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Compliance with Weekly Iron and Folic Acid Supplementation and Its Associated Factors among Adolescent Girls in Tamale Metropolis of Ghana

Compliance with Weekly Iron and Folic Acid Supplementation and Its Associated Factors among... Hindawi Journal of Nutrition and Metabolism Volume 2019, Article ID 8242896, 12 pages https://doi.org/10.1155/2019/8242896 Research Article Compliance with Weekly Iron and Folic Acid Supplementation and Its Associated Factors among Adolescent Girls in Tamale Metropolis of Ghana 1 2 3 1 S. Dajaan Dubik , Kingsley E. Amegah, Amshawu Alhassan, Louis N. Mornah, and Loveland Fiagbe Department of Nutritional Sciences, University for Development Studies, Box TL 1350, Tamale, Northern Region, Ghana Department of Health Information, Hohoe Municipal Hospital, Hohoe, Volta Region, Ghana Savelugu/Nanton Municipal Health Directorate, Ghana Health Service, Savelugu, Northern Region, Ghana Kete-Krachi District Health Directorate, Ghana Health Service, Kete-Krachi, Volta Region, Ghana Correspondence should be addressed to S. Dajaan Dubik; stephendubik@gmail.com Received 6 August 2019; Revised 2 November 2019; Accepted 29 November 2019; Published 11 December 2019 Academic Editor: C. S. Johnston Copyright © 2019 S. Dajaan Dubik et al. (is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. In Ghana, anaemia is a severe public health problem among adolescent girls. In an attempt to deal with this phenomenon, Ghana Ministry of Health in collaboration with other development partners developed and launched weekly iron and folic acid supplementation program for adolescent girls in Ghanaian junior high schools. (erefore, the main aim of this study was to determine the level of compliance with iron and folic acid supplementation (IFAS) and its associated factors among adolescent girls in the Tamale Metropolis of Ghana. Methods. A cross-sectional study was conducted among 424 randomly sampled adolescent girls in the Tamale Metropolis of Ghana from April to July 2019 using an interviewer-administered structured questionnaire. Twenty school health coordinators were purposively selected to answer questions on the challenges they face in implementing the IFAS program at the school level. Bivariate logistic regression and multivariate logistic regression were used to determine associations and strength of associations, respectively, at a significant threshold of p< 0.05. Results. Compliance with the IFAS was low (26.2%). Adolescent girls who were aware of anaemia (AOR � 3.57 (95% CI: 1.96, 6.51) p< 0.01), had good knowledge of anaemia (AOR � 1.82 (95% CI: 1.17, 2.81) p � 0.01), and had good knowledge of the IFAS program (AOR � 2.29 (95% CI: 1.47, 3.57) p< 0.01) were significantly associated with compliance with the IFAS. (e majority (60%) of the adolescent girls have ever missed taking the iron and folic acid (IFA) tablet because it was not issued to them by the teacher’s concern while about 48.3% (169) of the adolescent girls are taking the tablet because it prevents anaemia. Adolescent girls perceiving the tablet as family planning medicine (88.8%) and unavailability of water in classrooms (18.8%) were cited as the major challenges by school health coordinators. Conclusion. Compliance with the IFAS among adolescent girls was low. Level of education and occupation of mothers of adolescent girls, awareness on anaemia, and good knowledge of anaemia and of the IFAS program were significant predictors of compliance with the IFAS. Educating the adolescent girls on anaemia and benefits of the IFAS, constant supply of the IFA tablet, and engaging parents of the adolescent girls on the program will help improve the compliance level of the adolescent girls with the IFAS. adulthood, is characterized by intense growth resulting in 1. Introduction behavioural and sexual maturity in an individual [2]. It is the In developing countries, anaemia is a major public health second growth spurt of life where girls undergo different problem of not only pregnant women or children but also experiences. During adolescence, there is an increased de- adolescent girls [1]. Adolescence, a period of transition to mand for nutrition especially iron requirements [2]. 2 Journal of Nutrition and Metabolism weekly IFAS program in order to meet the challenge of the Adolescence is also considered as a golden time for in- terventions to curb anaemia. It also presents the right time high prevalence of anaemia among adolescent girls in Ghana. However, the major problem with the IFAS program for building a nutrition foundation for child bearing in later life [3]. is compliance with several interacting factors that still re- Globally, anaemia is affecting about 1.62 billion people main unclear in our study area [16]. Furthermore, the IFAS worldwide and approximately half of all anaemia can be program is relatively new among adolescent girls in Ghana. attributed to iron deficiency. Children, pregnant women, (erefore, the aim of this study was to