Assessing Health System Readiness for Scaling Antenatal MMS in Cambodia: A Mixed-Methods Assessment
Conditions: Anemia, Pregnancy, Micronutrients, Supplement, Health Systems, Supply Chain Vulnerabilities, Adherence
Sponsor: University of British Columbia

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Research Protocol 
 
Assessing Health System Readiness for Scaling Antenatal MMS in Cambodia:  
A Mixed-Methods Assessment 
 
Executive Summary 
Background: Malnutrition among pregnant women in low- and middle-income countries (LMICs) can 
cause micronutrient deficiencies that result in adverse maternal and neonatal health outcomes. The World 
Health Organization has recently recommended antenatal multiple micronutrient supplementation 
(MMS) that includes iron and folic acid (IFA) to improve maternal and neonatal health outcomes. MMS 
likely provides additional antenatal benefits over IFA supplementation alone. The Cambodian 
government, in partnership with Helen Keller International, is piloting MMS implementation in Takeo 
Province, which will inform nationwide scale-up of MMS.  
 
Study Purpose: The Takeo implementation must be evaluated to understand context-specific 
implementation of MMS and health system readiness for scale-up. This study assesses system readiness 
through four domains from the Intervention Scalability Assessment Tool (ISAT): (1) fidelity and 
adaptation, (2) reach and acceptability, (3) delivery setting and workforce capacity, and (4) 
implementation infrastructure.  
 
Population: The pilot involves transitioning to MMS from IFA across all 86 health centers, all 6 referral 
hospitals, and the provincial hospital in Takeo province. This study includes pregnant women receiving 
antenatal care, antenatal healthcare providers and facilities, and hospital managers in Takeo. The study 
also includes national governing bodies for MMS delivery.  
 
Methods: This mixed-methods study uses ISAT as a framework for developing data collection methods. 
Sampling strategies emphasize urban and rural representation across all operational districts in Takeo 
and diverse stakeholder perspectives at multiple levels of the health system. Data collection includes:  
1. 12 focus group discussions (FGDs) with health center providers to assess provider adherence to 
MMS delivery guidelines, perspectives on the transition to MMS, and additional resources needed 
for MMS delivery  
a. Workload assessment surveys at FGDs to quantify any burden on providers and resource 
gaps to deliver MMS 
2. MMS stockout monitoring at 18 health centers and 7 hospitals to assess supply chain reliability 
3. 15 key informant interviews with hospital managers to assess perspectives on the integration of 
MMS into antenatal services and facility readiness for MMS delivery 
4. Phone surveys with 630 pregnant women to assess acceptability and adherence to MMS at 90- 
and 180-days after MMS distribution  
5. 1 FGD with national-level stakeholders to assess national-level readiness, economic planning, 
and resource planning for sustainable MMS implementation and scale-up 
6. Rapid economic evaluation to estimate the cost of nationwide scale-up 
Potential Impact: This study will generate insights into real-world implementation of MMS in 
Cambodia. It will identify context-specific adaptations, implementation gaps, and resource planning 
frameworks needed for nationwide scale-up of MMS. Successful scale-up is anticipated to improve 
maternal and neonatal health in Cambodia. Findings can also be used to guide other LMICs seeking to 
transition to and sustainably implement MMS. 
 

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Table of Contents 
1. Background and Rationale ........................................................................................................... 3 
2. Objectives .................................................................................................................................... 4 
3. Study Design ................................................................................................................................ 4 
3.1. ISAT Framework .................................................................................................................. 4 
3.2. Setting ................................................................................................................................... 5 
3.3. Data Collection Methods and Tools ...................................................................................... 6 
4. Study Procedures ....................................................................................................................... 10 
4.1. Focus Group Discussions and Workload Survey: Health Center Providers ....................... 10 
4.2. Key Informant Interviews: Hospital Managers ................................................................... 11 
4.3. Stockout Monitoring: Health Facilities ............................................................................... 12 
4.4. User Acceptability and Adherence Survey: Pregnant Women ........................................... 13 
4.5. Focus Group Discussion: National-Level Stakeholders ..................................................... 16 
4.6. Economic Evaluation .......................................................................................................... 17 
5. Data Management ...................................................................................................................... 21 
6. Stakeholder Involvement and Dissemination Plan .................................................................... 21 
7. Risks and Benefits ..................................................................................................................... 21 
8. Ethics and IRB ........................................................................................................................... 21 
9. Timeline ..................................................................................................................................... 22 
10. References ................................................................................................................................ 22 
 
 
 

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1. Background and Rationale 
Malnutrition and micronutrient deficiencies during pregnancy have significant consequences for 
maternal and neonatal health, particularly in low- and middle-income countries (LMICs). Dietary 
diversity and quality in LMICs are often limited. Micronutrient deficiencies can result in low birthweight, 
preterm birth, stillbirth, and being born small for gestational age. Micronutrient deficiencies can increase 
the risk of maternal mortality and obstetric complications (Bourassa et al., 2019; Mei et al., 2017; 
UNICEF 2024). 
 
To combat this, the World Health Organization (WHO) previously recommended iron and folic acid 
(IFA) supplementation as part of antenatal care (ANC) (Mei et al., 2017). However, since 2020, WHO 
has acknowledged the significant body of evidence that multiple micronutrient supplementation (MMS) 
results in improved health outcomes for pregnant women and their babies in low- and middle-income 
countries (Bourassa et al., 2019; Keats et al., 2019; WHO, 2020). Now, WHO guidelines include MMS 
as an essential antenatal medicine (WHO, 2021). WHO has urged countries to conduct implementation 
research to drive feasible, acceptable, and context-specific MMS implementation (WHO, 2020).  
 
The UNIMMAP MMS formulation recommended by WHO contains 15 vitamins and minerals, including 
iron and folic acid, in the recommended safe doses for pregnant women. The formulation was developed 
in 1999 through a collaboration between WHO, the United Nations University, and UNICEF, and then 
tested rigorously through randomized controlled trials for safety and effectiveness. In 2021, UNIMMAP 
MMS was officially included in the World Health Organization’s Model List of Essential Medicines 
based on evidence that it is effective and safe (WHO, 2021). We have summarized a list of the key 
references highlighting publications that confirm UNIMMAP MMS's safety, efficacy, and cost-
effectiveness as Appendix A.  
 
Helen Keller Intl (Helen Keller) has been working with the Cambodian Ministry of Health (MoH) to 
conduct MMS implementation research in the Cambodian context. The Cambodian MoH will use MMS 
implementation studies in Cambodia to inform scale-up strategies for transitioning from IFA to MMS as 
a key part of ANC. In 2023, Helen Keller conducted a randomized cluster non-inferiority trial in 
Kampong Thom province to assess pregnant women’s adherence and acceptability to IFA compared to 
MMS (Hoang et al., 2024). This study found that adherence to MMS was superior to IFA, and pregnant 
women found MMS to be highly acceptable, thereby supporting the transition to MMS (Sauer et al., 
2024). With this evidence, the Cambodian national guidelines for ANC are being updated to include 
antenatal MMS, which includes 15 micronutrients, including iron and folic acid, versus IFA alone.  
 
