Skip to main content
Download PDF

Adherence to and predictors of iron-folate acid supplementation among pregnant women in a pastoral population in Ghana: a community-based cross-sectional study

Reproductive Health volume 21, Article number: 165 (2024) Cite this article

Abstract

Background

Iron-Folate Acid Supplementation (IFAS) interventions have been recognized globally as key in reducing the burden of anemia among pregnant women. However, adherence to and determinants of IFAS remain indistinct, as it is the main constraint with supplementation therapy, particularly among minority populations. Hence, this study sought to determine the adherence to and predictors of IFAS among nomadic Fulani pregnant women in the West Gonja Municipality of Ghana.

Methods

A community-based cross-sectional design was employed to involve 130 respondents between February to July, 2022 in the West Gonja Municipality of Ghana. Fulani pregnant women aged 15–49 years, possessing maternal and child health record book and were given iron-folate supplements within 16 weeks and resided within the study area ≥ 6 months before/during the data collection period were included in the study. Multivariable logistic regression was used to determine independent predictors of IFAS using SPSS version 25.0 (p ≤ 0.05 deemed statistically significant across all models).

ResultsUptake of and adherence to IFAS was 47.7% and 35.5% respectively. Major barriers to IFAS uptake were forgetfulness (25.7%) and unavailability (20.0%). About 65.4% of the respondents revealed poor knowledge of IFAS. Spousal occupation (AOR = 0.17, p = 0.010), spousal income (AOR = 4.125, p = 0.050) and knowledge on IFAS (AOR = 0.259, p = 0.039) were predictors of IFAS.

Conclusions

Poor adherence to and knowledge on IFAS were noted in the study and highlighted as a grave public health concern. Thus, nutrition and antenatal educational programs should give necessary attention to adherence to IFAS during pregnancy, particularly among nomadic and other vulnerable and minority populations to limit the burden of illnesses.

Plain language summary

Poor adherence to iron-folic acid supplementation (IFAS) has been linked to greater risks of maternal anemia and currently serves as one of the major supplementation therapy challenges during pregnancy. This paper aims to determine the adherence and predictors of IFAS among Fulani pregnant women in the West Gonja Municipality of Ghana. We recruited 130 Fulani pregnant women in a community-based cross-sectional study. Those who met the inclusion for the study were recruited. Adherence to and knowledge on IFAS was low. Forgetfulness was the main iron-folate supplementation barrier. Spousal occupation, spousal income and knowledge on IFAS were the predictors of iron-folate (IF) supplementation. Community health interventions should be intensified to capture remote populations. Governmental policies should also be strengthened particularly at the antenatal level for a healthier pregnant population base.

Peer Review reports

Background

Iron deficiency anemia (IDA) is most prevalent in underdeveloped nations such as Ghana, where poverty is on the rise due to poor levels of education, low socioeconomic class, as well as ethnic, social, and cultural influences [1]. Low-middle-income countries (LMICs) are faced with a fourfold higher prevalence than high-earning countries [2]. Studies have demonstrated that both women with sufficient and deficient iron status benefit from a low or moderate dosage of iron/folate supplementation in the early stages of pregnancy [3]. Iron-folate acid supplementation (IFAS) interventions have been recognized globally, as crucial in lessening the burden of anemia among pregnant women [4] with high chances of limiting maternal and neonatal morbidities and deaths [5], but remains indistinct as it is the main challenge with supplementation therapy [6]. Adherence to IFAS among pregnant women for ≥ 90 days in Ghana was 59.4% [7]. IFAS adherence rate of 26.2% was seen in adolescent girls in Northern Ghana [8]. In the West Gonja Municipality of Ghana, IFAS during antenatal care (ANC) at least 3 and 6 times from 2019 to 2021 was (9.7%, 9.9% and 9.4%) and (7.9%, 7.4%, 6.5%) respectively [9].

The Ghanaian government has rolled out interventions at the ANC level to reduce the burden of anemia by combined iron-folate (IF) and intermittent preventive treatment (IPTp) supplementation and deworming particularly through 6 weeks postpartum [10]. Additionally, the national health insurance coverage of IFAS in pregnancy and postpartum under the free maternal and child health care policy of the country for those with the insurance card has improved health. Sadly, individuals without the cards have to pay for or/buy these supplements to sustain a healthy pregnancy [11]. Again, facilities may run short on IF stock, thus limiting combined IF therapy. This subjects prescription to one supplementation regimen due to unavailability which may impede optimal growth [11]. IFAS adherence is deterred by various influences like limited stock for IF therapy, awareness and prevention of anemia, knowledge on IF benefits to mention but a few [12].

