Integrating Calcium Supplementation into Facility-Based Antenatal Care Services in Western Kenya: A Qualitative Process Evaluation to Identify Implementation Barriers and Facilitators

Abstract

BackgroundIn countries with low calcium intake, the WHO recommends integrating calcium supplementation into antenatal care (ANC) to reduce the risk of preeclampsia, a leading cause of maternal mortality. Current WHO guidelines recommend women take 3–4 calcium supplements plus 1 iron-folic acid supplement at separate times daily. There is limited evidence about implementing these guidelines through routine ANC. Through the Micronutrient Initiative-Cornell University Calcium (MICa) trial, we examined the effect of regimen on supplement consumption among ANC clients in western Kenya. A nested process evaluation examined factors that influence calcium supplementation delivery and uptake.ObjectivesThis process evaluation assessed ANC providers’, pregnant women's, and family members’ experiences with calcium supplementation, and investigated the feasibility and acceptability of engaging family members to support adherence.MethodsWe conducted semistructured interviews with 7 ANC providers, 32 pregnant women, and 20 adherence partners (family members who provide reminders and support), and 200 observations of ANC consultations. Interviews were transcribed, translated, and analyzed thematically. Observational data were summarized.ResultsANC providers reported positive feelings about calcium supplementation, the training received, and counseling materials, but reported increased workloads. Women reported that providers counseled them on supplement benefits and managing side effects, offered reminder strategies, and provided supplements and behavior change materials. Women explained that reminder materials and adherence partners improved adherence. Most adherence partners reported providing reminders and other instrumental support to help with pill taking, which women confirmed and appreciated. Some women reported that comorbidities, concerns about being perceived as HIV positive, pill burden, unfavorable organoleptic properties, and lack of food were adherence barriers.ConclusionsAlthough integrating calcium into antenatal iron-folic acid supplementation was generally acceptable to ANC providers, pregnant women, and their families, calcium supplementation presents unique challenges that must be considered to successfully implement these guidelines.This trial was registered at clinicaltrials.gov as NCT02238704.

Engaging family members in maternal, infant and young child nutrition activities in low‐ and middle‐income countries: A systematic scoping review

“…Our understanding of these interventions is further limited by the lack of process data describing attendance and coverage; fidelity of delivery; participant views on acceptability, quality, and relevance; and implementer views on feasibility. While a small number of studies explored these issues (Downs et al, 2019 ; Flax et al, 2019 ; Martin et al, 2015 , 2018 ; Nguyen et al, 2018 ; Salasibew et al, 2019 ; Tall et al, 2018 ) these gaps highlight the importance of utilizing reporting guidelines for social and behavioural interventions and related implementation research to ensure transparency and replicability (Yousafzai et al, 2018 ). In addition to examining the impact of interventions, it is also important to assess their implementation by evaluating intervention acceptability, adoption, appropriateness, cost, feasibility, fidelity and sustainability (Proctor et al, 2011 ).…”

“…and implementer views on feasibility. While a small number of studies explored these issues (Downs et al, 2019;Flax et al, 2019;Martin et al, 2015Martin et al, , 2018Nguyen et al, 2018;Salasibew et al, 2019;Tall et al, 2018) these gaps highlight the importance of utilizing reporting guidelines for social and behavioural interventions and related implementation research to ensure transparency and replicability (Yousafzai et al, 2018). In addition to examining the impact of interventions, it is also important to assess their implementation by evaluating intervention acceptability, adoption, appropriateness, cost, feasibility, fidelity and sustainability (Proctor et al, 2011 Kumar et al, 2018;Salasibew et al, 2019;Satzinger et al, 2009), cash transfer or food transfer (Hoddinott et al, 2018), parenting and early child development (Betancourt et al, 2020;Singla et al, 2015) and community development (Fiorella et al, 2019).…”

Implementation of the ‘Optimising the Health Extension Program’ Intervention in Ethiopia: A Process Evaluation Using Mixed Methods

“…The qualitative data were collected through semi-structured interviews conducted between June and July 2019, four months after the completion of implementation. Interview topics were determined a priori, based on a literature review of similar studies and varied depending on the respondent type [23,24]. Topics included implementers' overall impression of the intervention, what went well and what did not in implementing the intervention components, and the context within which the intervention was implemented.…”

Calcium supplementation for the prevention of hypertensive disorders of pregnancy: current evidence and programmatic considerations

“…Another study examined factors that influence calcium supplementation delivery and uptake of 32 pregnant women in Kenya 63 . It similarly showed that reminder materials and adherence partners (providing support to help with remembering to take the pills) improved adherence 68,69 . This study also recommended a consistent supply of supplements, high‐quality counseling from antenatal care providers, reminder materials for women to take home, and family support for the successful integration of calcium supplementation into antenatal care.…”