To advance the transition from IFA to MMS in Cambodia, the MoH, in collaboration with Helen Keller, 
Vitamin Angel Alliance, and Kirk Humanitarian, has designed a phased implementation approach 
beginning with a province-wide pilot in Takeo. This strategic pilot represents the first province-wide 
implementation of MMS in Cambodia, covering all 6 operational districts and 86 health centers. This 
pilot will generate critical evidence on implementation feasibility and offer insights on system readiness 
and how to prepare for national expansion.  Helen Keller presents this protocol as a tool to assess 
implementation readiness for MMS scale-up. The assessment employs a mixed-methods approach to 
examine four critical dimensions of implementation quality and health system readiness for scaling: 
 
1. Fidelity and adaptation 
2. Reach and acceptability 
3. Delivery setting and workforce 
4. Implementation infrastructure   
In this context, the assessment will help assess the scalability of antenatal MMS delivery, identify 
contextual factors facilitating or hindering scale-up, and provide a structured mechanism for working 

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through key gaps to facilitate a smooth rollout.  Study findings will make recommendations for future 
scale-up and inform the national strategic planning process. The quality of the MMS rollout and the 
health system's readiness will ultimately determine the extent to which Cambodian pregnant women 
receive the intended health benefits of MMS.  
 
The Cambodian government will use these findings to identify critical areas for adaptation when scaling 
MMS in other provinces to ensure a seamless transition to MMS. Strategies for adaptation may be related 
to cost, funding, healthcare provider training, national ANC guidelines, supply chain strengthening, 
planning for other resources, and individual- and household-level characteristics of pregnant women and 
their families. Importantly, the results from this context-specific protocol may inform implementation 
practices in other low- and middle-income countries that aim to transition to MMS to improve birth 
outcomes globally.  
 
2. Objectives 
This study aims to systematically evaluate the following key dimensions of MMS implementation in 
Cambodia:  
1. Fidelity and adaptation 
a. Assess implementation fidelity to the Cambodia Interim National Micronutrient 
Guidelines during MMS rollout and identify context-specific adaptations for optimal 
MMS delivery in the Cambodia healthcare system 
2. Reach and acceptability 
a. Determine the reach and perceived acceptability of the MMS intervention among 
healthcare providers and the pregnant women as well as their level of satisfaction with the 
implementation 
3. Delivery setting and workforce 
a. Evaluate the capacity of health workforce to deliver MMS effectively; specifically 
assessing health system infrastructure readiness, adequacy of healthcare provider training, 
resource availability, and supply chain reliability  
4. Implementation infrastructure 
a. Model the implementation infrastructure and resource requirements for nationwide MMS 
scale-up 
i. Cost analysis: Compare the economic implications of transitioning from IFA to 
MMS 
ii. Supply chain: MMS forecasting, procurement timelines, and considerations for a 
resource planning framework for sustainable implementation 
3. Study Design 
3.1. ISAT Framework 
This protocol uses the Intervention Scalability Assessment Tool (ISAT) as a framework to guide the 
development of data collection methods. ISAT is an adaptable framework to help stakeholders assess 
intervention scalability, identify contextual factors impacting scale-up, and identify gaps in knowledge 
to determine scalability (Australian Prevention Partnership Centre, 2019). The ISAT framework contains 
several domains. The domains within ISAT Part B, Intervention Implementation Planning, are most 
relevant to the objectives of this study. By assessing factors that affect the four domains in Part B, the 
ISAT framework will help decision-makers in Cambodia evaluate health system readiness for scaling 
MMS based on the rollout in Takeo. Table 1 summarizes the four ISAT domains and key considerations 
to guide data collection.  
 
Table 1. ISAT domains and contextual considerations (Australian Prevention Partnership Centre, 2019). 

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Domain 
Key Considerations 
1. Fidelity and 
Adaptation 
To what extent do healthcare providers adhere to the newly revised Interim National 
Micronutrient Guidelines regarding MMS dosage and distribution protocols? 
What mechanisms exist to monitor the implementation of fidelity?  
What context-specific adaptations should be made to the guidelines and training 
materials to optimize delivery in the Cambodian antenatal healthcare system?  
To what extent are the 15 micronutrients in MMS stable under field conditions? 
 
2. 
Reach 
and 
Acceptability  
What proportion of eligible pregnant women in Takeo province are taking MMS?  
To what extent do healthcare providers understand and accept their role in MMS 
distribution and counseling?  
How satisfied are pregnant women in Takeo with the organoleptic aspects of MMS?  
What percentage of pregnant women take MMS as prescribed throughout pregnancy?  
   
3. Delivery Setting 
and Workforce 
How well is MMS integrated into existing ANC services in health facilities?  
To what extent are healthcare providers adequately trained in MMS counseling and 
distribution?  
Are there sufficient material resources (job aids, counseling materials) to support 
MMS delivery?  
How reliable is the MMS supply chain across operational districts (frequency and 
duration of stockouts)? 
What is the health system’s capacity to monitor MMS distribution and adherence?  
 
4. Implementation 
Infrastructure 
What are the economic implications (one-time and recurring costs) of transitioning 
from IFA to MMS nationwide? 
How would the national supply chain need to be adapted for reliable MMS 
procurement and distribution? 
What sustainable financing mechanisms exist or must be developed for long-term 
MMS implementation? 
What human resource considerations are necessary for a nationwide scale-up? 
 
3.2. Setting 
This study will be conducted in Takeo province, a coastal province in southern Cambodia’s Mekong 
ecological zone. Takeo has 6 operational districts. A province-wide MMS rollout is planned to distribute 
MMS in all 86 health centers, 6 referral hospitals, and 1 provincial hospital across Takeo.   
 
Takeo was chosen for Cambodia’s first province-wide rollout to explore the translatability of previous 
implementation research (Hoang, 2024) to different provinces, generate a range of evidence for context-
specific implementation, and use generalizable findings to inform a nationwide MMS rollout. Takeo has 
urban and rural characteristics. However, contextual factors in each province will affect the 
generalizability of findings from Takeo. 
 
According to the 2019 national census, Takeo has a population of about 901,000 (Cambodia National 
Institute of Statistics, 2020). In 2024, Takeo was expected to have 19,837 pregnant women across all 
health facilities. See Table 2 to compare ANC and sociodemographic characteristics of Takeo to rural 
and urban averages, ranges across all provinces, and total averages across Cambodia. In summary, Takeo 
is similar to national averages for the percentage of women (age 15-49) who received ANC from a skilled 

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provider, had at least 4 ANC visits, and took any iron-containing supplements (IFA) when pregnant for 
their last live or still birth in the last 2 years. Takeo is above national averages for the percent of women 
who had only 1 ANC visit and the percent of women who took IFA during pregnancy for 90-179 days. 
IFA adherence was relatively high in Takeo at 93.4%. Finally, Takeo is similar to national averages for 
female literacy rates and employment rates (both sexes) for people aged above 15. 
 
