n = 4) were more compliant (76.2%, n = 112, aPR = 1.31;95%CI = 1.19-1.44, p < 0.001).

CONCLUSION

Few pregnant women were compliant with IFAS regimen, associated with: knowledgeability on IFAS, primi-gravidity, and IFAS counselling especially on management of its side effects. These underscore the need for approaches to scale up health awareness on the benefits of IFAS, mitigation measures for the side effects, as well as targeted counselling.

A Qualitative Study of Factors Influencing Initiation and Adherence to Micronutrient Supplementation Among Women of Reproductive Age in Vietnam

Background and objectives:

Initiation and adherence are both critical challenges for micronutrient supplementation programs, especially during the preconceptional period. This study examines factors influencing initiation of supplement use and continued adherence among women participating in PRECONCEPT, a double-blind randomized controlled trial of preconception micronutrient supplementation.

Methods:

In-depth interviews were conducted with 39 participants during different periods (prepregnancy [n = 15], pregnancy [n = 8], postpartum [n = 8], and dropouts [n = 8]). We examined participants’ knowledge about nutritional needs and micronutrient deficiencies, individual experience with nutritional supplements, and perceived benefits and side effects of supplements. Four focus groups were conducted with 24 village health workers (VHWs) to collect information on VHWs’ perceptions of factors influencing participants’ adherence and logistics of supplement distribution. Influences on initiation and adherence were examined within the Health Belief Model framework.

Results:

Primary barriers to initiation of supplement use were low perceptions of severity of nutrient deficiencies and personal susceptibility. These are associated with low knowledge and awareness around deficiencies. Perceived seriousness and susceptibility varied by nutrient: high for iron during pregnancy but low for all other micronutrient deficiencies, including iron outside pregnancy. Continued maintained adherence to an initiated regimen was influenced by the woman’s perceptions of the health benefits of, and barriers to, regular supplement use.

Conclusion:

Initiation of supplement use was influenced by perceived susceptibility and severity of nutrient deficiencies, while maintained adherence to consistent use was influenced by perceived benefits and barriers. Recognizing the influences on each stage may help improve adherence and maximize positive effects of future interventions.

Impact of weekly iron folic acid supplementation with and without vitamin B12 on anaemic adolescent girls: a randomised clinical trial

BACKGROUND/OBJECTIVES

In India, approx. 70% of the adolescent girls are anaemic (haemolgobin <120 g/l). The present study was a supervised randomised double-blind clinical trial conducted among adolescent girls (11-18 years) to assess and compare the impact of weekly iron folic acid (IFA) supplementation with or without vitamin B12 on reduction in the prevalence of anaemia and on blood/serum levels of haemoglobin, serum ferritin, folic acid and vitamin B12.

SUBJECTS/METHODS

Community-based randomized controlled trial was carried out in Kirti Nagar slums of West Delhi. A total of 446 mild (100-119 g/l) and moderate (70-99 g/l) anaemic volunteer adolescent girls were identified and randomised into two groups. Weekly supervised supplementation was given for 26 weeks: Group A (n=222): iron (100 mg), folic acid (500 mcg) and placebo; Group B (n=224): iron (100 mg), folic acid (500 mcg) and cyanocobalamin (500 mcg for 6 weeks and 15 mcg for 20 weeks). Haemoglobin, serum ferritin, folic acid and vitamin B12 levels were assessed at baseline and after intervention. A total of 373 subjects completed 26 weeks of supplementation successfully.

RESULTS

The mean haemoglobin increased from 106.7±11.2 g/l and 108.9±8.91 g/l in Group A and Group B at baseline to 116.4±10.8 g/l (P<0.001) and 116.5±10.26 g/l (P<0.001) at post-intervention, respectively, with the reduction in the prevalence of anaemia by 35.9% in Group A and 39.7% in Group B (P>0.05). A total of 63.3% participants had deficient vitamin B12 levels (<203 pg/ml) at baseline, which reduced to 40.4% after intervention with cyanocobalamin, whereas no change was observed in vitamin B12 status in the other group. Significant reduction (P=0.01) in the prevalence of serum ferritin deficiency (<15 ng/ml) was observed in the group supplemented with vitamin B12 (from 36.5 to 6.4%) as compared with the other group supplemented with only IFA (from 39.1 to 15.2%).

CONCLUSIONS

IFA supplementation with or without vitamin B12 is an effective measure to cure anaemia. Although addition of vitamin B12 had similar impact on improving haemoglobin status as IFA alone, it resulted in better ferritin status. Hence, more multi-centre studies with a longer duration of supplementation or higher dose of vitamin B12 may be undertaken to assess the possible impact of vitamin B12 on improving haemoglobin levels in the population.

"There is iron and iron…" Burkinabè women's perceptions of iron supplementation: a qualitative study

Most pregnant women in Burkina Faso are iron deficient and many are anemic. This study assessed women's understanding of anemia and the role of iron in preventing and treating this condition. A qualitative study was conducted within a randomized controlled trial of weekly iron supplementation in a rural malaria endemic area. Focus groups with women of similar age, parity, and marital status took place in 12 of 24 study villages. Two additional focus groups were conducted with female field workers. Tape-recorded transcripts were translated into French and analyzed using Framework analysis. Anemia, for which no Mooré term or traditional treatment for anemia was evident, was described in terms of blood volume. Moderate blood loss (diminished blood) could be easily replaced by eating well and was not considered serious. Massive blood loss (finished blood) was a rare, life-threatening illness. Iron tablets could increase blood volume and help women withstand massive blood loss at delivery, but for the latter, transfusion was indicated. Women had no knowledge of iron's role and did not readily concede that iron supplements contained elemental iron. Neither adolescents nor field workers were convinced of the benefits of supplementing non-pregnant adolescents, who were incorrectly considered to be at low risk of anemia. Young women's knowledge of anemia did not provide an adequate explanatory framework to motivate anemia prevention. Improving information on the role of iron is especially important for adolescent girls who may be incorrectly considered at low risk of anemia as they have not yet experienced pregnancy.