Social Support Enhances Adherence to Antenatal Calcium and Iron‐Folic Acid Supplements: Acceptability and Impact of Adherence Partners
Authors: Martin Stephanie , Omotayo Moshood , Stoltzfus Rebecca , Dickin Katherine 
Published: November 2023

WHO now recommends integrating calcium (Ca) supplementation into antenatal care (ANC) along with iron‐folic acid (IFA) to reduce maternal mortality. Pregnant women often list forgetting as a barrier to IFA adherence, a problem that will likely be exacerbated by the addition of multiple Ca supplements. Adherence partners (APs) are a novel behavior change strategy that leverages existing social support to improve adherence. Pregnant women identify APs from their social network (e.g., spouse, relative) and ask the AP to remind them to take their supplements. Embedded within a cluster‐randomized trial on adherence to different antenatal Ca regimens in western Kenya, the objective of this research was to investigate the acceptability and impact of APs for improving adherence. The study team trained ANC providers on Ca and IFA supplementation and counseling, provided counseling cards for providers and AP posters for women to take home, and ensured sufficient supplement supplies at health facilities. Pregnant women seeking ANC from 16 government health facilities were recruited (n=951) and demographic, psychosocial, and adherence data were collected during an exit interview and follow‐up visits at 4 and 8 weeks. Adherence was measured with pill counts and culturally‐adapted scales were used to measure general and adherence‐specific social support. Relationships between participant characteristics and AP status were tested using chi‐square and t‐tests and linear models were used to explore factors associated with adherence. Almost all participants (90%) asked someone to be their AP; most asked their husbands. Those who did not ask someone to be their AP had lower general social support and lower adherence self‐efficacy. Women with APs reported significantly higher mean adherence‐specific social support scores than those without (p<.0001). In linear regression models, adherence‐specific social support satisfaction scores were positively associated with Ca (p=0.044) and IFA (p=0.011) adherence at 4‐weeks. The AP actions reported to be most helpful were: reminding (67%), providing food (21%), or bringing pills (10%); only 2% reported their APs did not help them. At 8 weeks, 87% of participants were “very satisfied” with the support they had received from their APs; and 97% wanted their APs to continue helping them throughout pregnancy. APs were highly acceptable among this population and adherence‐specific social support was associated with improved adherence to Ca and IFA supplementation. Lower AP uptake among women with less support and confidence suggests additional targeted strategies may be needed to support adherence among these women. This research demonstrates the importance of adherence‐specific social support and the potential of low‐cost social support strategies, such as APs, to increase adherence and effectiveness of micronutrient supplementation programs.Support or Funding InformationFunding for this research was provided by the Micronutrient Initiative and the Sackler Institute for Nutrition Science at the New York Academy of Sciences