 
 
 
 
 
Table 2. Comparison of ANC and sociodemographic characteristics of Takeo with other areas of 
Cambodia. 
 
% Women (ages 15-49) reporting these events for their last live or 
still birth in the last 2 years1 
Rate 
of 
characteristic 
for 
people aged 15+ 2  
Area 
Received 
ANC 
from 
a 
skilled 
provider1 
Had 
only one 
ANC 
visit1  
Had at 
least 
four 
ANC 
visits1 
Took 
any 
iron-
containing 
supplements1  
Took 
iron-
containing 
supplements 
during pregnancy 
for 90-179 days1 
Female 
literacy2 
Employment (both 
sexes)2 
Takeo 
98.1 
1.7 
83.9 
98.5 
93.4 
86.2 
99.3 
Urban 
average 
99.1 
0.6 
91.3 
97.7 
87.4 
91.4 
98.2 
Rural 
average 
98.5 
1.4 
82.8 
97.8 
88.2 
80.2 
98.9 
Upper value 
across 
all 
provinces 
100 
10 
93.8 
100 
92.7 
94.9 
99.7 
Lower value 
across 
all 
provinces 
94.2 
0 
57.3 
88 
69.1 
65.3 
93.1 
Total 
average 
across 
all 
provinces 
98.7 
1.1 
86.1 
97.8 
87.9 
84.8 
98.7 
1 Indicator taken from Cambodia National Institute of Statistics (2020) 
2 Indicator taken from Cambodia DHS Program (2022)  
3.3. Data Collection Methods and Tools 
This cross-sectional study uses quantitative and qualitative methods to assess health system readiness 
for nationwide MMS implementation and scale-up based on the province-wide rollout of MMS in Takeo.  
 
Before the study, MMS will have already been rolled out across all 86 health centers, 6 referral hospitals, 
and the only provincial hospital in Takeo. All healthcare providers (doctors, nurses, and midwives) will 
have been trained to provide and counsel on MMS. All pregnant women attending at least one ANC visit 
will receive one 180-count bottle of MMS pills. They will not be given IFA unless they are anemic 
(hemoglobin level below 11.0 g/dL).  
 
Figure 1 and Table 3 present summaries of the data collection methods.  
 

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Figure 1. Summary of study methods (organized by section) and aligned ISAT domain. 
 
 
Table 3. Key questions, data collection tools and approaches, and metrics per ISAT domain.  
Key Question 
Data Collection Tools 
Collection Approach 
Metrics 
Domain 1: Fidelity and Adaptation 
To what extent are 
healthcare 
providers adhering 
to MMS dosage 
and distribution 
protocols as 
specified in the 
Cambodia MoH's 
draft 
Micronutrient 
Guidelines? 
FGD guide for healthcare 
providers (provider adherence 
to protocols and training 
effectiveness) 
12 facility-level FGDs (2 
per operational district) 
with 6-8 healthcare 
providers each  
Provider perceptions of 
training and resources to 
deliver and counsel on MMS 
  
Provider perceptions of 
ability to implement MMS 
per national guidelines 
Pill collection form for 
stability test (evaluate MMS 
stability under field 
conditions) 
200 pill samples collected 
from pregnant women's 
homes at 90- and 180-
days post-distribution 
Percent deviation of analyzed 
nutrient content per tablet in 
distributed ("field") MMS 
supplements compared to 
labeled nutrient content 
Phone survey questionnaire for 
pregnant women (user 
adherence to MMS)  
Phone surveys with 630 
pregnant women at 90 
and 180 days after first 
ANC visit, with 
verification through real-
time pill counts during 
calls 
Percent of pregnant women 
receiving the correct MMS 
dosage  
 
Percent of women receiving 
key MMS counseling 
messages 
 
Percent of pregnant women 
adhering to taking MMS as 
prescribed for 90 to 180 days 
Informed consent forms (2 
forms) 
- 
 
- 
 
Domain 2: Reach and Acceptability 
What is the 
coverage and 
Phone survey questionnaire for 
pregnant women (user 
Phone surveys with 630 
pregnant women at 90 
Average score of user 
acceptability toward sensory 

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acceptability of 
MMS among 
healthcare 
providers and 
pregnant women? 
acceptability of MMS)  
and 180 days after first 
ANC visit 
aspects of MMS 
 
Percent of pregnant women 
reporting acceptability-related 
barriers to taking MMS  
Recall phone survey 
questionnaire for user 
acceptability and adherence 
(quality assurance) 
Recall phone surveys 
with 10% of the 
population that 
participated in the 
acceptability and 
adherence surveys 
 
 
  
 
Brief provider workload 
assessment survey 
questionnaire (quantify 
provider changes in workload 
and acceptability of transition) 
Workload assessment 
survey given to all 
participants at facility-
level FGDs with 
healthcare providers 
Average score of provider 
acceptability of transition to 
MMS 
Average score of additional 
workload burden on providers 
to deliver MMS 
Enrollment form 
 
 
Informed consent form (2 
forms) 
 
 
 
 
Domain 3: Delivery Setting and Workforce 
How ready is the 
health system 
infrastructure and 
workforce for 
MMS 
implementation? 
FGD guide for healthcare 
providers (perspectives on 
training adequacy and resource 
needs) 
12 facility-level FGDs 
with 6-8 healthcare 
providers each 
Degree to which providers 
understand MMS guidelines, 
dosage, and counseling 
 
Provider perceptions of the 
sufficiency of training, job 
aids, and ongoing support for 
MMS implementation 
 
Provider perceptions of 
infrastructure readiness (i.e., 
MMS supply and stockouts), 
integration of MMS into 
routine ANC, and alignment 
with existing protocols 
Brief provider workload 
assessment survey 
questionnaire (quantify 
provider changes in workload 
and acceptability of transition) 
Workload assessment 
survey given to all 
participants at facility-
level FGDs with 
healthcare providers 
Average score of changes in 
provider workload or 
perceived burden to transition 
to and deliver MMS 
KII guide for hospital 
managers (perspectives on 
implementation and resource 
needs) 
15 KIIs with high-level 
management officials 
from 6 referral hospitals 
and 1 provincial hospital 
Manager perceptions of 
infrastructure readiness (i.e., 
MMS supply and stockouts), 
integration of MMS into 
routine ANC, and alignment 
with existing protocols 
 
Perceptions of policy support 
and coordination for MMS 
rollout 
 
 

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MMS stockout data collection 
form (monitoring supply chain 
reliability) 
Monthly stockout 
monitoring and health 
facility data review at 18 
health centers (20% 
sample), 6 referral 
hospitals, and the 
provincial hospital 
Percent of health facilities 
without MMS stockouts in 
the last month 
 
