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Translating formative research findings into a behaviour change strategy to promote antenatal calcium and iron and folic acid supplementation in western Kenya.

ABSTRACT: The World Health Organization now recommends integrating calcium supplements into antenatal micronutrient supplementation programmes to prevent pre-eclampsia, a leading cause of maternal mortality. As countries consider integrating calcium supplementation into antenatal care (ANC), it is important to identify context-specific barriers and facilitators to delivery and adherence. Such insights can be gained from women's and health workers' experiences with iron and folic acid (IFA) supplements. We conducted in-depth interviews with 22 pregnant and post-partum women and 20 community-based and facility-based health workers in Kenya to inform a calcium and IFA supplementation programme. Interviews assessed awareness of anaemia, pre-eclampsia and eclampsia; ANC attendance; and barriers and facilitators to IFA supplement delivery and adherence. We analyzed interviews inductively using the constant comparative method. Women and health workers identified poor diet quality in pregnancy as a major health concern. Neither women nor health workers identified pre-eclampsia, eclampsia, anaemia or related symptoms as serious health threats. Women and community-based health workers were unfamiliar with pre-eclampsia and eclampsia and considered anaemia symptoms normal. Most women had not received IFA supplements, and those who had received insufficient amounts and little information about supplement benefits. We then developed a multi-level (health facility, community, household and individual) behaviour change strategy to promote antenatal calcium and IFA supplementation. Formative research is an essential first step in guiding implementation of antenatal calcium supplementation programmes to reduce pre-eclampsia. Because evidence on how to implement successful calcium supplementation programmes is limited, experiences with antenatal IFA supplementation can be used to guide programme development.

SUBMITTER: Martin SL

PROVIDER: S-EPMC6866120 | biostudies-literature | 2017 Jan

REPOSITORIES: biostudies-literature

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Translating formative research findings into a behaviour change strategy to promote antenatal calcium and iron and folic acid supplementation in western Kenya.

Martin Stephanie L SL Seim Gretchen L GL Wawire Salome S Chapleau Gina M GM Young Sera L SL Dickin Katherine L KL

Maternal & child nutrition 20160222 1

The World Health Organization now recommends integrating calcium supplements into antenatal micronutrient supplementation programmes to prevent pre-eclampsia, a leading cause of maternal mortality. As countries consider integrating calcium supplementation into antenatal care (ANC), it is important to identify context-specific barriers and facilitators to delivery and adherence. Such insights can be gained from women's and health workers' experiences with iron and folic acid (IFA) supplements. We ...[more]

PMID: 26898417

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Project description:BackgroundIn countries with low calcium intake, the WHO recommends integrating calcium supplementation into antenatal care (ANC) to reduce the risk of preeclampsia, a leading cause of maternal mortality. Current WHO guidelines recommend women take 3-4 calcium supplements plus 1 iron-folic acid supplement at separate times daily. There is limited evidence about implementing these guidelines through routine ANC. Through the Micronutrient Initiative-Cornell University Calcium (MICa) trial, we examined the effect of regimen on supplement consumption among ANC clients in western Kenya. A nested process evaluation examined factors that influence calcium supplementation delivery and uptake.ObjectivesThis process evaluation assessed ANC providers', pregnant women's, and family members' experiences with calcium supplementation, and investigated the feasibility and acceptability of engaging family members to support adherence.MethodsWe conducted semistructured interviews with 7 ANC providers, 32 pregnant women, and 20 adherence partners (family members who provide reminders and support), and 200 observations of ANC consultations. Interviews were transcribed, translated, and analyzed thematically. Observational data were summarized.ResultsANC providers reported positive feelings about calcium supplementation, the training received, and counseling materials, but reported increased workloads. Women reported that providers counseled them on supplement benefits and managing side effects, offered reminder strategies, and provided supplements and behavior change materials. Women explained that reminder materials and adherence partners improved adherence. Most adherence partners reported providing reminders and other instrumental support to help with pill taking, which women confirmed and appreciated. Some women reported that comorbidities, concerns about being perceived as HIV positive, pill burden, unfavorable organoleptic properties, and lack of food were adherence barriers.ConclusionsAlthough integrating calcium into antenatal iron-folic acid supplementation was generally acceptable to ANC providers, pregnant women, and their families, calcium supplementation presents unique challenges that must be considered to successfully implement these guidelines.This trial was registered at clinicaltrials.gov as NCT02238704.