The Fulani are a significant wander-rover population in West Africa whose lifestyle and methods of feeding revolve around cattle [13]. They relocate in pursuit of better living conditions, comfort, and suitable acreage for cattle grazing [14]. Food crops, animals (sheep, cattle, and goats), and livestock products like milk are typically their main sources of income [15]. As a result, they are faced with significant obstacles to their existing survival. There is widespread poverty, illiteracy, and ignorance among nomads, which results in insufficient nutrition, and can induce anemia [14]

It is important to satisfy the 2030 goal of “leave no one behind” by improving access to affordable, available and reliable healthcare systems and to improve maternal and child health. Even though variety of studies have been conducted on the subject matter, there is no scientific evidence on adherence to and predictors of iron-folate supplementation among Fulani pregnant women in the study area. Hence this study sought to (1) determine the adherence of nomadic Fulani pregnant women to IFAS, (2) assess the predictors of IFAS among nomadic Fulani pregnant women.

Methods

Study location and design

The West Gonja Municipal is located west of Tamale, Ghana's Northern Regional Capital, between latitude 80 321 and 100 2 1 north and longitude 10 5 1 and 20 581 west with Damongo as its administrative capital [16]. The municipal has about 53,700 people with an expected pregnant population of 2173 and 12,882 women of fertility age. This study was part of a wider study to explore anemia and its associated factors among nomadic Fulani pregnant women in the West Gonja Municipality of Ghana employing a community-based exploratory sequential mixed methods approach [Unpublished]. This study used a community-based cross-sectional study design to determine the adherence to and predictors of iron-folate supplementation among nomadic Fulani pregnant women in the West Gonja Municipality of Ghana. Owing to the nature of cross-sectional designs in investigating the magnitude of a phenomena [17], it will help in determining the current adherence levels of IF supplementation among nomadic Fulani pregnant women.

Source and study population

All reproductive-aged nomadic Fulani pregnant women between 15 and 49 years who were living in the municipality were the population of interest. The study population was self-identified nomadic Fulani pregnant women aged 15–49 years, possessing maternal and child health (MCH) record book, who were given IF supplements within 16 weeks before/during the data collection period and agreed to participate (February–July, 2022). Fulani pregnant women (FPW) who disagreed to participate in the study, severely ill and were living in the study area less than six months were excluded.

Sample size and sampling technique

A total of 130 Fulani pregnant women were recruited for the study. The Fulani population are without a defined number and are not captured in national surveys and other records (thus, no sampling frame is available or can be constructed) because they are mostly a mobile and remote group (who are socially and medically disadvantaged), thus defined as a “hard-to-reach population” [18]. They are theorized to be a small population group, mostly scattered around community peripheries and at undefined locations. Random population samples are often inadequate to accumulate adequate samples of hard-to-reach groups such as the Fulani for population surveys or clinical trials [19].

Research has further shown difficulties in sampling groups defined as “hidden, remote or hard-to-reach”, largely comprising persons who avoid being identified [19]. Research also shows that, there are difficulties in sampling groups with low population numbers such as Indigenous people and so forth [19]. Thus, population-based probability sampling methods are a time consuming and costly strategy for sampling socially and medically disenfranchised populations [19].

Common methods for sampling hard-to-reach populations include non-probability-based approaches (such as census approach, snowball sampling) [20]. Therefore, a census and snowball/referral chain/social network recruitment approach was employed to select eligible respondents from the West Gonja Municipality. The census approach was used to select all eligible respondents because the sample population is theorized to be small without a sampling frame. As suggested by Raifman et al. [21], hard-to-reach populations may be difficult to completely survey even with an assumed sampling frame. They further alluded that, hard-to-reach-populations frequently constitute a small percentage of the general populace and are drifting away from society or socially unnoticed, possibly stemming from their experiences with social marginalization [21]. The referral chain method was used because of the difficult nature of recruiting a large-enough sample. This process relied on peer referrals, where enumerators chose initial respondents (seeds) who recruited their peers, then themselves recruited their peers through referrals, and so on until all eligible respondents were recruited. Similarly, Shedlin et al. [22] employed snowball sampling methods in a community-based study to recruit hard-to-reach respondents. In this study, two community partners/local peers/known community members recommended by the West Gonja Municipal Health Directorate led the enumerators to well-connected members of Fulani communities to aid rapport-building to increase the likelihood of people participating in the study. The community survey was conducted in the Busunu sub-municipality and Canteen sub-municipality due to their higher percentages of Fulani populations [9]. Ten (Kojope, Langantre, Busunu, Achubunyor, Mempeasem, Solepe, Kidendilipa, Kpiri, Sagiss, Kotito (Sore) number 3) out of thirteen (Kojope, Langantre, Busunu, Achubunyor, Mempeasem, Solepe, Kidendilipa, Kpiri, Sagiss, Kotito (Sore)number 1, Kotito (Sore) number 2 and Kotito (Sore) number 3, Jonokponto) dominant Fulani communities according to the municipal health directorate were selected from the sub-municipalities. The 3 communities that were not sampled was due to difficulty to access Fulani pregnant women, distance and poor road network.