MMS coverage (women 
receiving MMS/women in 
need)  
Informed consent forms (2 
forms) 
 
 
Domain 4: Implementation Infrastructure 
What are the 
required resources 
and economic 
implications for 
nationwide MMS 
scale-up? 
MMS cost data collection 
forms (rapid economic 
evaluation including 
procurement, workforce 
training, and supply chain 
costs) 
Health facility data 
review, health department 
records analysis, national 
government data review 
Average MMS unit cost 
compared to IFA unit cost  
 
Average MMS transition 
cost, including training, 
advocacy, and policy updates 
Average recurring MMS 
costs, including procurement, 
distribution, and monitoring 
Average financing gap for 
long-term sustainability of 
MMS implementation  
Proportion of projected MMS 
costs financed through 
domestic versus international 
means 
FGD guide for national-level 
stakeholders 
(to 
assess 
infrastructure and resources 
needed to transition to MMS 
and 
sustainably 
implement 
MMS nationwide)  
1 FGD with National 
MMS 
Steering 
Committee 
(6-8 
members)  
Perceptions of MMS 
integration into existing ANC 
services  
 
Degree of alignment on 
additional resources, systems, 
and capacity needed to scale-
up and sustainably implement 
MMS nationwide 
 
Degree of alignment on long-
term financing mechanisms 
for MMS 
 
Willingness to adopt MMS 
into national essential 
medicines lists and approve 
as final the Interim 
Micronutrient Guidelines 
Informed consent forms (1 
form) 
 
 
 
The protocol uses 17 unique data collection tools across all domains, including: 
• 7 informed consent forms for different participant groups 
• 1 enrollment form (for user acceptability and adherence survey) 
• 2 FGD guides (for providers at health facilities and national-level stakeholders) 
• 1 brief survey instrument for workload assessment (for healthcare providers at FGDs) 
• 1 KII guide (hospital managers) 

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• 1 stockout monitoring form 
• 3 survey instruments for pregnant women (acceptability, adherence, and recall surveys) 
• 1 pill collection form for stability testing 
• 1 economic data collection form 
4. Study Procedures 
4.1. Focus Group Discussions and Workload Survey: Health Center Providers 
4.1.1. Overview and ISAT Domain Alignment 
There will be 12 FGDs with healthcare providers from 12 health centers. Participants will complete a 
workload assessment survey at each FGD. 
 
Data Collection 
Tool 
Data to be collected related to ISAT Domains 
 
Domain 1: Fidelity and Adaptation  
Health 
facility 
providers FGDs 
Provider adherence to specified MMS dosage and distribution protocols 
Provider adherence to counseling content and frequency as outlined in Cambodia’s 
draft Micronutrient Guidelines 
Mechanisms to monitor and ensure fidelity to implementation guidelines 
Context-specific adaptations made to accommodate resource constraints 
Appropriateness of adaptations in maintaining essential intervention components 
 
Domain 2: Reach and Acceptability 
Health 
facility 
providers FGDs 
Provider understanding of their role in MMS counseling and distribution 
Provider assessment of pregnant women's receptivity to MMS 
Perceived barriers affecting provider ability to effectively reach all eligible women 
Provider observations of patient adherence patterns and influencing factors 
Strategies employed by providers to enhance acceptability and adherence 
 
Provider survey 
(workload 
assessment) 
Provider acceptability of and agreement with transition to MMS (Likert scale) 
Provider level of commitment to transitioning to and providing MMS counseling 
(Likert scale) 
 
Domain 3: Delivery Setting and Workforce 
Health 
facility 
providers FGDs 
 
Integration of MMS into existing ANC services and workflows 
Adequacy of provider training on MMS counseling and distribution 
Availability of supporting materials (job aids, counseling tools) for MMS delivery 
Interest in or need for exploring task-shifting for MMS delivery 
Time and resource implications of transitioning from IFA to MMS distribution 
Supply chain reliability at facility level and frequency of MMS stockouts 
Capacity to monitor MMS distribution and patient adherence 
 
Provider survey 
(workload 
assessment) 
 
Change in provider workload (i.e., time spent in training) to transition to MMS 
(hours of time per week or Likert scale of level of increased burden) 
Change in provider workload to counsel on and deliver MMS (hours of time per 
week or Likert scale of level of increased burden) 
Provider perception of added burden of MMS delivery (Likert scale) 
 
 

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4.1.2. Study Population 
Healthcare providers (doctors, nurses, midwives) with direct involvement in MMS distribution or 
counseling at the health facility level and who are willing to participate and available to attend. The 
population excludes personnel from referral hospitals and the provincial hospital. 
 
4.1.3. Sampling Approach 
From each operational district, one urban and one rural health center will be randomly selected (total of 
12 health centers). From each of the 12 health centers, 6-8 personnel will be invited to participate using 
convenience sampling, with 8-10 people initially approached to account for a 20% non-attendance rate. 
 
4.1.4. Data Collection 
FGD: A trained moderator and notetaker will conduct each 70-minute FGD in a private, comfortable 
location using a structured guide aligned with the 4 ISAT domains. All discussions will be audio-recorded 
after obtaining written informed consent. The moderator will ensure balanced participation while the 
notetaker will document contextual factors and non-verbal cues that may inform interpretation of findings. 
 
Survey: Survey instruments will be developed in English and translated into Khmer using forward and 
backward translation. The survey will be kept brief (5-7 questions) so that completion does not take 
longer than 3-5 minutes. Finalized surveys will be on paper and self-administered due to time constraints. 
 
The FGD moderator will provide all participants with the survey at the end of each FGD. Participants 
will complete the survey and return it to the moderator. 
 
4.1.5. Data Analysis  
FGD: Audio recordings will be transcribed verbatim into English. Local language recordings will be 
translated and transcribed into English. Transcripts will undergo quality checks against the audio and 
notetaker notes. After transcription, transcribers and coders will clean the data, and final transcripts will 
be reviewed for completeness and clarity. 
 
Qualitative analysis experts will conduct thematic content analysis. Coding schemes will be refined after 
reviewing a sample of transcripts. Lead researchers will verify coder accuracy through interrater 
reliability before finalizing the scheme, which will then be shared with the study team. Assigned coders 
will analyze transcripts using QSR NVivo. NVivo will be used to identify patterns in code summaries 
(context, descriptions, language, narratives) to extract common themes, opinions, and perspectives. 
 
Survey: Surveys will be analyzed by calculating mean scores related to provider acceptability of the 
transition to and delivery of MMS and increases in provider burden to transition to and deliver MMS. 
 
Integrated Analysis: Findings will be triangulated with (1) delivery setting assessments and (2) user 
reach and acceptability assessments (Section 4.4) to identify resource implications of overcoming barriers. 
 