determine the level of and women of reproductive age are greatly affected [4]. (e compliance with the IFAS and its influencing factors among number of nonpregnant women of reproductive age affected adolescent girls in the Tamale Metropolis of Ghana. (e specific aims of the present study were to (1) determine by anaemia increased from 464 million in 2000 to 578 million in 2016 across the globe. Africa and Asia are the compliance level of the adolescent girls with the IFAS, (2) assess factors influencing compliance with the IFAS, (3) hardest hit with the prevalence of over 35% and therefore require increased efforts to curb the problem [5]. determine the adolescent girls’ level of knowledge on anaemia and the IFAS, and (4) assess challenges faced by Worldwide, it is estimated that the absence of investment in prevention of anaemia would result in 265 million more teachers in implementing the program at the school level. cases of anaemia in women including adolescent girls by 2025 and nearly 800,000 more child deaths and 7,000–14,000 2. Methods more maternal deaths [6]. Anaemia, a direct indication of undernutrition and poor 2.1. Study Area and Design. A cross-sectional study was dietary intake of iron, is a serious public health problem conducted using quantitative data collection methods from among adolescent girls [2]. Adolescent girls are at greater April to July 2019 among adolescent girls in twenty selected risk of iron deficiency and anaemia due to increased growth, junior high schools in the Tamale Metropolis of Ghana. poor dietary intake of iron, low bioavailability of dietary Tamale Metropolis is geographically located between lati- ° ° ° ° iron, and high rate of infectious diseases, parasitic infections, tude 9 16 and 9 34 North and longitudes 0 36 and 0 57 and menstrual blood loss [7]. Iron deficiency anaemia occurs West. Tamale Metropolis is one of the 14 Districts in the more often in adolescent girls than in adolescent boys. (is is Northern Region. It is located in the central part of the due to excessive loss of iron during menstruation. Moreover, region and shares boundaries with Sagnarigu, Mion, East the risk of anaemia in adolescent girls is increased by poor Gonja, and Central Gonja districts. (e Metropolis has a literacy, ignorance, and lack of knowledge about iron de- total estimated land size of 646.90180 km [17]. According to ficiency [8]. the Ghana 2010 population and housing census, Tamale Anaemia has serious consequences; it can lead to poor Metropolis has a population of 233,252 constituting 49.7% school performance among schoolchildren, impaired males and 50.3% females. Among those aged 3 years and physical growth, and poor cognitive development, thereby older and are currently attending school, 18.2% are in junior hindering development socially and economically [4]. high schools. (e metropolis has 112 junior high schools Anaemia can also leave adolescent girls physically inactive, [17]. hindering their progress in school and ultimately causing them to drop out of school [3]. (e ultimate aim of man- aging anaemia is to help elevate the haemoglobin level of the 2.2. 0e Weekly IFAS Program among Adolescent Girls in individual concern, and this is mostly done through iron Ghana. In Ghana, IFAS has been for only pregnant women therapy and blood transfusion [9]. However, at the pop- neglecting adolescent girls [3]. Weekly IFAS program which ulation level, iron deficiency anaemia can be tackled through is the first of its kind in Ghana among adolescent girls was deworming, iron supplementation, fortification of foods launched in 2017 by Ghana Ministry of Health with support with micronutrients, and proper dietary education with from development partners such as UNICEF and WHO. (e improved food security [3, 10]. initiative is expected to reach about 360,000 girls in junior In Ghana, the prevalence of anaemia among adolescent and senior high schools and 600,000 girls who are out of girls is unacceptably high. Data from the Ghana De- school [18]. mographic Health Survey (GDHS) indicate a high preva- (e IFAS program is in the pilot phase in four of the ten lence of 48% among adolescent girls [11]. Iron and folic acid regions, namely, Northern Region, Brong Ahafo Region, and supplementation are known as the most cost-effective way of Upper West and Upper East regions with the main aim of improving the iron status of adolescent girls in developing contributing to the reduction of anaemia among adolescent countries [8]. (erefore, constant use of iron and folic acid girls. About 4,500 school health coordinators who are supplements together with a diet rich in micronutrients is teachers in the participating schools and 3,000 health essential for the prevention of iron deficiency anaemia workers have been trained to support the implementation of among adolescent girls [2]. In addition, the effectiveness of the program [18]. Teachers are expected to encourage ad- weekly supplementation of IFA in preventing anaemia olescent girls in school to take one