Peer chain referrals were helpful since the recruitment process was mainly dependent on Fulani pregnant women, who probably have a better knowledge of the population than the enumerators. Though, community survey methods and referral chain approaches could lead to oversampling, Kalton et al. [23] and Kalsbeek et al. [24] argue that they could be applicable to low prevalence population groups, like the Fulani. Moreover, Platt et al. [25] compared a probability-based approach in sampling hard-to-reach-populations with snowball sampling to reach high risk HIV respondents and found that although referral chain sampling was more expensive, it led to increased response rates. Due to the fact that hard-to-reach populations may hide from being recognized as members of a group or refuse to take part in studies because they fear the law, distrust researchers [26], and believe that their involvement will not serve them personally or their community and could instead lead to discrimination, harassment or exploitation, multiple reports [27, 28] suggest that engaging local partners to assist in research could boost response rates and build trust.

Operational definitions

Household

A household was defined as a husband, wife/wives, and/or dependents (children, grandparents and other close relations) living together.

Adherence to IFAS

Respondents were asked if they took iron-folate tablets in the past week before the study and responses were dichotomized into yes or no. Fulani pregnant women who took at least 65% of the expected dose of the iron-folate tablets in the past week before the study, equivalent to intake of at least a tablet daily for 4 days in the week uninterruptedly or intake of 20 tablets in per month every day without forfeiting the recommended doses [29] were said to have adhered to IF supplementation regimen.

Anemia in pregnancy

Anemia was defined as hemoglobin (Hb) levels less than 11 g/dl [30].

Gestational age

Gestational age of 12 weeks or less, larger than 12 weeks but less than 24 weeks, and greater than 24 weeks but less than 42 weeks denoted the first, second, and third pregnancy trimesters, respectively.

IFAS knowledge

Five questions on importance of IFAS, 7 on likely negative effects of IFAS, 6 on management of the likely negative effects, 6 on consequences of reduced iron/folate intake, 7 on anemia signs and symptoms, 7 on dietary intake that boosts hemoglobin states, 1 on possible frequency of ingestion of IF supplements, and 1 on possible duration for IF supplement intake, were asked on IFAS knowledge and responses of the respondents were ranked on 40 Likert scale. A correct response (based on literature) was given a score of one, while a wrong response was allotted a score of zero. If the Fulani pregnant women recorded median score and above, they had good knowledge and Fulani pregnant women who recorded below the median score, had poor knowledge. This categorization has been seen in similar studies [6, 8, 31].

Biological sample collection

The finger was wiped with a swab of alcohol after approval was sought. The clean finger was punctured using a lancet. A microcuvette was employed in collecting the sample of blood from punctured site. Blood drops were steadily dipped in the well of the hemoglobin (Hb) strip of the Hb meter. Hb assay was carried out instantly using URIT 12 \(\circledR \), a battery-operated hand carrier Hb meter. Respondents were updated of their Hb status on-site. Individuals with Hb < 7 g/dL were counselled to request healthcare treatment.

Data collection procedure and quality control

A detailed review of literature [8, 31, 32] and responses from professional reviews were used to create the questionnaire. A face-to-face administered questionnaire was used to elicit replies. The questionnaire contained socio-demographic factors, obstetric factors, health care system related factors, and client related factors. Hb concentration was estimated using URIT 12 ® and current gestational age was estimated using a hand carrier ultrasound apparatus. Data on ANC attendance, gestational age at first antenatal attendance, Hb at first antenatal attendance, IFAS among others during pregnancy were gathered from MCH record books. A two-day training was organized for enumerators (four enumerators who were fluent in Hausa/Fulfulde, other native Ghanaian languages, and English). Two community partners were also recruited to aid rapport building, in order to get more people to participate in the study. Back-translated questions (Hausa/Fulfulde to English language and back) were used to inspect questionnaire accuracy, and needed amendments were made. Questionnaires were pretested in a close community with 20 respondents who shared comparable characteristics to the study's respondents. The flow of the questions was assessed for inclusiveness and fine-tuned as desired. On the interview day, FPW who agreed to contribute to the study had their Hb levels tested. Day-to-day, complete questions were assessed for wholeness, and remaining questions were addressed. Respondents who were unable to answer questions on their own were assisted. For authentication and reviews, information on the questionnaire was compared to typed data on the computer. Individual interviews lasted from 20 and 45 min.

Data processing and analysis

Excel spreadsheet was used to enter and clean data, which was then transported to Statistical Package for Social Services Version 25. Descriptive statistics were produced for categorical and continuous data. To identify the independent predictors of IFAS in pregnancy, factors that were significant in the bivariable model using Chi-square test (χ2) were included into a multivariable logistic regression model. All statistical tests were two-tailed with P-value ≤ 0.05 deemed significant level across all models.