4.2. Key Informant Interviews: Hospital Managers 
4.2.1. Overview and ISAT Domain Alignment 
15 KIIs will be conducted with high-level management officials at the 6 referral hospitals and 1 provincial 
hospital. 
Data Collection 
Tool 
Data to be collected related to ISAT Domains 
 
Domain 3: Delivery Setting and Workforce 
Hospital 
manager KII 
Integration of MMS into existing ANC services and workflows  
Time and resource implications of transitioning from IFA to MMS distribution 

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Supply chain reliability at facility level and frequency of MMS stockouts 
Capacity to monitor MMS distribution and patient adherence 
 
Domain 4: Implementation Infrastructure 
Hospital 
manager KII 
 
Economic implications of transitioning from IFA to MMS at facility level 
Additional costs (one-time and recurring) associated with MMS implementation 
Human resource considerations for scalable facility-level implementation 
Supply chain strengthening needs for reliable MMS procurement and distribution 
Barriers to feasibility and sustainability of facility-level MMS implementation 
 
4.2.2. Study Population 
High-level management officials with direct involvement in MMS management at referral hospitals and 
the provincial hospital and who are willing to participate and available to attend. This population excludes 
personnel from health centers.  
 
4.2.3. Sampling Approach 
For each referral hospital and the provincial hospital, 6-8 personnel will be invited to participate using 
convenience sampling, with 8-10 people initially approached to account for a 20% non-attendance rate.  
 
4.2.4. Data Collection  
A trained interviewer will conduct each 60-minute KII in a private, comfortable location using a 
structured guide aligned with the ISAT domains. All discussions will be audio-recorded after obtaining 
written informed consent. The interviewer will take notes to document contextual factors and non-verbal 
cues that may inform interpretation of findings. 
 
4.2.5. Data Analysis  
Audio recordings will be transcribed verbatim into English. Local language recordings will be translated 
and transcribed into English. Transcripts will undergo quality checks against the audio and notetaker 
notes. After transcription, transcribers and coders will clean the data, and final transcripts will be 
reviewed for completeness and clarity. 
 
Qualitative analysis experts will conduct thematic content analysis. Coding schemes will be refined after 
reviewing a sample of transcripts. Lead researchers will verify coder accuracy through interrater 
reliability before finalizing the scheme, which will then be shared with the study team. Assigned coders 
will analyze transcripts using QSR NVivo. NVivo will be used to identify patterns in code summaries 
(context, descriptions, language, narratives) to extract common themes, opinions, and perspectives. 
 
Integrated Analysis: Findings will be triangulated with delivery setting assessments to understand 
health system readiness. 
 
4.3. Stockout Monitoring: Health Facilities 
4.3.1. Overview and ISAT Domain Alignment  
Monthly MMS stockout frequency and duration will be collected from a random sample of 18 health 
centers across all operational districts, 6 referral hospitals, and 1 provincial hospital.  
 
Data Collection 
Tool 
Data to be collected related to ISAT Domains 
 
Domain 3: Delivery Setting and Workforce 
Stockout 
monitoring 
Supply chain reliability at facility level and frequency of MMS stockouts 

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4.3.2. Study Population 
Health centers, referral hospitals, and the provincial hospital (all will receive MMS to distribute) that are 
willing to participate.  
4.3.3. Sampling Approach 
18 health centers will be randomly selected (~20% of the total number of health centers). All 6 referral 
hospitals and the 1 provincial hospital will be included for data collection. A total of 25 health centers 
and hospitals will be included.  
4.3.4. Data Collection  
Monthly stockout data will be collected. Health centers and hospitals already conduct monthly inventory 
checks and documentation, so data can be pulled from existing sources.  
Missing Data: Reasons for missed data should be documented by data collectors. Depending on the 
amount and nature of missing data, imputation strategies or a sensitivity analysis may be considered 
during data analysis. 
4.3.5. Data Analysis  
Stockout data will be analyzed to assess: (1) percentage of facilities and hospitals reporting stockout 
within the past month and (2) percentage of MMS coverage (pregnant women received MMS / pregnant 
women in need of MMS).  
Integrated Analysis: Findings will be integrated with other delivery setting assessments to understand 
the effect of supply chain readiness on health system readiness. 
 
4.4. User Acceptability and Adherence Survey: Pregnant Women 
4.4.1. Overview and ISAT Domain Alignment 
Home visits will be conducted with pregnant women at 90- and 180-days after first ANC visit (where 
they first received MMS) to assess user acceptability and adherence using a structured acceptability and 
adherence survey.  
 
Data Collection 
Tool 
Data to be collected related to ISAT Domains 
 
Domain 1: Fidelity and Adaptation  
Household 
survey  
Pregnant women receiving correct MMS dosage at ANC visits 
Pregnant women receiving correct MMS counseling (benefits of MMS, how 
to take MMS) from healthcare providers 
Pregnant women adhering to taking MMS as prescribed  
 
Domain 2: Reach and Acceptability 
Household 
survey  
Satisfaction level among pregnant women with the sensory aspects of MMS 
Barriers that affect uptake and continued use among the target population 
 
4.4.2. Study Population 
Inclusion criteria: Women who are (1) at least 18 years old, (2) able to provide informed consent, (3) 
have attended at least one ANC visit at a health center or hospital in Takeo during the study period, and 
(4) can provide a functioning phone number for follow-up contact. 
 
Women will be enrolled regardless of gestational age to evaluate acceptability and adherence patterns 
across different pregnancy stages and reflect the real-world setting. This will provide insights into 
potential timing-related barriers to MMS use. 
 
Exclusion criteria: (1) Women with diagnosed anemia who require IFA supplementation instead of 
MMS, (2) women unable to communicate via telephone, (3) women who withdraw consent at any point. 
 

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During informed consent, the participants will have the opportunity to learn about the study and will 
have full decision to participate. If they decide not to participate in the study, they will have the 
opportunity to take IFA instead of MMS. Therefore, yes, there will be a choice for all pregnant women 
to participate in the study and to take the MMS. 
 
 
4.4.3. Sampling Approach 
Sample Size and Power: The sample size of 630 women was calculated to allow for detection of a 
minimum difference of 10% in the primary outcome measure (MMS adherence rate) with 95% 
confidence level and 80% power, accounting for the cluster sampling approach across health centers and 
hospitals. This includes a 30% margin for potential loss to follow-up between enrollment and the 180-
day assessment point. The sample size is sufficient to generate province-representative estimates of 
intervention reach and acceptability across rural and urban settings and all six operational districts. 
 
Sampling Approach: A stratified random sampling approach will be employed to ensure balanced 
representation across all six operational districts and between urban and rural health centers and urban 
hospitals. 
 
Enrollment: Eligible women will be recruited during their first ANC visit at participating health centers 
and hospitals. Healthcare workers will be trained in the standardized protocol for enrollment, including 
obtaining written consent and recording registration data. 
 
Follow-up sample selection: For each assessment timepoint (90 and 180 days), data collectors will be 
provided with a randomized list of enrolled women due for follow-up. The lists will be stratified by health 
center or hospital and date of first ANC visit to ensure representative sampling. 
 
