Comprehensive Approach for Improving Adherence to Prenatal Iron and Folic Acid Supplements Based on Intervention Studies in Bangladesh, Burkina Faso, Ethiopia, and India

Plain language title Designing Comprehensive Interventions to Improve the Consumption of Prenatal Iron and Folic Acid Supplements in Low- and Middle-Income Countries Plain language summary Anemia among women of reproductive age, particularly during pregnancy, is widespread, but there are remedies such as iron and folic acid (IFA) supplements that can increase iron intake. This study documents the barriers faced by pregnant women (PW) in adhering to daily IFA supplementation as recommended by the World Health Organization. We designed interventions for large-scale antenatal care programs to improve adherence in Bangladesh, Burkina Faso, Ethiopia, and India. The barriers included poor supplies, lack of counseling during antenatal visits, and insufficient community and family support for PW. We strengthened service delivery protocols and the capacity of community workers to engage families. We trained health workers, improved supervision and counseling quality, strengthened supply systems for IFA tablets, and facilitated family support for PW. We improved women's knowledge, beliefs, self-efficacy, and perception of social norms through interventions tailored for each country setting. Considering the high burden of anemia in low- and middle-income countries among women especially during pregnancy and health consequences for mothers and newborns of low iron intake, decision makers and implementers need to pay greater attention to understanding local barriers to adherence and designing interventions that can improve adherence. Social and behavioral science theories and health systems strengthening frameworks provide a strong technical basis for designing effective interventions to improve IFA adherence. Background: The World Health Organization recommends daily iron and folic acid (IFA) supplementation during pregnancy, but consumption remains low, and high prevalence of anemia among pregnant women (PW) persists. Objectives: This study aims to (1) examine factors at the health system, community, and individual levels, which influence adherence to IFA supplements; and (2) describe a comprehensive approach for designing interventions to improve adherence based on lessons learned from 4 country experiences. Methods: We conducted literature search, formative research, and baseline surveys in Bangladesh, Burkina Faso, Ethiopia, and India and applied health systems strengthening and social and behavior change principles to design interventions. The interventions addressed underlying barriers at the individual, community, and health system levels. Interventions were further adapted for integration into existing large-scale antenatal care programs through continuous monitoring. Results: Key factors related to low adherence were lack of operational protocols to implement policies, supply chain bottlenecks, low capacity to counsel women, negative social norms, and individual cognitive barriers. We reinforced antenatal care services and linked them with community workers and families to address knowledge, beliefs, self-efficacy, and perceived social norms. Evaluations showed that adherence improved in all countries. Based on implementation lessons, we developed a program pathway and details of interventions for mobilizing health systems and community platforms for improving adherence. Conclusion: A proven process for designing interventions to address IFA supplement adherence will contribute to achieving global nutrition targets for anemia reduction in PW. This evidence-based comprehensive approach may be applied in other countries with high anemia prevalence and low IFA adherence.

Automated summary

This study aimed to improve the consumption of prenatal iron and folic acid supplements in low- and middle-income countries through designing comprehensive interventions. The barriers faced by pregnant women in adhering to daily supplementation were identified, and interventions were developed to address these barriers, including strengthening service delivery, improving counseling quality, and facilitating family support. The interventions successfully improved adherence in all countries and can be applied in other countries with similar challenges.