Results

Socio-demographic and obstetric characteristics of respondents

Table 1 below indicates the frequency distribution of socio-demographic and obstetric variables of respondents. Most (54.6%) of the women were ≥ 25 years and the mean (± SD) age was 26.65 (± 7.32). About 92.3% of the respondents were married/cohabiting with 77.7% of them having no formal education. Almost 80.0% of spouses had no formal education with 33.8% of them possessing an average monthly income of above GHS 1000.00 (98.04 USD). Approximately 49% of the respondents were housewives as well as 50.8% of the spouses being cattle herders/animal rearer/farmers. More than half (57.7%) of the respondents had of less than 3 children with mean parity (± SD) of 2.26 (± 1.83). About 83.8% of the women attended ANC for less than 4 times with most of them in their third trimesters. At first antenatal attendance, 60.0% of the respondents were in their second trimesters with 86.2% of them spacing their births at 24 months interval or below (Table 1).

Table 1 Socio-demographic and obstetric characteristics of respondents
Full size table

Knowledge on and adherence to IFAS characteristics of respondents

Table 2 shows the knowledge on and adherence to IFAS characteristics of respondents. About half (47.7%) of the respondents indicated that, they consumed IFAS with 35.5% of them adhering to IFAS, indicating poor adherence to IFA regimen. Almost 65.4% of the women revealed poor knowledge on IFAS with median and mean (± SD) knowledge on IFAS of 6.50 and 6.27 (± 2.52) respectively. Approximately 56.5% of respondents showed that, they had barriers with the intake of IFAS. About 69.4% of the respondents indicated that, they acquired IFAS from health facilities with few (34.6%) receiving counselling on IFAS (Table 2).

Table 2 Knowledge on and adherence to IFAS characteristics of respondents
Full size table

Bivariate analysis of socio-demographic and obstetric characteristics of respondents

Bivariate analysis of socio-demographic and obstetric characteristics of respondents showed statistical significance between IF supplementation and spousal income level (χ2 = 5.195, p = 0.032) as well as spousal occupational status, (χ2 = 8.429, p = 0.010) (Table 3).

Table 3 Bivariate analysis of socio-demographic and obstetric characteristics of respondents
Full size table

Bivariate analysis of knowledge on and adherence to IFAS of respondents

In the bivariate analysis below, knowledge of respondents on IFAS was revealed as the only associated variable with the IF supplementation (χ2 = 8.349, p = 0.033) (Table 4).

Table 4 Bivariate analysis of knowledge on and adherence to IFAS of respondents
Full size table

Barriers confronted by Fulani pregnant women with IFAS

Figure 1 indicates the barriers Fulani pregnant women face with the intake of IF supplements. The respondents revealed that the major barriers with IFAS intake were forgetting to consume IFAS (25.71%) and unavailability of IFAS (20.00%).

Fig.1
figure 1

Barriers faced by Fulani pregnant women with IF supplementation

Full size image

Predictors of IFAS among Fulani pregnant women

The following factors were predictors of IF supplementation in the multivariate regression analysis (spousal occupation, spousal income and knowledge on IFAS). Pregnant women with spouses who were traders/vendors/businessmen were about 83% times less likely to consume IF supplements as opposed their counterparts (AOR = 0.17, 95% (CI) (0.047—0.654), p = 0.010). Also, respondents with husbands who earned averagely more than GHS 1000.00 (98.04 USD) per month were about 4.13 times more likely to consume IF supplements as compared to their counterparts (AOR = 4.125, 95% (CI) (1.001—17.003), p = 0.050). Furthermore, respondents with good knowledge on IFAS were about 74% times less likely to consume IF supplements than their peers (AOR = 0.259, 95% (CI) (0.072—0.935), p = 0.039) (Table 5).

Table 5 Multivariate analysis of the predictors of IFAS among respondents
Full size table

Discussion

Widely, pregnant women are supposed to attend ANCs and come out with desirable health outcomes. For some reasons, this is not totally achieved and may lead to unwarranted mother and child health. Nevertheless, pregnant women are put on IF supplements among other therapies during ANCs to prevent and treat ailments for optimal health. A community-based cross-sectional design was employed in this study with IFAS adherence rate noted as 35.5%, signifying poor adherence against World Health Organization (WHO) standards. This finding was relatively lower than the results found among pastoralist pregnant women in southern Ethiopia (51.4%) [31]. The authors identified culture, geography, and drug availability as reasons for these inconsistencies.

Also, increased knowledge of women on IFAS might contribute to better adherence. IFAS adherence was over 50% among pregnant women in Ghana [7], which is incongruent with this study’s findings. Studies in SSNP, Ethiopia by [33] among pregnant populations in eight rural districts highlighted adherence to IFAS to be 74.9%. Research in southern India [34] and West Bengal India [35] noted a 64.7% and 81.74% adherence to IFAS regimen accordingly. This reveals non-conformance to findings of the current study. These authors revealed that, the poor adherence to IFAS was due to forgetfulness to take IFAS and fear of the side effects of IFAS. Other studies also identified adherence to IFAS to be 20.4% [32] and 24.5% [36] which is far below the findings of this study. The discrepancies in these findings from that of this study could be associated to socio-economic status, time study was conducted, medical advice, understanding of the importance of IFAS in pregnancy, counseling and belief on IF supplement intake.