4.4.4. Data Collection  
Survey Parameters:  
• Reach 
o Verification of MMS receipt at ANC visit 
o Timing of MMS distribution relative to pregnancy stage 
o Quantity of MMS received 
• Acceptability 
o Sensory evaluation using Likert scales (taste, smell, swallowability, appearance) 
o Overall satisfaction with MMS supplementation 
o Cultural appropriateness and fit with daily routines 
• Adherence  
o Household survey and pill count at participant’s home 
o Consistency of usage patterns since first receiving MMS 
o Calculation of adherence rate (tablets consumed/days available for consumption) 
o Social and cultural factors influencing adherence (role of husbands, mother-in-law, 
community leaders, other pregnant women)  
• Barriers and facilitators 
o Reported side effects or concerns 
o Storage and handling practices 
o Quality of counseling received from healthcare providers 
o Knowledge of MMS benefits 
o Social support for supplement use 
o Suggestions for improving MMS delivery 
 
Survey instruments will be developed in English and translated into Khmer using forward and backward 
translation. They will be validated through cognitive interviews with 5-10 women similar to the target 

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population. Surveys will then be pilot tested with 20 women to assess comprehension and administration 
time.  
 
Finalized surveys will be programmed into electronic data collection forms for standardized 
administration. For acceptability and adherence monitoring will take place at the participants' homes. 
Tablet counts will be conducted at the 90-day and 180-day time-points post enrollment. 
 
Side Effect Monitoring.  Monitoring of all side effects associated with MMS is a critical aspect of the 
study and is included in the household visit questionnaire and will also be included in the following 
procedures.  
• 
Health Provider Training: All health providers involved in MMS distribution will receive 
targeted training to actively encourage pregnant women to report any adverse side effects they 
experience. 
• 
Clear Reporting Channels: Health providers will be instructed to promptly report any adverse 
events to the designated provincial project coordinator. 
• 
Dedicated Provincial Oversight: Each province will have a dedicated, trained provincial 
project coordinator responsible for collecting and escalating reports of adverse impacts to the 
central research team. 
• 
Participant Education: Pregnant women will be informed about the importance of reporting 
any side effects, and will be reassured that many symptoms such as nausea, dizziness, and 
fatigue are common in early pregnancy. 
 
These measures are designed to ensure that any potential side effects are detected and addressed in a 
timely manner, safeguarding participant well-being and maintaining the integrity of the study. 
 
Quality Assurance: To ensure data quality and reliability, 5% of participants will receive a household 
recall survey conducted by a different data collector within 48-72 hours of their original survey.  
 
All data collectors will receive standardized training on survey administration, including role-playing 
exercises and observed practice calls. The first five surveys conducted by each data collector will be 
monitored in real-time by a supervisor. 
 
Weekly data quality checks will be performed to identify and address potential systematic errors or biases. 
Data collectors will document call quality, participant engagement, and any technical issues encountered. 
 
Participant Contact Protocol: Data collectors will make up to three household visits to each selected 
participant. Household visits will be separated by at least 1 week and scheduled between 7:00 AM and 
7:00 PM to maximize response rates. Non-responsive participants after three attempts will be documented, 
and the data collector will proceed to the next individual on the randomized list. 
 
Upon successful contact, data collectors will verify participant identity, reconfirm consent verbally before 
data collection, and proceed with the survey administration. 
 
Missing Data: Reasons for missed data should be documented by data collectors. Depending on the 
amount and nature of missing data, imputation strategies or a sensitivity analysis may be considered 
during data analysis.  
 
4.4.5. Data Analysis  
• Reach 
o Proportion of eligible women who received MMS (calculated using health facility ANC 
attendance as denominator) 

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o Geographical and demographic patterns in MMS coverage 
o Proportion of women receiving adequate MMS counseling 
• Acceptability 
o Mean scores for each sensory parameter (taste, smell, swallowability, appearance) 
o Overall acceptance rate (proportion of women reporting satisfaction) 
o Thematic analysis of qualitative responses regarding barriers and facilitators 
• Adherence 
o Mean adherence rate at 90 and 180 days 
o Proportion of women adherent above the threshold of 76%, in alignment with the 
adherence threshold used in the Hoang et al. (2024) study in Cambodia 
o Correlation between self-reported adherence and pill count verification 
o Factors associated with higher/lower adherence (demographic, geographic, 
implementation factors, social, cultural) 
• Integrated analysis 
o Changes in acceptability and adherence between 90 and 180 days 
o Correlation between acceptability ratings and adherence rates 
o Relationship between quality of counseling and adherence 
o Key barriers affecting MMS uptake and continued use 
 
 
4.5. Focus Group Discussion: National-Level Stakeholders 
4.5.1. Overview and ISAT Domain Alignment 
One FGD will be conducted with members of the National MMS Steering Committee to assess national 
MMS scalability.  
 
Data Collection 
Tool 
Data to be collected related to ISAT Domains 
 
Domain 4: Implementation Infrastructure 
National-level 
FGD 
 
Integration of MMS into existing ANC services and workflows 
Availability of supporting workforce and materials for MMS delivery 
Implications on time, resources, and human resources for national transition to 
MMS from IFA and scale-up 
Supply chain reliability and strengthening for national procurement and 
distribution  
National capacity to monitor MMS distribution, delivery, and coverage 
Barriers to feasibility and sustainability of national MMS implementation 
Economic implications of transitioning to MMS from IFA at the national level 
(one-time and recurring costs) 
 
 
4.5.2. Study Population 
Members of the National MMS Steering Committee with direct involvement in MMS program planning, 
implementation, supply chain management, or delivery at various administrative levels. Participants must 
be willing to participate and available to attend.  
 
4.5.3. Sampling Approach 
6-8 personnel will be invited to participate using convenience sampling, with 8-10 people initially 
approached to account for a 20% non-attendance rate.  
 

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4.5.4. Data Collection  
 trained moderator and notetaker will conduct each 70-minute FGD in a private, comfortable location 
using a structured guide aligned with the 4 ISAT domains. All discussions will be audio-recorded after 
obtaining written informed consent. The moderator will ensure balanced participation while the notetaker 
will document contextual factors and non-verbal cues that may inform interpretation of findings. 
 
4.5.5. Data Analysis  
Audio recordings will be transcribed verbatim into English. Local language recordings will be translated 
and transcribed into English. Transcripts will undergo quality checks against the audio and notetaker 
notes. After transcription, transcribers and coders will clean the data, and final transcripts will be 
reviewed for completeness and clarity. 
 
Qualitative analysis experts will conduct thematic content analysis. Coding schemes will be refined after 
reviewing a sample of transcripts. Lead researchers will verify coder accuracy through interrater 
reliability before finalizing the scheme, which will then be shared with the study team. Assigned coders 
will analyze transcripts using QSR NVivo. NVivo will be used to identify patterns in code summaries 
(context, descriptions, language, narratives) to extract common themes, opinions, and perspectives. 
Integrated Analysis: Economic probes from this FGD will be triangulated with (1) implementation 
infrastructure assessments and (2) MMS stockout data to inform supply chain strengthening needs. 
 
