title: How can formative research inform the design of an iron-folic acid supplementation intervention starting in first trimester of pregnancy in Bangladesh?
abstract: BACKGROUND
  The study objective was to understand community preparedness for iron and folic acid (IFA) supplementation early in pregnancy and to inform the design of a large-scale trial of early introduction of IFA supplementation in rural Bangladesh.
  
  
  METHODS
  66 in-depth interviews (pregnant women, husbands, and older women in the household), 20 key-informant interviews, 3 focus-group discussions (community health workers and adolescent female students), and observation of two community-based clinics were conducted.
  
  
  RESULTS
  Most of the women who used IFA tablets during pregnancy reported better health and physical strength after taking them. Women perceived that IFA increased blood volume, leading to foetal nourishment and compensated for blood loss during delivery. However, a culturally informed perceived barrier was the belief that IFA supplementation will increase foetus size, leading to birth complications, hospitalisation, caesarean section and financial burden for the family. Community health workers (CHWs) of BRAC (a non-government organisation) were the main sources of IFA information and supplements, although knowledge of IFA tablets among women's social networks also helped to make it acceptable. Pregnant women felt that they could start taking IFA during the first trimester of pregnancy if advised by the CHWs. Programme managers and healthcare providers expressed concern about starting IFA supplementation early.
  
  
  CONCLUSIONS
  Our study suggests that introduction of IFA supplementation early in pregnancy is feasible with support from CHWs. Promotion of IFA could benefit from efforts to include culturally sensitive reasons for usage; improvement of the CHW training modules; targeted home visits and counselling; and outreach to standardize messages.
authors.affiliation: Sydney School of Public Health, The University of Sydney, Sydney, NSW, 2006, Australia. neeloy.alam@sydney.edu.au.
authors.forename: Ashraful
authors.initials: A
authors.lastname: Alam
authors.affiliation: International Centre for Diarrhoeal Disease Research, Bangladesh, GPO Box 128, Dhaka, 1000, Bangladesh. sabrina1@icddrb.org.
authors.forename: Sabrina
authors.initials: S
authors.lastname: Rasheed
authors.affiliation: International Centre for Diarrhoeal Disease Research, Bangladesh, GPO Box 128, Dhaka, 1000, Bangladesh. nazib@icddrb.org.
authors.forename: Nazib U Z
authors.initials: NU
authors.lastname: Khan
authors.affiliation: International Centre for Diarrhoeal Disease Research, Bangladesh, GPO Box 128, Dhaka, 1000, Bangladesh. tamanna@icddrb.org.
authors.forename: Tamanna
authors.initials: T
authors.lastname: Sharmin
authors.affiliation: International Centre for Diarrhoeal Disease Research, Bangladesh, GPO Box 128, Dhaka, 1000, Bangladesh. thuda@icddrb.org.
authors.forename: Tanvir M
authors.initials: TM
authors.lastname: Huda
authors.affiliation: International Centre for Diarrhoeal Disease Research, Bangladesh, GPO Box 128, Dhaka, 1000, Bangladesh. shams@icddrb.org.
authors.forename: Shams E
authors.initials: SE
authors.lastname: Arifeen
authors.affiliation: Sydney School of Public Health, The University of Sydney, Sydney, NSW, 2006, Australia. michael.dibley@sydney.edu.au.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Dibley
mesh_terms: D000328:Adult; D000368:Aged; D018798:Anemia, Iron-Deficiency / Q000517:prevention & control*; D001459:Bangladesh; D019587:Dietary Supplements; D005260:Female; D005492:Folic Acid / Q000627:therapeutic use*; D005494:Folic Acid Deficiency / Q000517:prevention & control*; D006801:Humans; D007501:Iron / Q000097:blood; D018977:Micronutrients / Q000627:therapeutic use; D008875:Middle Aged; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D011247:Pregnancy; D011261:Pregnancy Trimester, First / Q000502:physiology*; D012424:Rural Population / Q000706:statistics & numerical data*; D055815:Young Adult
chemical_list: D018977:Micronutrients; D005492:Folic Acid; D007501:Iron