Cross‐Country Comparison of the Acceptability of a Social Support Behavior Change Strategy to Improve Adherence to Antenatal Calcium and Iron‐Folic Acid Supplementation

In populations with low calcium (Ca) intake, WHO now recommends providing Ca supplementation alongside iron‐folic acid (IFA) as part of antenatal care (ANC) services to reduce maternal mortality. Even when pregnant women have a stable supply of micronutrient supplements, they often cite forgetting as a barrier to adherence. Adherence partners (APs), a behavior change strategy to expand social support to improve adherence, have not been assessed in the context of antenatal micronutrient supplementation. Pregnant women are encouraged to select APs from their social network (e.g., a spouse, family members) and ask APs to remind them to take their supplements. The objective of this research was to investigate the acceptability of APs to support adherence to antenatal Ca and IFA supplementation among pregnant women in Ethiopia and Kenya. We conducted trials of improved practices, a formative research methodology that follows participants over time as they try a new behavior. We provided pregnant women in Ethiopia (n=50) and Kenya (n=34) with Ca and IFA supplements, counseling, and reminder calendars, and then offered the option of selecting an AP. For each pregnant woman, qualitative data on AP acceptability were collected during 3 to 4 semi‐structured interviews every two weeks, and levels of social support were measured using an adapted scale. Interview transcripts were then analyzed inductively using the constant comparative method. In Ethiopia, 42 of 50 women agreed to try an AP; half asked their husbands, and others asked their children, relatives, or neighbors. In Kenya, 26 of 34 women agreed to try an AP; almost all selected their husbands and a few chose female relatives. For most women in both countries, APs were acceptable and provided reminders and encouragement supporting adherence. In Ethiopia, women reported receiving support from APs that extended beyond adherence (e.g., help with chores) whereas in Kenya women reported only adherence‐specific support. Several participants chose school‐aged children as APs in Ethiopia, but not in Kenya. In both countries, some women who did not select APs explained they did not need support for taking supplements and a few reported not having anyone to ask. Pill‐taking self‐reliance emerged as an important theme related to AP uptake. To examine this, we categorized participants’ social support scores as high or low and compared them with expressed feelings of self‐reliance ( Figure 1). Participants who were more self‐reliant chose APs less often than participants who were less self‐reliant; this was especially true for women in Ethiopia with low social support. APs were acceptable for most women in both settings, even in the context of limited family support in Kenya. The relationship between adherence and available social support and feelings of self‐reliance should be explored in future research. APs are a low‐cost intervention with the potential to support antenatal micronutrient supplementation, and warrant additional research to assess feasibility and impact. Support or Funding Information Funding for this research was provided by the Micronutrient Initiative and the Sackler Institute for Nutrition Science at the New York Academy of Sciences 1Participants’ adherence partner decisions by levels of perceived social support and expressed feelings of self‐reliance