4.6. Economic Evaluation 
4.6.1. Overview and ISAT Domain Alignment 
This is an evaluation of the economic and resource needs to scale and implement MMS nationwide. It 
builds on and integrates methods in other sections of this protocol. This will guide the development of 
an evidence-based resource planning framework for sustainable MMS scale-up beyond the Takeo pilot. 
 
Data Collection 
Tool 
Data to be collected related to ISAT Domains 
 
Domain 4: Implementation Infrastructure 
Economic 
evaluation 
 
 
Economic implications (one-time and recurring costs) of transitioning from IFA to 
MMS nationwide 
National supply chain strengthening needs for reliable MMS procurement and 
distribution 
Sustainable financing mechanisms that exist or need to be developed for long-term 
MMS implementation 
Human resource considerations for nationwide scale-up 
 
4.6.2. Study Population 
Inclusion criteria: Institutions and individuals with direct involvement in MMS-related financial 
planning, budgeting, supply chain management, or resource allocation, including (1) health facilities 
across all six operational districts in Takeo province, (2) district health departments and Takeo provincial 
health department representatives, (3) national government agencies (Ministry of Health Finance 
Department, Central Medical Stores), (4) National MMS Steering Committee members, and (5) 
development partners and NGOs contributing to MMS financing or implementation. 
 
Exclusion criteria: Institutions without direct financial involvement in MMS implementation or 
individuals without authority to provide financial or resource utilization data. 
 
4.6.3. Sampling Approach 
A stratified purposive sampling approach will be employed to ensure comprehensive representation 

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across all levels of the health system (facility to national), urban and rural contexts, different operational 
districts with varying resources.  
 
Facility-Level Economic Data: All health facilities involved in the facility-level FGDs (Section 4.1) 
and an additional 12 randomly selected facilities (2 per operational district) for a total sample of 24 health 
facilities (28% of all facilities).  
 
District- and Province-Level Economic Data: All six operational district health offices in Takeo and 
the Provincial Health Department Finance and Planning Division 
 
National-Level Data: Members of the National MMS Steering Committee and the Ministry of Health 
Maternal and Child Health Division, Finance Department, and Central Medical Stores.  
 
4.6.4. Data Collection Dimensions 
Cost Data Collection: Cost data collection forms will be used to collect detailed financial information 
through administrative record reviews. Data will be collected across seven dimensions: 
• MMS Procurement Costs 
o Unit costs under different procurement scenarios (international/local) 
o Comparison with historical IFA procurement costs 
o Volume-based price modeling for nationwide procurement 
o Foreign exchange and importation considerations 
• Training Implementation Costs 
o Personnel time (trainers and trainees) 
o Training venue and materials 
o Per diems and transportation 
o Follow-up supervision costs 
• Material Development Expenses 
o Development costs for training manuals/materials 
o Job aid production and distribution 
o Counseling materials development 
o Printing and distribution expenses 
• Supply Chain Management Costs 
o Storage requirements and costs 
o Transportation expenses from central to health facility level 
o Inventory management systems 
o Quality assurance mechanisms 
• Human Resource Requirements 
o Additional staff time for MMS-related activities 
o Opportunity costs of existing staff reallocation 
o Supervision and monitoring expenses 
• Infrastructure Adaptations 
o Storage facility modifications 
o Distribution system adjustments 
o Information system updates for tracking 
• Recurrent and One-time Costs 
o Clear disaggregation of transitional (one-time) versus recurrent costs 
o Annual recurrent cost projections for different scale-up scenarios 
 
Economic Assessment within National-Level FGD: An economic component will be included in the 
national-level FGD with specific probes on: 
 

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• Budget Planning and Financial Sustainability 
o Government budget allocation processes for MMS 
o Donor transition planning for sustainable financing 
o Integration with existing health financing mechanisms 
• Supply Chain Readiness 
o Central Medical Stores capacity for nationwide MMS distribution 
o Inventory management system strengths and limitations 
o Risk mitigation strategies for supply disruptions 
• Resource Planning Framework 
o Human resource allocation mechanisms 
o Equipment and infrastructure needs 
o Monitoring and supervision systems 
 
• Coordination Mechanisms 
o Inter-ministerial coordination structures 
o Public-private partnership opportunities 
o Development partner engagement processes 
 
Economic Assessment within Facility-Level FGD: An economic component will be included in the 
facility-level FGDs with specific probes on: 
 
• Implementation Costs 
o Additional time burden for healthcare providers 
o Storage and inventory management challenges 
o Administrative requirements 
• Resource Constraints 
o Perceived resource gaps affecting implementation 
o Opportunity costs and trade-offs 
o Suggestions for efficiency improvements 
 
4.6.5. Data Collection  
Economic Data Collection at Health Facilities:  
• Data collectors with financial/economic training will visit selected health facilities and review 
records using data collection forms 
• Health facility administrators will be interviewed to validate/contextualize financial data 
• Healthcare providers will be interviewed to collect data on time allocation  
District and Provincial Data Collection:  
• Meetings with finance officers at district and provincial health departments 
• Structured review of budgetary allocations, expenditure reports, and financial projections 
• Documentation of financing mechanisms and fund flows 
• Assessment of financial management capacity for scale-up  
National-Level Data Collection: 
• Review of national financial records related to maternal health commodity procurement 
• Documentation of budget allocation processes and financial sustainability strategies 
• Assessment of Central Medical Stores capacity and supply chain costs 
• Collection of cost data from previous health program scale-up efforts as benchmarks 
 
Integration of FGD Economic Data: 
• Economic components from national and facility-level FGDs will be appropriately coded 
• Qualitative cost descriptions will be quantified where possible 

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• Resource constraints and opportunities noted in FGDs will be incorporated into analysis 
 
4.6.6. Data Analysis  
Cost Analysis: 
 
• Ingredient-based Costing 
o Detailed itemization of all resources required for MMS implementation 
o Valuation of each ingredient at current market prices 
o Sensitivity analysis for price fluctuations 
 
• Comparative Cost Analysis 
o Direct comparison of MMS versus IFA costs across all dimensions 
o Incremental cost calculation for transition 
o Cost projections for nationwide scale-up using demographic data 
• Scale-up Modeling 
o Development of three scale-up scenarios (rapid, phased, and capacity-contingent) 
o Cost projections for each scenario with 5-year time horizon 
o Identification of efficiency gains possible at scale 
• Budget Impact Analysis 
o Assessment of fiscal implications for national and provincial health budgets 
o Funding gap analysis for different implementation scenarios 
o Identification of sustainable financing options 
 
Supply Chain Analysis: 
 
• Capacity Assessment 
o Quantification of storage capacity requirements at each level 
o Transportation and logistics capacity mapping 
o Identification of supply chain bottlenecks 
• Risk Assessment 
o Vulnerability analysis of the supply chain 
o Stockout probability modeling 
o Mitigation strategy development 
 
Resource Planning Framework Development:  
• Gap Analysis 
o Identification of critical resource gaps for nationwide implementation 
o Prioritization of gaps based on impact on implementation 
o Development of phased approach to address gaps 
• Sustainability Assessment 
o Evaluation of long-term financial sustainability options 
o Assessment of integration potential within existing systems 
o Development of resource transition plan, policy development plan, and timeline from 
donor to government funding 
Sensitivity Analysis: 
• Compare findings against national cost-effectiveness analysis that is being led by Vitamin Angels 
as part of their Transforming Lives Through Nutrition consortium  
 
Integrated Analysis: This assessment will be triangulated with (1) results from Sections 4.1, 4.2, and 
4.6, (2) MMS stockout data (Section 4.2) to inform supply chain strengthening needs, and (3) user 

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acceptability and adherence findings (Section 4.4) to identify resource implications of overcoming 
barriers.  
 