This study outlined that spousal occupation had a statistically significant relationship with adherence to IFAS. Generally, occupation has been shown to have a linkage with IF consumption [35]. Employment status has also been shown to influence IFAS during pregnancy [37]. Women with spouses who were traders/vendors/businessmen were about 83% times less likely to consume IF supplements as opposed to their counterparts. It could be that spouses engage only in one form of trade but do not trade in livestock which accounts for majority of the Fulani populations income [15]. Thus, are unable to cater for the health needs of their pregnant population. It might also be that, traders/vendors/businessmen do not attract work almost all the time and by so doing do not make enough wealth to provide for the healthcare needs of the pregnant women. This might decrease the chances of purchase of IF supplements and transportation of pregnant woman for ANC services leading to poorer adherence to ANC protocols and unimproved health since frequency of ANC visits [38] and history of poor health status [32, 36] have been noted to influence IFAS adherence. Though studies have not shown a significant relationship between spousal occupation and IFAS adherence, several studies have identified negative spousal influence as a determinant of poor health outcome which might have been as a result of poor uptake IFAS [39, 40].

Socio-demographic determinants have been revealed to impact maternal and child health and healthcare practices [37, 41, 42]. Respondents with spouses earning averagely more than GHS 1000.00 (98.04 USD) per month were about 4.13 times more likely to consume IF supplements as compared to their peers. Socio-economic status may influence access to maternal and child health services like ANCs, regular medical check-up, medications and foods that improve maternal and neonatal health. Income has also been shown to have a linkage with IFAS adherence [37]. Spouses with relatively higher earnings are more likely to purchase IFA supplements, and pay medical bills for MCH counseling and healthcare. This can positively influence the rate at which these women adhere to IFAS during pregnancy. Due to population differences, this study is subjected to findings that are not shown in other works. The period of the study, methodology employed and the study area may also play a role in the development of such findings.

Maternal knowledge is an important predictor of positive mother and child outcomes of pregnancy. Respondents with good knowledge on IFAS were about 74% times less likely to consume IF supplements. This outcome is contrary to studies conducted in Debre Tabor General Hospital, Ethiopia [43], Mecha District [32] and on utilization of IFAS during pregnancy in eight districts of Ethiopia [33]. The authors labeled the knowledge of IFAS effects, benefits and outcomes of missed IFAS as the probable cause. Even though, knowledge is positively correlated with awareness, attitude and practice and adequate knowledge on anemia and IFAS would inform applauded practices toward adherence to IFAS [44], adequate knowledge on a phenomenon does not necessarily translate to positive use or practice, which could explain the findings of this study. Nevertheless, the behavior change model [45] and the espoused health belief theory of Strecher and Rosenstock [46] oppose the current study findings.

This is one of the first investigations to determine the adherence to and predictors of IFAS among nomadic FPW in the West Gonja Municipality of Ghana where there is paucity of data. It will guide policy frameworks on measures to ensure optimal adherence to IFAS. The study will add knowledge to exiting literature on IFAS adherence and its determinants, particularly among nomadic populations. The study approach was useful since a level of trust was required to recruit study respondents. Notwithstanding the strengths of the study, it has some limitations attached to it. Few communities were sampled for the study. Sophisticated methods like iron-biding capacity tests or complete blood count tests were not used in measuring hemoglobin status and IDA. Other determinants such as attitude and practice towards IFAS among others were not explored. As a result of distance, poor road network, limited resources, financial constraints and difficulty in reaching respondents due to their demography, larger samples were not employed. The cross-sectional design and small sample size employed limited the potential of the study for generalizing findings. Other study designs and methods could produce more advanced results than this study, because the study design and type and sample size and population employed (Fulani, who are considered as socially and medically disadvantaged, disenfranchised and hard-to-reach) could have produced over or under estimated findings and may be opened to other forms of biases such as social desirability and response biases and underreporting. Additionally, selection and gatekeeper biases cannot be discounted, since the sampling strategy employed could limit the validity of the sample. The selection of initial seeds could have likely impacted the overall composition of the sample, preventing the sample from being a true reflection of the target population, hence findings cannot be generalized to the entire Fulani pregnant population. Most data obtained from snowball sampling are used as if it was based on probability sampling, this study could be affected by this, thus preventing generalization of findings. Moreover, it was difficult or impossible to measure systematic error in the study due to the approach used. More accurate tests with advanced tools and long-term studies on the nomadic Fulani and their health status is imperative to determine the magnitude of IF supplementation adherence and its predictors to inform policy and practice around it.

Conclusion

In this study, IFAS adherence was low against international standards. Spousal occupation, spousal income and knowledge on IFAS were predictors of IF supplementation. Forgetfulness to consume IF supplements and unavailability of IFAS were the main barriers towards IF uptake. These findings are indicative of community sensitization on the importance of IFAS and ANC attendance. Again, nutrition and ANC educational programs should give necessary attention to adherence to IFAS during pregnancy, particularly among remote populations.

Availability of data and materials

All datasets analyzed during the current study are contained within the manuscript.

