Deconstructing Adherence: Understanding patient and providerperceptions of iron and folic acid supplements to promotealternative solutions for maternal anemia in Ayacucho, Peru Öffentlichkeit

Abstract

Background: Anemia is the most common health condition affecting women during pregnancy and leads to adverse health outcomes of both the mother and infant. Women's adherence to iron and folic acid (IFA) supplements in the Peruvian region of Ayacucho remain low despite a government program that provides the tablets for free to pregnant women. Numerous quantitative studies have identified reasons for high discontinuation rates, while qualitative studies on the issue are lacking.

Objective: This study aims to understand the perceptions of patients and providers about the IFA supplementation program in Peru and make recommendations for improvements.

Methods: Twenty-two in-depth interviews and three focus group discussions with participatory learning activities were conducted with women 16 weeks gestation to two months post-partum in urban, semi-urban, and rural communities. Additionally, nine key participant interviews took place with obstetricians and directors of maternal health programs at the hospital and district levels.

Results: Findings indicate that adherence is influenced by six four primary factors: 1) the physical attributes of the tablets including their appearance and smel , associated side effects, and price; 2) the individual characteristics of a woman such as her age, parity, residence in urban or rural community, and the level of partner support she receives; 3) a woman's perceptions of the causes, prevalence, and prevention of anemia; and 4) the counseling or sensibilización that the provider conducts during each ANC visit.

Discussion: In order to overcome barriers to supplementation, providers should gain the trust of a patient during her first visit and particularly during her first pregnancy through successful counseling strategies. It is recommended that the Peruvian government adopts social marketing strategies to target these influencing factors. Specifical y, addressing the product, price, place, promotion, and policy of IFA supplements may increase women's adherence to the supplementation regimen and reduce iron deficiency maternal anemia.

Table of Contents

List of Tables and Figures................................................................... ix

Abbreviations................................................................................... x

Chapter 1: INTRODUCTION............................................................... 1

Chapter 2: LITERATURE REVIEW........................................................ 5

2.1 Introduction to Literature Review................................................. 5

2.2 Etiology of anemia..................................................................... 6

2.3 Consequences of anemia............................................................. 8

2.4 Efficacious and effective strategies for anemia prevention............... 10

2.5 Adherence to iron supplements................................................... 12

2.6 Role of providers in supplementation............................................ 13

2.7 Iron Deficiency in Peru and Ayacucho.......................................... 15

2.8 Effectiveness of Peruvian strategies to address anemia................... 17

2.9 Adherence to IFA supplements in Peru.......................................... 21

2.10 Filling the research gaps........................................................... 24

Chapter 3: METHODS...................................................................... 25

3.1 Study Design............................................................................ 25

3.2 Study Sites.............................................................................. 25

3.3 Study Population and Sampling..................................................... 27

3.4 Data Collection Tools.................................................................. 30

3.5 Data Collection Procedures.......................................................... 30

3.5.1 Key Participant Interviews........................................................ 30

3.5.2 Focus Group Discussions and Participatory Learning Activities.......... 32

3.6 Description of guides................................................................... 32

3.7 Ethics....................................................................................... 33

3.8 Data Processing.......................................................................... 33

3.9 Limitations.................................................................................. 34

4.1 Anemia....................................................................................... 37

4.1.1 Causes and general perceptions................................................... 37

4.1.2 Prevalence............................................................................... 39

4.1.3 Prevention............................................................................... .40

4.2 Barriers to IFA adherence............................................................... 42

4.2.1 Timing of entry into ANC........................................................ ......42

4.2.2 Physical presentation of IFA.......................................................... 43

4.2.3 Side effects................................................................................ 44

4.2.4 Alternative forms of IFA Supplementation......................................... 45

4.3 Facilitators.................................................................................... 46

4.3.1 Price.......................................................................................... 46

4.3.2 Supply........................................................................................ 46

4.3.3 Partner Support............................................................................ 48

4.4 The importance of counseling for adherence to supplementation............... 49

4.5 Patient and provider recommendations for improving the IFA supplementation program....51

Chapter 5: DISCUSSION......................................................................... 55

5.1 Study findings in perspective............................................................. 55

5.2 Recommendations............................................................................ 58

5.3 Social Marketing Campaign to promote IFA adherence............................. 59

5.3.1 Product........................................................................................ 60

5.3.2 Price............................................................................................ 61

5.3.3 Place............................................................................................ 61

5.3.4 Promotion...................................................................................... 62

5.3.5 Policy............................................................................................ 63

5.4 Programmatic (DIRESA, JUNTOS, CARE).................................................. 64

5.5 Directions for future research............................................................... 65

5.6 Conclusion........................................................................................ 66

REFERENCES........................................................................................... 67

APPENDIX............................................................................................... 72

Code book used during analysis................................................................... 72

Focus Group Discussion Guide..................................................................... 75

Interview guide for mothers........................................................................ 77

Interview guide for partners........................................................................ 79

Interview guide for providers....................................................................... 80

List of Tables and Figures

Table 1. Severity of anemia and cutoffs in women by pregnancy status and public health significance of anemia by prevalence in population....... 6

Table 2. Percent distribution of women by number of days taking IFA supplement during pregnancy in 2011.... 21

Table 3.Pregnant women's experience with supplements, Ayacucho..................... 22

Table 4. Risk factors for low adherence to IFA supplements................................ 23

Table 5. Methodology for data collection......................................................... 29

Table 6. SISMED records of tablet and syrup stock........................................... 47

Table 7. Proportion of pregnant women who received IFA................................... 47

Figure 1. Conceptual Framework for Iron Supplementation during Pregnancy............ 8

Figure 2. Proportion of pregnant women with anemia in Latin America and the Caribbean.... 15

Figure 3. Primary factors contributing to maternal anemia in Peru.......................... 19

Figure 4. Flow chart of IFA supply chain, from manufacturer to patient................... 20

Figure 5. Map of the Ayacucho region, Peru....................................................... 26

Figure 6. Summary of results from anemia problem tree activity.............................. 39

Figure 7. How patients and providers perceive women's prioritization of health.......... 41

Figure 8. Factors influencing pregnant women's adherence to IFA supplements.......... 53

Figure 9. Elements to consider in iron-supplementation programs............................. 58

Figure 10. Future directions for improving IFA supplementation............................... 59

About this Master's Thesis

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School	Rollins School of Public Health
Department	Hubert Department of Global Health
Degree	MPH
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health
Stichwort	Iron and folic acid Pregnancy Latin America Supplementation Anemia
Committee Chair / Thesis Advisor	Girard, Amy Webb, Emory University
Committee Members	Andes, Karen, Emory University
Partnering Agencies	International Non-governmental organization (e.g., CARE, Inc.)

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