A qualitative study of factors influencing adherence with micronutrient supplementation among women of reproductive age in Viet Nam Open Access

Abstract

Objective : To identify factors that influence adherence to consumption of micronutrient supplements before and during pregnancy among participants of a double-blind randomized controlled trial (PRECONCEPT) assessing the impact of weekly preconceptional multiple micronutrient supplements on maternal and child health outcomes in 20 rural communes in northern Viet Nam.

Methods: In-depth interviews were conducted with current and former PRECONCEPT participants, including 15 pre-pregnant women receiving weekly micronutrient supplements, 8 pregnant women receiving daily iron-folate supplements, 8 women who had delivered and 8 drop-outs. Domains of interest included participants' experiences with supplements and knowledge about nutritional needs, micronutrient deficiencies, and the study. Four focus groups (one per participating district) were also conducted with Village Health Workers who distributed the supplements. Data were transcribed, translated, and coded and analyzed using MAXQDA software, applying the principles of grounded theory.

Results : Basic knowledge about anemia is high, and most women recognize that it is important to take iron supplements during pregnancy. Anemia is universally conflated with iron-deficiency anemia, though recent surveys suggest that less than half of all anemia in this population is caused by iron deficiency. There is very low knowledge of micronutrient deficiencies other than anemia, and low awareness of the health benefits of taking micronutrient supplements other than iron. Outside of pregnancy, women sometimes take iron or certain B or C vitamins on a curative basis only, terminating use when symptoms fade. The primary barriers to consistent adherence are forgetting and adverse side effects. Functional support and positive reinforcement from health workers and family members may improve adherence.

Conclusions : Initiation of supplement use requires recognition of the health consequences of micronutrient deficiencies and perceived personal susceptibility to those deficiencies, while maintaining consistent use requires a defined cue to action and minimization of attrition due to side effects. Increased awareness of micronutrient deficiencies among health center staff and Village Health Workers may improve women's valuation of micronutrient supplementation outside of pregnancy, and therefore increase initiation. Once supplement use is initiated, functional support from health workers and the cultivation of social support mechanisms can maximize adherence.

Table of Contents

Table of Contents

Chapter 1: Introduction............................................1

Abbreviations ...........................................4

Chapter 2: Literature Review.....................................5

Chapter 3: Methods and Results...............................23

Methods......................................................23 Results........................................................30

Chapter 4: Discussion and Recommendations..............40

Discussion....................................................40

Conclusions and Recommendations....................48

References...........................................................51 Tables

Table 1: Factors with positive and negative influence on adherence to large-scale maternal supplementation programs (Victora et al., 2012)................12

Table 2: Prevalence of anemia among pregnant and non-pregnant women in Viet Nam, 1995-2010 (NIN & UNICEF, 2012; Ninh et al, 2003)....................13

Table 3: Prevalence of micronutrient deficiencies and associated health outcomes among WRA in Viet Nam, 2010 ( Laillou et al., 2012) .........................14

Table 4: Factors associated with supplement adherence among women of reproductive age in Viet Nam.................................................................19

Table 5: Characteristics of PRECONCEPT participants at baseline (n=5011) (Nguyen et al., 2012)..........................................................................24

Table 6: Characteristics of PRECONCEPT participants in selected communes at baseline.......................................................................................26

Table 7: Adherence rates for PRECONCEPT in participating communes..............................................................................................................30

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, Nutrition Health Sciences, Public Health
Keyword	Reproductive health Nutrition Adherence Maternal and child health Micronutrient deficiencies Micronutrient supplementation Anemia
Committee Chair / Thesis Advisor	Ramakrishnan, Usha, Emory University
Committee Members	Girard, Amy Webb, Emory University
Partnering Agencies	Emory University schools, faculty or affiliated programs University, college or educational institution (other than Emory)

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