Abbreviations

ANC:

Antenatal care

FPW:

Fulani pregnant women

Hb:

Hemoglobin

IDA:

Iron deficiency anemia

IF:

Iron-folate

IFAS:

Iron-folate supplementation

LMIC:

Low-and-middle-income countries

WGMAHPRR:

West Gonja Municipal Annual Health Performance Review Report

MCH:

Maternal and child health

WHO:

World Health Organization

References

  1. ACC/SCN. What Works? A review of the efficacy and effectiveness of nutrition interventions, Allen, L.H. and Gillespie, S.R. ACC/SCN: Geneva in collaboration with the Asian Development Bank, Manila. 2001.

  2. Chathuranga G, Balasuriya T, Perera R. Anaemia among female undergraduates residing in the hostels of University of Sri Jayewardenepura, Sri Lanka. Anemia. 2014. https://doiorg.publicaciones.saludcastillayleon.es/10.1155/2014/526308.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Rodriguez-Bernal CL, Rebagliato M, Ballester F. Maternal nutrition and fetal growth: the role of iron status and intake during pregnancy. Nutr Dietary Suppl. 2012;4:25.

    Article  CAS  Google Scholar 

  4. WHO. World Health Statistics. 2013. Vol. 84. Retrieved from http://ir.obihiro.ac.jp/dspace/handle/10322/3933

  5. Müngen E. Iron supplementation in pregnancy. J Perinatal Med. 2003. https://doiorg.publicaciones.saludcastillayleon.es/10.1515/JPM.2003.065.

    Article  Google Scholar 

  6. Arega Sadore A, Abebe Gebretsadik L, Aman HM. Compliance with iron-folate supplement and associated factors among antenatal care attendant mothers in Misha District, South Ethiopia: community based cross-sectional study. J Env Public Health. 2015. https://doiorg.publicaciones.saludcastillayleon.es/10.1155/2015/781973.

    Article  Google Scholar 

  7. Yawson AE, Amoaful EO, Senaya LK, Yawson AO, Aboagye PK, Mahama AB, et al. The lancet series nutritional interventions in Ghana: a determinants analysis approach to inform nutrition strategic planning. BMC Nutr. 2017;3:1–8.

    Article  Google Scholar 

  8. Dubik SD, Amegah KE, Alhassan A, Mornah LN, Fiagbe L. Compliance with weekly iron and folic acid supplementation and its associated factors among adolescent girls in tamale metropolis of Ghana. J Nutr Metabolism. 2019. https://doiorg.publicaciones.saludcastillayleon.es/10.1155/2019/8242896.

    Article  Google Scholar 

  9. West Gonja Municipal Health Directorate Annual Health Performance Review Report. Damongo: West Gonja Municipality-Ghana. 2021.

  10. Ghana Health Service. Iron &Folic Acid (IFA) Supplementation for Adolescent Girls and Women. Participants Manual for Health Workers. Ghana Education Service (GES), UNICEF, CANADIAN FUND, CDC, KOICA, USAID, WHO. 2017: P 1–33.

  11. Wemakor A, Garti H, Akai MM, Napari AA, Dankyi-Frimpomaa J. Prevalence and factors associated with compliance to iron and folic acid supplementation in pregnancy in Tamale Metropolis. Ghana Nutrire. 2020;45:1–10.

    Google Scholar 

  12. Lacerte P, Pradipasen M, Temcharoen P, Imamee N, Vorapongsathorn T. Determinants of adherence to iron/folate supplementation during pregnancy in two provinces in Cambodia. Asia Pac J Public Health. 2011;23(3):315–23.

    Article  PubMed  Google Scholar 

  13. Glew RH, Crossey MJ, Polanams J, Okolie HI, VanderJagt DJ. Vitamin D status of seminomadic fulani men and women. J Nat Med Assoc. 2010;102(6):485–90. https://doiorg.publicaciones.saludcastillayleon.es/10.1016/S0027-9684(15)30556-3.

    Article  Google Scholar 

  14. Sachdev B. Perspectives on health, health needs and health care services among select nomad tribal populations of Rajasthan, India. Med Anthropol. 2012;8(73):81.

    Google Scholar 

  15. Majekodunmi AO, Fajinmi A, Dongkum C, Shaw APM, Welburn SC. Pastoral livelihoods of the Fulani on the Jos Plateau of Nigeria. Pastoralism. 2014;4(1):1–16. https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s13570-014-0020-7.

    Article  CAS  Google Scholar 

  16. Ghana Statistical Service (GSS) Population and Housing Census. District analytical report. Accra: West Gonja District; 2010.

    Google Scholar 

  17. Setia MS. Methodology series module 3: cross-sectional studies. Ind J Dermatol. 2016;61(3):261.

    Article  Google Scholar 

  18. Johnston LG. Sampling migrants: how respondent driven sampling works. In: Tyldum G, Johnston LG, editors. Applying respondent driven sampling to migrant populations lessons from the field. London: Palgrave Macmillan UK; 2014.

