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Soc Sci Med. 1994 Aug;39(3):381-90.

Determinants of compliance with iron supplementation: supplies, side effects, or psychology?

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Population, Health and Nutrition Department, World Bank, Washington, DC 20433.


Iron deficiency anemia affects over 2 billion people. Particularly at risk are pregnant women and young children. Although distribution of iron supplements is practised in many antenatal care programs in developing countries, it has often been alleged that pregnant women do not take them. Poor compliance arises not only because of patient behavior but also from factors out of the patient's control. This paper presents the results of a review of the literature on medical compliance to determine whether iron supplementation is different from other medications, to assess the known levels of compliance, and to synthesize recommendations for improving compliance relevant to iron supplementation. The review showed that compliance with iron therapy is a specific case of medical compliance. Reasons for non-compliance with iron deficiency treatment include: inadequate program support (lack of political commitment and financial support); insufficient service delivery (poor provider-user dynamics; lack of supplies, access, training, and motivation of health care professionals); and patient factors (misunderstanding instructions, side effects, frustration about the frequency and number of pills taken, migration, fear of having big babies, personal problems, nausea that accompanies pregnancy, and the subtlety of anemia which makes demand for treatment low). Much has been made about the side effects (nausea, constipation, etc.) that women might experience during iron therapy as the cause of poor compliance with iron supplementation without justification according to this review. Instead, unavailability of iron supplements was the most common reason why women did not take iron supplements. Women bear a disproportionate burden from iron deficiency anemia even though the technology exists to address the problem at low cost. Governments and health care professionals must renew their commitment to iron therapy by monitoring and improving compliance. We can significantly improve compliance by: making sure that iron supplements are available at all times; providing advanced warning about the possibility of side effects; involving the patient in the therapeutic strategy; and providing reminders, such as posters and calendars, about taking supplements.

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