ABSTRACT
Objectives: Nepal led a 9 year national scale-up of Iron Intensification Program to address maternal anemia, utilizing an integrated delivery-platform that extended distribution of Iron Folic Acid (IFA) through peer-selected female community health volunteers (FCHVs). The study's purpose, as a segment of a larger-study was to understand the perceptions and acceptability of FCHVs to mothers in Nepal and how this influenced their acceptance and access to health services, antenatal-care (ANC), and access to IFA during pregnancy. Methods: Twelve districts were purposively selected to represent Nepal's diverse ecological-zones (Mountain, Hills and Terai) and exposure to the intervention. One focus group discussion (FGD) with 6-10 mothers was conducted in each district (n=96). Interviews were conducted in Nepali, transcribed verbatim, then translated into English. Coding done in Atlas. ti identified mothers' perspectives of FCHVs, descriptive context, barriers and enablers for accessing ANC and IFA. Results: Mothers suggested that FCHVs are highly valued for their roles in providing IFA during pregnancy, referrals to ANC, and for advice. Remote areas with least access to healthcare expressed greatest appreciation for FCHVs' role in providing treatment and counseling for all conditions, but especially maternal-child health. However, in some peri-urban areas, FCHVs were perceived as having low-literacy and there was a preference for facility-based service and health professionals. Conclusions: Mothers in Nepal perceive FCHVs as integral for providing access and counseling for IFA and referral to ANC; however, with an emerging preference for higher trained professionals in some regions, minimum education standards and trainings for FCHVs may help maintain the relevance of program going forward.
ABSTRACT
Objectives: The Micronutrient Initiative (MI) is supporting host governments to demonstrate effective strategies to strengthen zinc supplementation as adjunct to ORS for the treatment of diarrhea and IFA supplementation to reduce anemia among pregnant women across three Asian countries. The objective of this paper is to describe experiences related to designing and implementing a monitoring framework in these programs in Indonesia, Bangladesh and Afghanistan. Methods: A monitoring framework was developed with two key components. Key indicators on coverage and stocks were incorporated in the government HMIS. Data on knowledge, and practices were collected through MI district field officers with short and simple checklists. Regular feedback based on this information was provide to the health system managers for program improvements. Results: In Bangladesh and Afghanistan HMIS was modified to record and report on coverage of zinc supplements in treatment of diarrhea among children <5 years. Stock out indicators for zinc and ORS were also incorporated in the system. An indicator receipt of >180 IFA tablets during pregnancy is being introduced.
ABSTRACT
Objectives: To identify existing barriers and potential enabling opportunities for the revitalization of iron and folic acid (IFA) supplementation to reduce anemia in pregnant women. Methods: A synthesis of formative research results from eight countries (Afghanistan, Bangladesh, Ethiopia, Indonesia, Kenya, Nepal, Nigeria, Senegal) was conducted to understand current antenatal care-seeking practices and identify relevant barriers and enablers associated with improved coverage and adherence to prenatal IFA supplementation. Results: Anemia in pregnancy is a well-known health concern by women, family decision-makers and health care providers in all countries studied. Widely varying views on when to start IFA supplementation, the dosage and the duration were expressed by women, family members and health care providers. Broad awareness of and modest attendance at facility-based ANC by pregnant women support this delivery channel for IFA, yet timely access is hindered by conflicting beliefs about the value of early initiation of ANC and the importance of prenatal IFA without anemia symptoms. Variable access and poor quality ANC services, specifically inadequate counseling on managing side effects and insufficient number of tablets given, are barriers to improving IFA coverage and ensuring adherence (≥90 tablets). In some cases, community-based delivery of ANC and IFA provided greater accessibility and follow-up for pregnant women. Conclusions: Improved ANC access and quality is needed to facilitate IFA supplementation. There is potential for community-based delivery and counseling to address concerns with IFA supplement supply and adherence. Renewed investment in IFA programs with strong behaviour change designs is urgently needed to achieve reductions in anemia.
ABSTRACT
Objectives: Treatment of diarrhea with zinc and ORS has both life-saving potential and diarrhea prevention benefits, yet here we explore the barriers as to why coverage and adherence remain low. Methods: A synthesis of formative research results from nine countries (Afghanistan, Bangladesh, Ethiopia, India, Indonesia, Kenya, Nepal, Nigeria, Senegal) was conducted to understand child diarrhea treatment practices and identify the barriers and enablers associated with ORS and zinc use. Results: In all countries, caregivers felt that diarrhea can be adequately cared for at home with local foods and drinks, traditional remedies and herbal medicine, tailored to the type of diarrhea. Perceived causes of diarrhea and advice from senior family members directly influenced treatment seeking. ORS was widely known for preventing dehydration in children with diarrhea, but was perceived as ineffective in stopping diarrhea. Caregivers and some health workers preferred antibiotics and anti-diarrheal medicines to “stop” diarrhea promptly. Outreach activities and free treatment for child diarrhea motivated caregivers to seek facility-based treatment. Barriers to ORS and zinc use include low awareness of zinc at multiple levels, frequent supply stock-outs and poor prescribing practices of health workers. Barriers to adherence to the full course of zinc include the common practice of stopping treatment when diarrhea stops and a lack of caregiver awareness of the benefits of zinc for prevention of diarrhea. Conclusions: Addressing context-specific beliefs about diarrhea causes and the effectiveness of home-remedies is essential to improve care-seeking behaviours. Maintaining adequate supplies and promoting the benefits of zinc will help to improve coverage and adherence.
ABSTRACT
Objectives: A national scale-up of an integrated facility and community-based delivery of iron and folic acid (IFA) supplements in Nepal spanned almost ten years through the Iron Intensification Program (IIP), over which time national coverage of IFA in pregnant women increased from 23% to 80%. The objective of this research was to estimate the potential effect of duration of district-level exposure to IIP on IFA coverage, and on anemia in mothers in Nepal. Methods: With data of the 2006 and 2011 Demographic Health Surveys (DHS), we used multiple regression modelling and controlled for IIP district exposure, age, pregnancy status, wealth, religion, parity in the last 5 years, weight, education, and ecological region (Terai, Hills & Mountain regions). Results: In 2006, women who had given birth during the intervention implementation period (n=5,110) exposed to the intervention for 1-3 years had a 7% reduced the odds of having anemia (OR: 0.93; 95CI 0.91, 0.95). In 2011, among women who had given birth in the previous 5 years in the Terai (n=864), intervention exposure for 3-5 years suggested a 45% reduction in the odds of having anemia (OR: 0.55; 95CI 0.31, 0.99). Intervention exposure also suggested benefits in likelihoods of mothers receiving IFA (6-11%), and de-worming (12-28%). Conclusions: These results suggest that the IIP had a role in increasing IFA and de-worming coverage and may have protected against anemia. Nepal's example suggests that large scale national programs with long term commitment can successfully impact IFA coverage and potentially impact anemia.