supplement (60 mg of among adolescent girls has been documented in several elemental iron and 400 μg (0.4 mg) of folic acid) every studies [12–15]. Taking cognizance of this, Ghana Ministry Wednesday in a week at noon. Community health workers of Health in 2017 with support from the Ministry of Edu- are expected to assist girls who are out of school to take the cation and other development partners has launched a tablet [3]. Journal of Nutrition and Metabolism 3 questionnaires which were mostly closed-ended with mul- 2.3. Study Population. All Adolescent girls attending junior high school in Tamale Metropolis were the source population. tiple choice and dichotomous responses were divided into sections and administered to both adolescent girls and (e study population consisted of randomly sampled girls who were attending junior high school in the study area in the teachers. Section A consisted of 8 questions to elicit in- third term of the 2018/2019 academic year. Girls who were formation on sociodemographic characteristics of the ad- absent and those who declined to answer the research olescent girls and section B was made of 9 questions to questions were excluded from the study. School health co- determine compliance level of the adolescent girls with the ordinators of the 20 schools also participated in the study. IFAS whereas section C consisted of 16 questions which sought to assess the level of knowledge of the adolescent girls of anaemia and of the IFAS program. Section C also sought 2.4. Sample Size Determination and Sampling Procedures. to find out the side effects experienced by adolescent girls. (e sample size was determined using Cochran’s formula Section D which was the only section administered to the N � (Z2 × p(1 − p))/d2 [19] with 95% confidence interval teachers sought to determine the challenges faced by and 5% margin error with assumed compliance rate of 50%, teachers in implementing the IFAS program at the school where N is the sample size, Z (statistic) � 1.96, p (compliance level. Data collection was done by two community health rate) � 0.5, and d (margin of error) � 0.05: nurses and two masters students in public health nutrition. (1.96)2 × 0.5(1 − 0.5) One-day training was organized for the data collectors by the (1) n � � 384.16. (0.05)2 principal investigator. (ey were trained on objectives of the study, how to ensure confidentiality of the data, and how to (e IFAS program is relatively a new program among fill the questionnaires. (ey were also trained on how to adolescent girls in Ghana, hence the justification for the initiate the interview process by reading the informed assumed compliance rate for the sample size calculation. (e consent to every respondent for voluntary participation. calculated sample size was therefore 385. After adding a 10% After data collection, the principal investigator reviewed nonresponse rate, the final sample size obtained was 424 each questionnaire in order to ensure the accuracy and research participants. completeness of the data collected. Simple random sampling was used to select the schools and the adolescent girls while purposive sampling was used to select the school health coordinators. Twenty schools were 2.6. Statistical Analysis. (e quantitative data were coded selected using lottery method. (e names of all junior high and analysed using STATA 14.1. Sociodemographic char- schools in the metropolis were written on pieces of papers acteristics, level of compliance, and knowledge of anaemia and placed in a bowl. With blind draw, the schools were and of the IFAS program were first presented in text, figures, randomly picked one by one without replacement until 20 and tables using descriptive statistics such as frequencies and schools were reached. (e final sample size of 424 was percentages. Bivariate logistic regression test was done to proportionally allocated to the 20 schools based on the determine the association between the sociodemographic enrolment of girls in each school. (e study participants characteristics and the outcome variables (compliance level, were selected from each class through simple random knowledge of anaemia, and knowledge of the IFAS pro- sampling using random numbers generated for each class gram). Logistic regression analysis was also done to de- using the girls attendance register. Twenty school health termine the effect of awareness of anaemia, knowledge of coordinators in the selected schools were purposively anaemia, and knowledge of the IFAS program on compli- sampled to participate in the study. ance level. Multivariate logistic regression was further done for variables that were statistically significant after the bi- 2.5. Data Collection. (e data collection tool used in col- variate analysis. Crude and adjusted odds ratios with their respective confidence intervals (95%) were computed to lecting the research data was structured pretested ques- determine the strength of association of each variable. tionnaires while data collection was done with the help of IFAS