    Google Scholar 

  19. Bonevski B, Randell M, Paul C, Chapman K, Twyman L, Bryant J, et al. Reaching the hard-to-reach: a systematic review of strategies for improving health and medical research with socially disadvantaged groups. BMC Med Res Methodol. 2014;14:1–29.

    Article  Google Scholar 

  20. Magnani R, Sabin K, Saidel T, Heckathorn D. Review of sampling hard-to-reach and hidden populations for HIV surveillance. AIDS. 2005;19(Suppl 2):S67-72.

    Article  PubMed  Google Scholar 

  21. Raifman S, DeVost MA, Digitale JC, Chen YH, Morris MD. Respondent-driven sampling: a sampling method for hard-to-reach populations and beyond. Curr Epidemiol Reports. 2022;9(1):38–47.

    Article  Google Scholar 

  22. Shedlin MG, Decena CU, Mangadu T, Martinez A. Research participant recruitment in Hispanic communities: lessons learned. J Immigr Minor Health. 2011;13:352–60.

    Article  PubMed  Google Scholar 

  23. Kalton G. Methods for oversampling rare subpopulations in social surveys. Surv Meth. 2009;35(2):125–41.

    Google Scholar 

  24. Kalsbeek WD. Sampling minority groups in health surveys. Stat Med. 2003;22:1527–49.

    Article  PubMed  Google Scholar 

  25. Platt L, Wall M, Rhodes T, Judd A, Hickman M, Johnston LG, et al. Methods to recruit hard-to-reach groups: comparing two chain referral sampling methods of recruiting injecting drug users across nine studies in Russia and Estonia. J Urban Health Bull New York Acad Med. 2006;83(7):i39–53.

    Google Scholar 

  26. Tourangeau R. Defining hard to survey populations. In: Edwards B, Johnson TP, Wolter KM, Bates N, Tourangeau R, editors. Hard-to-survey populations. Cambridge: Cambridge University Press; 2014.

    Chapter  Google Scholar 

  27. Harper GW, Carver LJ. “Out-of-the-mainstream” Youth Partners in Collaborative research: exploring the benefits and challenges. Health Educ Behav. 1999;26:250–65.

    Article  PubMed  CAS  Google Scholar 

  28. Martin MA, Swider SM, Olinger T, Avery E, Lynas CMT, Carlson K, et al. Recruitment of Mexican American adults for an intensive diabetes intervention trial. Ethn Dis. 2011;21(1):7–12.

    PubMed  Google Scholar 

  29. WHO. Guideline: Daily iron and folic acid supplementation in pregnant women. Geneva: World Health Organization; 2012.

    Google Scholar 

  30. WHO. Global Nutrition Targets 2025: Anaemia Policy Brief (WHO/NMH/NHD/14.4). Global Nutrition Targets 2025, 2(WHO/NMH/NHD/14.4). 2014: 8. WHO/NMH/NHD/14.4

  31. Boti N, Bekele T, Godana W, Getahun E, Gebremeskel F, Tsegaye B, et al. Adherence to Iron-Folate supplementation and associated factors among Pastoralist’s pregnant women in Burji districts, Segen area People’s zone, southern Ethiopia: community-based cross-sectional study. Int J Reprod Med. 2018. https://doiorg.publicaciones.saludcastillayleon.es/10.1155/2018/2365362.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Taye B, Abeje G, Mekonen A. Factors associated with compliance of prenatal iron folate supplementation among women in Mecha district. Western Amhara a cross-sectional study: Pan Afr Med J; 2015. https://doiorg.publicaciones.saludcastillayleon.es/10.11604/pamj.2015.20.43.4894.

    Book  Google Scholar 

  33. Gebremedhin S, Samuel A, Mamo G, Moges T, Assefa T. Coverage, compliance and factors associated with utilization of iron supplementation during pregnancy in eight rural districts of Ethiopia: a cross-sectional study. BMC Public Health. 2014;14:1–8.

    Article  Google Scholar 

  34. Mithra P, Unnikrishnan B, Rekha T, Nithin K, Mohan K, Kulkarni V, et al. Compliance with iron-folic acid (IFA) therapy among pregnant women in an urban area of south India. Afr Health Sci. 2013;14(1):255–60.

    Article  Google Scholar 

  35. Debi S, Basu G, Mondal R, Chakrabarti S, Roy SK. Ghosh S compliance to iron-folic-acid supplementation and associated factors among pregnant women: a cross-sectional survey in a district of West Bengal, India. J Fam Med Prim Care. 2020;9(7):3613.

    Article  Google Scholar 

  36. Dinga LA. Factors associated with adherence to iron/folate supplementation among pregnant women attending antenatal clinic at Thika District Hospital in Kiambu County, Kenya. Kenya: University of Nairobi; 2013.

