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Background: The World Health Organization recommends daily iron and folic acid (IFA) supplementation during pregnancy, but consumption remains low, and high prevalence of anemia among pregnant women (PW) persists. Objectives: This study aims to (1) examine factors at the health system, community, and individual levels, which influence adherence to IFA supplements; and (2) describe a comprehensive approach for designing interventions to improve adherence based on lessons learned from 4 country experiences. Methods: We conducted literature search, formative research, and baseline surveys in Bangladesh, Burkina Faso, Ethiopia, and India and applied health systems strengthening and social and behavior change principles to design interventions. The interventions addressed underlying barriers at the individual, community, and health system levels. Interventions were further adapted for integration into existing large-scale antenatal care programs through continuous monitoring. Results: Key factors related to low adherence were lack of operational protocols to implement policies, supply chain bottlenecks, low capacity to counsel women, negative social norms, and individual cognitive barriers. We reinforced antenatal care services and linked them with community workers and families to address knowledge, beliefs, self-efficacy, and perceived social norms. Evaluations showed that adherence improved in all countries. Based on implementation lessons, we developed a program pathway and details of interventions for mobilizing health systems and community platforms for improving adherence. Conclusion: A proven process for designing interventions to address IFA supplement adherence will contribute to achieving global nutrition targets for anemia reduction in PW. This evidence-based comprehensive approach may be applied in other countries with high anemia prevalence and low IFA adherence. Plain language title: Designing Comprehensive Interventions to Improve the Consumption of Prenatal Iron and Folic Acid Supplements in Low- and Middle-Income Countries Plain language summary: Anemia among women of reproductive age, particularly during pregnancy, is widespread, but there are remedies such as iron and folic acid (IFA) supplements that can increase iron intake. This study documents the barriers faced by pregnant women (PW) in adhering to daily IFA supplementation as recommended by the World Health Organization. We designed interventions for large-scale antenatal care programs to improve adherence in Bangladesh, Burkina Faso, Ethiopia, and India. The barriers included poor supplies, lack of counseling during antenatal visits, and insufficient community and family support for PW. We strengthened service delivery protocols and the capacity of community workers to engage families. We trained health workers, improved supervision and counseling quality, strengthened supply systems for IFA tablets, and facilitated family support for PW. We improved women's knowledge, beliefs, self-efficacy, and perception of social norms through interventions tailored for each country setting. Considering the high burden of anemia in low- and middle-income countries among women especially during pregnancy and health consequences for mothers and newborns of low iron intake, decision makers and implementers need to pay greater attention to understanding local barriers to adherence and designing interventions that can improve adherence. Social and behavioral science theories and health systems strengthening frameworks provide a strong technical basis for designing effective interventions to improve IFA adherence. [ABSTRACT FROM AUTHOR]

Abstract: Reducing health inequities and improving the health of communities require an informed public that is aware of the social determinants of health and how policies and programs have an impact on the health of their communities. People Assessing Their Health (PATH) is a process that uses community-driven health impact assessment to build the capacity of people to become active participants in the decisions that affect the well-being of their community. The PATH process is both a health promotion and a community development approach that builds people''s ability to bring critical analysis to a situation and to engage in effective social action to bring about desired change. Because it increases analytical skills and provides communities with their own unique tool to assess the potential impact of projects, programs or policies on the health and well-being of their community it is an empowering process. PATH was originally used in three communities in northeastern Nova Scotia, Canada in 1996 when the Canadian health care system was being restructured to a more decentralized system. Since then it has been used in other communities in Nova Scotia and India. This paper will describe the PATH process and the use of the community health impact assessment as well as the methodology used in the PATH process. The lessons learned from PATH''s experiences of building capacity among the community in Canada and India will be presented. [Copyright &y& Elsevier]