Department of Prevention and Community Health, Milken Institute School of Public Health, The George Washington University, 950 New Hampshire, Washington D.C., 20052, USA.
DCOR Consulting, Bhubaneswar, Odisha, India.
BMC Public Health. 2020 Apr 6;20(1):457. doi: 10.1186/s12889-020-08574-z.
To reduce the prevalence of anemia, the Indian government recommends daily iron and folic acid supplements (iron supplements) for pregnant women and weekly iron supplements for adolescents and all women of reproductive age. The government has distributed free iron supplements to adolescents and pregnant women for over four decades. However, initial uptake and adherence remain inadequate and non-pregnant women of reproductive age are largely ignored. The aim of this study is to examine the multilevel barriers to iron supplement use and to subsequently identify promising areas to intervene.
We conducted a qualitative study in the state of Odisha, India. Data collection included key informant interviews, focus group discussions with women, husbands, and mothers-in-law, and direct observations in health centers, pharmacies and village health and nutrition days.
We found that at the individual level, participants knew that iron supplements prevent anemia but underestimated anemia prevalence and risk in their community. Participants also believed that taking too many iron supplements during pregnancy would "make your baby big" causing a painful birth and a costly cesarean section. At the interpersonal level, mothers-in-law were not supportive of their daughters-in-law taking regular iron supplements during pregnancy but husbands were more supportive. At the community level, participants reported that only pregnant women and adolescents are taking iron supplements, ignoring non-pregnant women altogether. Unequal gender norms are also an upstream barrier for non-pregnant women to prioritize their health to obtain iron supplements. At the policy level, frontline health workers distribute iron supplements to pregnant women only and do not follow up on adherence.
Interventions should address multiple barriers to iron supplement use along the socio-ecological model. They should also be tailored to a woman's reproductive life course stage: adolescents, pregnancy, and non-pregnant women of reproductive age because social norms and available services differ between the subpopulations.
为了降低贫血的患病率，印度政府建议孕妇每日补充铁和叶酸（铁补充剂），青少年和所有育龄妇女每周补充铁。政府已经为青少年和孕妇免费发放铁补充剂四十多年了。然而，最初的服用率和依从率仍然不足，育龄非孕妇基本被忽视。本研究旨在探讨铁补充剂使用的多层次障碍，随后确定有希望的干预领域。
我们在印度奥里萨邦进行了一项定性研究。数据收集包括与妇女、丈夫和婆婆的关键知情人访谈、妇女小组讨论以及在卫生中心、药房和乡村卫生和营养日的直接观察。
我们发现，在个人层面上，参与者知道铁补充剂可预防贫血，但低估了社区内贫血的患病率和风险。参与者还认为，怀孕期间服用过多的铁补充剂会“使你的宝宝变大”，导致分娩疼痛和昂贵的剖腹产。在人际层面上，婆婆不支持儿媳在怀孕期间定期服用铁补充剂，但丈夫则更支持。在社区层面上，参与者报告说只有孕妇和青少年在服用铁补充剂，完全忽略了非孕妇。不平等的性别规范也是非孕妇优先考虑自身健康以获得铁补充剂的上游障碍。在政策层面上，一线卫生工作者只向孕妇发放铁补充剂，不跟踪服用依从性。
干预措施应针对社会生态模式中与铁补充剂使用相关的多重障碍。它们还应根据妇女的生殖生命历程阶段进行定制：青少年、怀孕和育龄非孕妇，因为亚人群体之间的社会规范和可用服务有所不同。
