Women's perceptions of iron deficiency and anemia prevention and control in eight developing countries
Introduction
Iron deficiency anemia affects over two billion people worldwide. The World Health Organization estimates that 58% of pregnant women in developing countries are anemic (ACC/SCN, 1997). For women, the consequences of anemia include reduced energy and capacity for work (Basta, Soekirman, Karyadi, & Scrimshaw, 1979; Levin, 1986), poor pregnancy and birth outcomes including premature delivery, low birth weight, and increased perinatal mortality (Murphy, O’Riordan, Newcombe, Cole, & Pearson, 1986; Scholl and Hediger, 1994), and increased risk of death during delivery and postpartum (Llewellyn-Jones, 1965; Ojo & Savage, 1974; Zucker et al., 1994; Sarin, 1995). It is estimated that as many as 20% of maternal deaths are caused by anemia and that anemia may be an associated cause in as many as 50% of maternal deaths worldwide (Gillespie, Kevany, & Mason, 1991).
Most Ministries of Health in developing countries have policies to give pregnant women either iron by itself or combined with folate in tablet form or in prenatal vitamins.1 For example, national protocols in India require the provision of 100 tablets containing 100 mg elemental iron and 0.5 mg folic acid for daily consumption to all women during pregnancy and lactation. The Government of Indonesia provides 50–60% of the recommended number of iron supplements (60 mg elemental iron each with folate) for women (90 tablets during pregnancy and 40 tablets during the postpartum period). Despite these policies, anemia prevalence has not declined significantly (Gillespie et al., 1991). Many nutrition experts believe that one of the main reasons national iron supplementation programs have failed is women's “non-compliance/non-adherence”2 with taking iron supplements daily because of gastrointestinal upset and other side effects that sometimes occur when taking iron (DeMaeyer, 1989). Recent reviews on the topic suggest, however, that there are a number of reasons for ineffective programs including sporadic or inadequate supplies, poor quality tablets, problems with delivery and distribution systems, poorly trained and uncommitted health providers, ineffective communication materials to promote behavior change, lack of access to or use of prenatal care, and poor monitoring of the problem. (Gillespie et al., 1991; Galloway & McGuire, 1994; Yip, 1996).
To investigate factors that influence women's decisions to take iron supplements and suggest ways to improve existing programs, The MotherCare Project3 supported formative research, using qualitative methods, on this subject in eight countries (Bolivia, Burkina Faso, Guatemala, Honduras, India, Indonesia, Malawi and Pakistan). In all cases, except Burkina Faso, the research was subsequently used to improve the iron supplementation component of prenatal care in on-going MotherCare programs.
Section snippets
Methods
During the period 1991–98, MotherCare and its partners4
Sampling
To capture diversity of the population, sampling was purposive and study respondents were selected to represent the spectrum of different groups within a target population related to age, socioeconomic status or class, ethnicity and culture, and location (e.g., rural and urban). Social scientists were members of the study team and advised on adequate sample sizes to capture diversity of the study populations. For a more detailed description of the study populations and sampling methods, see
Data collection
In all countries, data were collected using a variety of qualitative methods. Either semi-structured, structured, or in-depth interviews and focus group discussions were consistently conducted in all countries. Observations of health services were made in Guatemala, Honduras, and South Kalimantan, Indonesia. In India, additional methods also included free listing of common illnesses and symptoms of pregnant women and ranking these illnesses according to their perceived severity, Venn diagrams,
Data analysis
A variety of software packages were used for data analysis including Gofer, Anthropak, and EpiInfo. In some cases, analysis was conducted by hand. Quotes that represented a majority view on a topic were identified and are presented in this paper.
Anemia and its symptoms
There was overwhelming agreement among ethnic groups, countries and regions on how women viewed the symptoms of anemia. In all but one country, anemia is recognized by its symptoms rather than by a specific clinical name or as a specific disease.6
Discussion
This paper reports on formative research, using qualitative methods, with women designed to determine the barriers and facilitators to existing iron supplementation programs in eight countries. In all countries, most women recognize signs and symptoms of anemia and have a local term(s) for these conditions. In many of the study sites, women consider weakness and dizziness to be normal conditions of pregnancy, but half of the women surveyed could identify negative consequences of the condition,
Conclusions
Formative research, using qualitative methods, is a useful tool for designing and refining iron supplementation program strategies and messages for communication materials. A number of barriers to taking iron supplements were identified and include: lack of knowledge and awareness of anemia and its consequences among women, problematic iron supplement supply and distribution systems, misconceptions about negative physiological impacts of iron supplements (e.g., causing hypertensive disease) and
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