    Google Scholar 

  37. Gebreamlak B, Dadi AF, Atnafu A. High adherence to iron/folic acid supplementation during pregnancy time among antenatal and postnatal care attendant mothers in governmental health centers in Akaki Kality Sub City, Addis Ababa, Ethiopia: hierarchical negative binomial poisson regression. PLoS ONE. 2017;12(1):e0169415.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Gebre A, Mulugeta A, Etana B. Assessment of factors associated with adherence to iron-folic acid supplementation among urban and rural pregnant women in North Western Zone of Tigray, Ethiopia: comparative Study. Int J Nutr Food Sci. 2015;4(2):161.

    Article  Google Scholar 

  39. Ghose B, Feng D, Tang S, Yaya S, He Z, Udenigwe O, et al. Women’s decision-making autonomy and utilisation of maternal healthcare services: results from the Bangladesh Demographic and Health Survey. BMJ Open. 2017;7(9):e017142.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Mullany BC, Becker S, Hindin MJ. The impact of including husbands in antenatal health education services on maternal health practices in urban Nepal: results from a randomized controlled trial. Health Edu Res. 2007;22(2):166–76.

    Article  Google Scholar 

  41. Getachew M, Abay M, Zelalem H, Gebremedhin T, Grum T, Bayray A. Magnitude and factors associated with adherence to Iron-folic acid supplementation among pregnant women in Eritrean refugee camps, northern Ethiopia. BMC Preg Childbirth. 2018;18:1–8.

    Article  Google Scholar 

  42. Birhanu TM, Birarra MK, Mekonnen FA. Compliance to iron and folic acid supplementation in pregnancy, Northwest Ethiopia. BMC Res Notes. 2018;11:1–5.

    Article  Google Scholar 

  43. Gebremariam AD, Tiruneh SA, Abate BA, Engidaw MT, Asnakew DT. Adherence to iron with folic acid supplementation and its associated factors among pregnant women attending antenatal care follow up at Debre Tabor General Hospital, Ethiopia, 2017. PLoS ONE. 2019;14(1):e0210086.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  44. Solomon Y, Sema A, Menberu T. Adherence and associated factors to iron and folic acid supplementation among pregnant women attending antenatal care in public hospitals of Dire Dawa Eastern Ethiopia. Eur J Midwif. 2021. https://doiorg.publicaciones.saludcastillayleon.es/10.18332/ejm/138595.

    Article  Google Scholar 

  45. Panter-Brick C, Clarke SE, Lomas H, Pinder M, Lindsay SW. Culturally compelling strategies for behaviour change: a social ecology model and case study in malaria prevention. Soc Sci Med. 2006;62(11):2810–25. https://doiorg.publicaciones.saludcastillayleon.es/10.1016/j.socscimed.2005.10.009. (PMID: 16352385).

    Article  PubMed  Google Scholar 

  46. Strecher VJ, Rosenstock IM. The health belief model. Cambridge Handbook Psychol Health Med. 1997;25(113):117.

    Google Scholar 

Download references

Acknowledgements

We thank the West Gonja Municipal Health Directorate, enumerators and respondents for their support throughout the study.

Funding

No funding was available for the study.

Author information

Authors and Affiliations

  1. Department of Population and Reproductive Health, School of Public Health, University for Development Studies, Tamale, Ghana

    Yula Salifu, Yaa Nyarko Agyeman & Joseph Lasong

Authors
  1. Yula Salifu
    View author publications

    You can also search for this author inPubMed Google Scholar

  2. Yaa Nyarko Agyeman
    View author publications

    You can also search for this author inPubMed Google Scholar

  3. Joseph Lasong
    View author publications

    You can also search for this author inPubMed Google Scholar

Contributions

YS and JL drafted the research plan. YNA helped to edit and review the manuscript. YS, and JL helped in the statistical analyses, interpretation of the results and proofed read the manuscript. All authors contributed to the discussion of the paper, read and approved the final version.

Corresponding author

Correspondence to Joseph Lasong.

Ethics declarations

Ethics approval and consent to participate

The study was permitted and granted ethical approval based on the Helsinki Declaration from the West Gonja Municipal Health Directorate and the University for Development Studies Ethical Review Board [UDS/RB/059/22]. As a result of the conflicting nature of legal marital age and cultural distances expressed by the Fulani, authorization was sought from husbands/close relatives of under-aged women (women < 18 years). Due to the high illiteracy numbers in rural Ghana, respondents (women ≥ 18 years) were asked to provide written/thumb-printed informed consent. All respondents were assured full discretional use of the information for the purposes of the study. Authors report that all experiments conducted on humans and/or the use of human tissue samples/human data were performed in accordance with relevant guidelines and regulations such as the Declaration of Helsinki.

Consent for publication

Not Applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Salifu, Y., Agyeman, Y.N. & Lasong, J. Adherence to and predictors of iron-folate acid supplementation among pregnant women in a pastoral population in Ghana: a community-based cross-sectional study. Reprod Health 21, 165 (2024). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12978-024-01877-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12978-024-01877-z

Keywords

Reproductive Health

ISSN: 1742-4755