Implementation fidelity of Iron and Folic Acid supplementation (IFAs) and associated challenges among pregnant women in Uasin Gishu County Kenya
Abstract Introduction While Iron and Folic Acid Supplementation (IFAs) policy is offered free of charge in Kenya and has been implemented in Kenya and other low and middle-income-countries for decades, effectiveness of this intervention in improving maternal nutrition status has been inadequate. This study aims to acquire insight into the degree to which IFAs policy guidelines during pregnancy have been implemented as intended and the challenges to implementation fidelity. Methods Data was collected in rural Uasin Gishu County in the western part of Kenya through document analysis, questionnaires among programme recipients (n=188) and semi-structured interviews with programme implementers (n=6). Themes emerging from data are critically discussed using a conceptual framework based on programme theory and the programme implementation fidelity framework. Results Coverage of IFAs is widespread. However, policy content, frequency and participant responsiveness is not fully implemented. Only 10% accessed intervention within the first trimester as recommended by policy guidelines, only 18% and 15% of the respondents received 90 or more iron and folic acid pills respectively during their entire pregnancy period only 28% reported receiving nutritional counselling, and 66% completed taking the IFAs pills that were issued to them. Late initial bookings to antenatal care, drug stock shortage, staff shortage and long queues, confusing dosage instructions, side effects of the pills were established to be the main challenges to effective implementation fidelity. Anticipated health consequences and emphasis by the health officer to take the pills were established to be motivations for adherence to supplements. Conclusions Rather than targeting pregnant women who turn up for care at the health facilities, IFAs interventions should introduce community-based outreach programmes and make use of community-based health workers. This will not only relief the crowded health facilities for effective implementation integrity, but will also reach out to pregnant women within the first trimester when IFAs impact on health is greater and reach out to those women do not turn up at all for interventions at a health facility. Due to shortage and low compliance to IFAs pills, nutritional counselling is vital to promote consumption of locally available micro-nutrient rich food sources.