Project description:Recommendations for antenatal calcium supplementation to prevent preeclampsia could substantially reduce maternal mortality, but adherence to multiple daily doses may constrain effectiveness. World Health Organization guidelines recommend 3 daily calcium supplements (1.5-2 g/d), taken separately from 1 iron-folic acid (IFA) supplement; however, limited data suggest lower calcium doses may also be effective. We conducted mixed-methods household trials to identify strategies for supporting adherence and integrating calcium into antenatal IFA supplementation programming in Ethiopia. Participants were randomly assigned to 3 regimens varying in dose and timing and were later given a choice of regimens. Semistructured interviews conducted over 6 weeks explored acceptability, barriers, and facilitators and offered opportunities to choose calcium pill type. Interviews were transcribed, translated, and analyzed thematically. Calcium adherence was measured using medication event monitoring. All participants (N=48) agreed to try supplementation. Adherence barriers included forgetting to take pills when busy or travelling and perceived side effects. Midday doses were the most challenging because of farming, market, and social events; women avoided taking supplements in public due to fear of being perceived as HIV positive. Social support from families, visual reminders, and anticipated benefits motivated adherence. More participants (75%) selected chewable versus conventional supplements due to organoleptic properties, but this preference declined over time. Adherence rates did not substantially differ across regimens with 2 (81.1%), 3 (83.4%), or 4 (77.1%) pill-taking events. Women indicated that the 2-event regimen was more acceptable than 3- and 4-event regimens, but this acceptability was not associated with higher adherence. Consequently, mean daily calcium consumption (811.3 mg) was lower than for 3-event (1,251.1 mg) and 4-event (1,156.4 mg) regimens. Integrating calcium into antenatal IFA supplementation is acceptable to Ethiopian women, with a 3-event regimen yielding the highest consumption rates. Despite women experiencing challenges with midday dosing and stigma, using simple home-based strategies and being counseled on the purpose of supplementation were more effective than reducing dosage for mitigating barriers and improving adherence.

Project description:BackgroundCoverage of iron-folic acid (IFA) supplementation is a key indicator for tracking programmatic progress within and across countries. However, the validity of maternal report of this information during household surveys has yet to be determined.ObjectivesThis study aimed to examine the validity of maternal recall of receipt of IFA supplementation during antenatal care (ANC) and factors associated with accuracy of maternal recall.MethodsA longitudinal cohort design was employed. The direct observation of the IFA received during all ANC visits at the 5 study health posts served as the "gold standard" to the maternal report of IFA received during the postpartum interview. Individual-level validity was assessed by calculating indicator sensitivity, specificity, and AUC. The inflation factor (IF) measured population-level bias. A multivariable log-binomial model was used to assess factors associated with accurate recall.ResultsThe majority (95.8%) of women were observed receiving IFA during pregnancy. Women overreported the number of IFA tablets received compared with what was observed during ANC visits (mean difference: 45 tablets). Maternal report of any IFA receipt was moderate (AUC = 0.60; 95% CI: 0.50, 0.71), and population bias was low (IF = 1.01). However, the individual-level validity was poor across the 7 IFA tablet count categories; the AUC for categories ranged from misleading to moderate. Driven by the trend of maternal overreport, the IF indicated that maternal report drastically underestimated the coverage of lower tablet categories and overestimated the coverage of higher tablet counts. Accuracy of maternal report was not associated with months since last ANC observation nor any maternal characteristics.ConclusionsMaternal report of the amount of IFA supplementation received during pregnancy produced extremely biased population coverage and performed poorly to moderately for individual-level validity. It is imperative to improve this indicator because it is used in global frameworks and national program planning.

