Moving beyond individual barriers and identifying multi-level strategies to reduce anemia in Odisha India.

BACKGROUND: To reduce the prevalence of anemia, the Indian government recommends daily iron and folic acid supplements (iron supplements) for pregnant women and weekly iron supplements for adolescents and all women of reproductive age. The government has distributed free iron supplements to adolescents and pregnant women for over four decades. However, initial uptake and adherence remain inadequate and non-pregnant women of reproductive age are largely ignored. The aim of this study is to examine the multilevel barriers to iron supplement use and to subsequently identify promising areas to intervene. METHODS: We conducted a qualitative study in the state of Odisha, India. Data collection included key informant interviews, focus group discussions with women, husbands, and mothers-in-law, and direct observations in health centers, pharmacies and village health and nutrition days. RESULTS: We found that at the individual level, participants knew that iron supplements prevent anemia but underestimated anemia prevalence and risk in their community. Participants also believed that taking too many iron supplements during pregnancy would "make your baby big" causing a painful birth and a costly cesarean section. At the interpersonal level, mothers-in-law were not supportive of their daughters-in-law taking regular iron supplements during pregnancy but husbands were more supportive. At the community level, participants reported that only pregnant women and adolescents are taking iron supplements, ignoring non-pregnant women altogether. Unequal gender norms are also an upstream barrier for non-pregnant women to prioritize their health to obtain iron supplements. At the policy level, frontline health workers distribute iron supplements to pregnant women only and do not follow up on adherence. CONCLUSIONS: Interventions should address multiple barriers to iron supplement use along the socio-ecological model. They should also be tailored to a woman's reproductive life course stage: adolescents, pregnancy, and non-pregnant women of reproductive age because social norms and available services differ between the subpopulations.

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.

Interventional study to strengthen the health promoting behaviours of pregnant women to prevent anaemia in southern India.

OBJECTIVES: to determine the effectiveness of a health information package in terms of empowering the pregnant women to modify their health-care behaviour and take appropriate action to combat anaemia in pregnancy. DESIGN: the study was conceptualized based on Rosenstock and Becker's health belief model. A quasi-experimental pretest-posttest control group design was used. The sample consists of 225 anaemic pregnant women randomly allocated in experimental (n=75), control group A (n=75) and control group B (n=75). The health seeking behaviour outcome measure included knowledge regarding anaemia, food selection ability, increase in haemoglobin level and compliance to iron supplementation. Intervention was a validated planned educational programme with visual aids and iron supplementation. FINDINGS: the results show the mean gain of knowledge scores of experimental group was comparatively higher and control groups A and B showed that F ratio was (F(2,190)=11.910, p<0.01) indicating that the pregnant women learned more about anaemia prevention than others. With regard to food selection ability scores of experimental, control groups A and B the F ratio was also significant (F(2,190)=20.92, p<0.01). Nearly 61.2% of the subjects in experimental group became non-anaemic after the intervention when compared to control group A. This indicated that inspite of iron supplementation received by the three groups health education contributed significantly in modifying their health seeking behaviour and their perception about significance of anaemia has a problem. CONCLUSION: developing countries still face the critical problem of anaemia in pregnancy. These are the socio-cultural priority problems that demand immediate attention by the policy makers and health professionals. The national anaemia control programme focuses on iron supplementation, but nutritional education and supervision of iron supplementation has failed in different regions. The study implies that economic empowerment; strengthening health literacy through planned educational programs will definitely improve the health behaviour of individual and community at large.

The effectiveness of weekly iron supplementation in pregnant women of rural northern Malawi.

A weekly iron/folate supplement was compared with a standard daily iron/folate supplement in pregnant women living in rural Malawi. Women were enrolled as they attended the local antenatal clinic, stratified by grade of anaemia and then randomized to receive either 60 mg iron/0.25 mg folate per day (n = 211) or 120 mg iron/0.50 mg folate once a week (n = 202). Supplementation was continued for a minimum of 8 weeks (10 weeks on average) and was self administered by the women at home. Initial haemoglobin values for the daily (mu = 105.7 g/l) and weekly (mu = 104.4 g/l) groups as well as final haemoglobin values (107.5 g/l and 105.6 g/l, respectively) did not differ significantly between the two groups. Haemoglobin values increased by similar levels in both groups with the subset of anaemic women increasing by an average of 6.3 g/l in the daily group (n = 70) and 5.9 g/l in the weekly group (n = 66) for all women. For compliant, anaemic women, the increases were 7.4 g/l and 6.6 g/l for the daily and weekly groups, respectively. Compliance, as indicated by self reporting and by regular counts of remaining tablets, was significantly higher in the weekly group (76% compared with 60%, P < 0.05), however compliance was identical in both groups when assessed by a stool test for elemental iron. Reported side effects were significantly reduced in the weekly group (6% compared with 17%, P < 0.05). We conclude that a weekly iron supplement given to pregnant women in rural Malawi has similar haematologic effects, and an improved side effect profile, in comparison with a standard daily supplement when administered through an existing primary healthcare programme, although both regimens are relatively unsuccessful in the reduction of anaemia prevalence during pregnancy.