Effectiveness of Public Health Education on the Uptake of Iron-And Folic Acid Supplements Among Pregnant Women: Findings from a Stepped Wedge Cluster Randomized Trial

Objective: To determine the effectiveness of public health education on the uptake of iron and folic acid supplements (IFAS) among pregnant women. Design: A stepped wedge cluster randomized trial. Setting: 12 antenatal care clinics (ANC) in Embu County - Kenya. The clinics are outpatient departments in health facilities dedicated to providing care for pregnant women. Participants: Pregnant women receiving antenatal care services in the study sites. Intervention: After a baseline observational phase, a multifaceted intervention bundle was implemented. The intervention included a 60-minute IFAS information session for health workers at the start of intervention. Health workers then provided daily IFAS literacy sessions to all the pregnant women and issued them with IFAS related information materials (a pill reminder card, and a personalized calendar). The study team conducted biweekly facility audits for quality assurance. The total duration of the study was 8 months, starting June 2022. Primary outcome: The primary outcome was the proportion of pregnant women taking IFAS daily in the intervention phase compared with control phase. This was measured through IFAS residual pill count during every ANC visit. Results: A total of 4,749 ANC visits were monitored for 2,132 women receiving antenatal care in the 12 clinics. Participant characteristics were similar across control and intervention phases. The uptake of IFAS significantly improved from 44.8% (95% CI 34.7 to 55.0) in control phase to 83.3% (95% CI 75.9 to 90.9) during the intervention. This translates to a 38.5 (95% CI 26.0 to 51.1) percentage points improvement. The number needed to treat (NNT) for this intervention was 3 patients (95% CI 2 to 4). Conclusion: IFAS uptake significantly improved following the intervention. The findings support public health education as an effective strategy for improving the uptake of IFAS in ANC settings.