Project description:Introduction:Pregnant women are at a high risk of anaemia, with iron-folate deficiency being the most common cause of anaemia among pregnant women. Despite the well-known importance of iron and folic acid supplementation (IFAS) during pregnancy, adherence to these supplements is relatively low and associated factors were not well identified in the study area. This study is aimed at investigating adherence to IFAS and associated factors among pregnant women in Kasulu district, north-western Tanzania. Methods:A health facility cross-sectional survey with a mixed-method approach was conducted in Kasulu district from March to April 2019. A structured questionnaire was given to 320 women with children aged 0-6 months to assess factors associated with adherence to IFAS among pregnant women. Data were entered into SPSS version 22.0 for analysis. Binary logistic regression was further employed to determine the factors associated with adherence to IFAS. Focus group discussions were done with 19 pregnant women and 15 mothers of children aged 0-6 months to obtain more clarifications on the factors associated with adherence to IFAS. Furthermore, in-depth interviews were done with six health care providers to explore their perceptions of IFAS. Results:Out of the 320 respondents of the survey, 20.3% (n = 65) adhered to IFAS. Factors associated with adherence to IFAS among pregnant women included time to start ANC (AOR = 3.72, 95% CI: 1.42, 9.79), knowledge of anaemia (AOR = 3.84, 95% CI: 1.335, 10.66), counseling on the importance of the iron-folic acid (AOR = 3.86, 95% CI: 1.42, 10.50), IFAS given during clinical visit (AOR = 15.72, 95% CI: 5.34, 46.31), number of meals consumed (AOR = 3.44, 95% CI: 1.28, 9.21), number of children (AOR = 3.462, 95% CI: 1.035, 11.58), and distance to health facility (AOR = 0.34, 95% CI: 0.131, 0.886). Qualitative findings revealed that delayed first ANC visit, lack of remainder for pregnant women to take IFAS, low awareness about the negative effects of anaemia, low of knowledge of IFAS and management of side effects, negative beliefs about the use of IFAS, and follow-up mechanism were major reasons for poor adherence. Conclusion:Adherence to iron-folic acid supplementation during pregnancy was low. Strengthening systems for creating reminding mechanism, raising community awareness through educational programs to pregnant women and health providers could improve adherence to IFAS.

Project description:BackgroundDaily antenatal multiple micronutrient (MM) compared with iron folic acid (IFA) supplementation from early pregnancy improved birth outcomes and maternal micronutrient status in rural Bangladesh, but effects on newborn status are unknown.ObjectiveWe examined cord blood micronutrient biomarkers in relation to antenatal MM and IFA supplementation and maternal gestational micronutrient status in rural Bangladeshi newborns.DesignIn a double-blinded, cluster-randomized trial of antenatal IFA or MM (with the same IFA content), we analyzed cord blood plasma from 333 singleton births, and corresponding maternal plasma at 32.5 ± 2.6 wk of gestation, for ferritin (iron stores), folate, cobalamin (vitamin B-12), retinol (vitamin A), 25-hydroxyvitamin D [25(OH)D, vitamin D status], α-tocopherol (vitamin E), zinc, thyroglobulin, and free thyroxine (iodine status). Intervention effects and associations were determined using linear regression, exploring maternal status as a mediator of intervention effects on cord biomarkers.ResultsThe MM intervention increased cord ferritin (mean: +12.4%; 95% CI: 1.3, 24.6%), 25(OH)D (mean: +14.7%; 95% CI: 4.8, 25.6%), and zinc (mean: +5.8%; 95% CI: 1.0, 10.8%). Cord folate (mean: +26.8%; 95% CI: 19.6, 34.5%), cobalamin (mean: +31.3%; 95% CI: 24.6, 38.3%), 25(OH)D (mean: +26.7%; 95% CI: 23.2, 30.3%), α-tocopherol (mean: +8.7%; 95% CI: 3.6, 13.7%), zinc (mean: +2.3%; 95% CI: 0.5, 4.2%), thyroglobulin (mean: +20.1%; 95% CI: 9.0, 32.2%) and thyroxine (mean: +1.5%; 95% CI: 0.0, 3.0%) increased per 1-SD increment in maternal status (all P < 0.05); ferritin and retinol changed by +2.0%; 95% CI: -8.9, 14.3%; P = 0.72; and +3.5%; 95% CI: -0.4, 7.3%; P = 0.07, respectively. Ferritin, folate, cobalamin, zinc, and thyroglobulin averaged 1.57-6.75 times higher and retinol, α-tocopherol, and 25(OH)D 0.30-0.84 times lower in cord than maternal plasma, suggesting preferential maternal-fetal transfer of iron, folate, cobalamin, and zinc; limited transfer of fat-soluble vitamins; and high fetal iodine demand.ConclusionsAntenatal MM supplementation increased newborn ferritin, 25(OH)D, and zinc, while maternal and newborn folate, vitamins B-12, D, and E, zinc, and iodine biomarkers were positively related. Despite limited effects of MM, better maternal micronutrient status was associated with improved micronutrient status of Bangladeshi newborns. This trial was registered at clinicaltrials.gov as NCT00860470.

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Translating formative research findings into a behaviour change strategy to promote antenatal calcium and iron and folic acid supplementation in western Kenya.

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Translating formative research findings into a behaviour change strategy to promote antenatal calcium and iron and folic acid supplementation in western Kenya.

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