5. Data Management  
Data will be linked to identifiers to track participants and prevent duplication. Identifiable data will be 
securely stored at Helen Keller offices, accessible only to PIs and Co-PIs. Designated personnel will 
clean and de-identify the data using anonymous ID numbers for analysis, with the process documented. 
All results will be de-identified. 
 
Only authorized research staff with human subjects training will access the data. Paper notes from FGDs 
and KIIs will be securely stored until final analysis. Electronic data will be password-protected, stored 
on ONA, managed in SPSS, and uploaded to secure storage within six months of collection. At project 
completion, electronic data will be transferred to Helen Keller’s country offices, with other copies deleted. 
Hard-copy data will be retained for up to three years before being shredded. 
6. Stakeholder Involvement and Dissemination Plan 
The National MMS Steering Committee will vet this research protocol before implementation. 
Throughout protocol implementation, the committee will be engaged at key decision points and regularly 
updated on the progress and findings. They will receive quarterly progress reports, presentations, 
meetings, and updates on MMS guidelines. They will be able to vet all study findings.  
 
To disseminate study results (i.e., implementation successes, challenges, and health system readiness for 
scale-up) a roundtable discussion can be held with the Helen Keller team, National MMS Steering 
Committee members, and representatives from Takeo provincial and district health departments. 
Participants should have direct involvement in MMS program planning, implementation, supply chain 
management, or delivery at various administrative levels.  
 
Opportunities for community dialogue can be held to share the findings with study participants, including 
pregnant women in Cambodia and their families.  
 
The Helen Keller team can work with the National MMS Steering Committee to create a template to 
translate findings into actionable policy guidance. Together, they can use the ISAT domains to facilitate 
discussion around policy recommendations and sustainability planning to address adaptations for MMS 
scalability and feasibility before it can be rolled out across Cambodia.  
7. Risks and Benefits 
This study has minimal risks for participants. MMS is proven to improve health outcomes for mothers 
and babies, and it is recommended by the World Health Organization. The research methods do not pose 
risk of adverse events.  
8. Ethics and IRB 
Ethical clearance will be sought from the Ministry of Health, National Ethics Committee for Health 
Research. Ethical issues will be considered very carefully throughout the research. Before conducting the 
surveys, participants will receive a clear verbal and written explanation of the research's aim, objectives, 
and purpose. Participants will be informed of their rights, i.e., to participate or not to participate, or to 
drop out from the study or request for their responses not to be used even at the end of the interview if 
they wish. Consent forms will be required for all study participants. All study activities will be done in 
Khmer. The research participants' dignity, rights, value, and safety will be considered carefully during 

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the study process. Privacy and confidentiality of the participants will be maintained throughout the study 
using personal de-identifiers and password-protected data storage and analysis.  
 
9. Timeline 
Figure 2. Proposed timeline of MMS pilot in Takeo province.  
 
 
 
 
 
10. References  
Australian Prevention Partnership Centre. (2019). The Intervention Scalability Assessment Tool: A 
guide for assessing the scalability of health interventions. https://preventioncentre.org.au/wp-
content/uploads/2019/11/The-ISAT-Oct-2019_FINAL.pdf  
 
Bourassa, M.W., Osendarp, S.J.M., Adu-Afarwuah, S., et al. (2019). Review of the evidence regarding 
the use of antenatal multiple micronutrient supplementation in low- and middle-income countries. Ann 
N Y Acad Sci., 1444(1), 6-21. doi: 10.1111/nyas.14121  
 
Cambodia National Institute of Statistics: Ministry of Planning. (2020). General Population Census of 
the Kingdom of Cambodia 2019: National Report on Census Results. 
https://nis.gov.kh/nis/Census2019/Final%20General%20Population%20Census%202019-English.pdf  
 
DHS Program. (2022). Cambodia DHS, 2021-22 Final Report (English). 
https://dhsprogram.com/publications/publication-FR377-DHS-Final-Reports.cfm 
 
Hoang, MA, Kroeun, H., Klemm, R. et al. (2024). Adherence and acceptability of multiple 

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micronutrient supplementation during pregnancy: Study protocol for a cluster-randomized non-
inferiority trial in Cambodia. Trials, 25(289). https://doi.org/10.1186/s13063-023-07891-z 
 
Keats, E. C., Haider, B. A., Tam, E., & Bhutta, Z. A. (2019). Multiple‐micronutrient supplementation 
for women during pregnancy. Cochrane Database of Systematic Reviews, 3. 
https://doi.org/10.1002/14651858.CD004905.pub6  
 
Mei, Z., Jefferds, M.E., Namaste, S., Suchdev, P.S., & Flores-Ayala, R.C. (2017). Monitoring and 
surveillance for multiple micronutrient supplements in pregnancy. Matern Child Nutr.,14(Suppl 5). doi: 
10.1111/mcn.12501  
 
Sauer, C., Hoang, MA, Kroeun, H. et al. (2025). Assessing the adherence to iron and folic acid 
compared with multiple micronutrient supplements during pregnancy: A cluster randomized 
noninferiority trial in Cambodia. American Journal of Clinical Nutrition 2025; 122: 166-173. 
 
United Nations Children’s Fund (UNICEF). (2024). Improving maternal nutrition: An acceleration plan 
to prevent malnutrition and anemia during pregnancy (2024–2025). 
https://www.unicef.org/media/153581/file/Maternal%20nutrition%20acceleration%20plan.pdf 
 
World Health Organization (WHO). (2020). WHO antenatal care recommendations for a positive 
pregnancy experience. Nutritional interventions update: Multiple micronutrient supplements during 
pregnancy. https://www.who.int/publications/i/item/9789240007789  
 
World Health Organization (WHO). (2021). World Health Organization Model List of Essential 
Medicines – 22nd List; 2021. https://iris.who.int/bitstream/handle/10665/345533/WHO-MHP-HPS-
EML-2021.02-eng.pdf?sequence=1