compliance level was measured based on the interviewer-assisted questionnaire administration. Pretest- number of tablets consumed in the past 7 weeks. Adolescent ing of the data collection tool was done in Sagnerigu Mu- girls who consumed at least five tablets of the expected dose nicipality since it shares similar characteristics with the study in the previous 7 weeks (1 tablet per week) which is area. (e data collection tool was adapted and modified from similar published studies [1, 2, 7, 20]. (e adoption of the equivalent to consuming 70% of the expected dose before the day of the data collection was considered compliant. Ado- data collection tool from similar published studies was to ensure the validity of the data collection tool. (irty ado- lescent girls who consumed less than five tablets were considered noncompliant [16]. Records kept by the school lescent girls were conveniently chosen in one school for the pretesting of the data collection tool. Pretesting was done to health coordinators were used to validate each respondent’s compliance status. ensure the reliability of the data collection tool. Questions Knowledge on anaemia was measured by summing up that gave responses that were not certain were reframed and 19 relevant knowledge items on anaemia (1 item on the tested again on the same respondents to ensure their meaning of anaemia, 4 items on causes of anaemia, 6 items reliability. on signs and symptoms of anaemia, 4 items on consequences A prior appointment was taken from headmasters and of anaemia, and 4 items on prevention of anaemia). A correct health coordinators of the selected schools. (e 4 Journal of Nutrition and Metabolism Table 1: Sociodemographic characteristics of respondents. response was scored “1” and an incorrect response was scored “0” with a maximum score of 19. (ose who scored above the Variables Frequency, N � 424 Percent (%) median mark were considered as having good knowledge of Mean age (SD) 14.4 (1.7) anaemia while those who scored below the median mark were Age group (years) considered as having poor knowledge [16]. 10–15 338 79.7 Knowledge of the IFAS program was scored by summing 16–20 86 20.3 up 15 relevant knowledge items on the IFAS program: one item Class on why they are given the tablet, 4 items on benefits of taking JHS 1 197 46.5 IFA tablet, 3 items on food that inhibits iron and folic acid JHS 2 227 53.5 absorption, 5 items on side effects of taking IFA tablets, and 2 Ethnicity items on why girls are given the iron and folic acid tablet. A Dagomba 288 67.9 correct answer was scored “1” and an incorrect answer was Mamprusi 24 5.7 scored “0”. With a maximum score of 15, those who scored Others 112 26.4 above the median mark were considered having good knowl- Religion edge on the IFAS program while those who scored below the Christianity 112 26.4 median mark were considered as having poor knowledge [21]. Islam 312 73.6 Mother’s level of education No formal education 204 48.1 2.7. Ethical Consideration. Ethical clearance for the study Basic 100 23.6 was sought from the University for Development Studies. Secondary 60 14.2 Approval letter for the study was granted by Ghana Health Tertiary 60 14.2 Service while permission to go into the school was obtained Father’s level of education from the Tamale Metropolitan Education Office. Informed No formal education 190 44.8 assent was obtained from underaged participants in their Basic 50 11.8 schools while informed consent was obtained from the Secondary 78 18.4 parents of the girls. Selected girls were given informed Tertiary 106 25.0 consent forms for their parents to thumbprint/sign signalling Mother’s occupation their agreement for their child to participate in the study. Unemployed 56 13.2 Public/civil servant 135 31.8 Trader 220 51.9 3. Results Retired 13 3.1 3.1. Sociodemographic Characteristics of the Adolescent Girls. Father’s occupation (e total number of respondents in this current study was Unemployed 21 5.0 424 with a mean age (SD) of 14.4 (±1.7). Majority (79.7%) of Public/civil servant 195 46.0 Farmer 185 43.6 the respondents had their ages ranging between 10 and 15 Retired 23 5.4 years with over half (53.5%) in junior high school two. Majority (67.9%) of the adolescent girls were Dagombas with 73.6% of them affiliated to the Islamic religion. Most (48.1%) reason for ceasing to take the IFA tablet. About 82.5% of the of the respondents’ mothers had no formal education while adolescent girls have ever missed taking the IFA tablet in very few (14.2%) had tertiary education, and about half school. Most (60%) of the adolescent girls have ever missed (51.9%) of the respondents’ mothers were petty traders. taking the IFA tablet because it was not issued to them by the Twenty-five percent of the respondents’ fathers had tertiary teacher’s concern while another 28.9% cited the fact that education while most (44.8%) of them had no formal edu- they were absent from school. Among those who have ever cation with 46% of them being public/civil servants (Table 1). taken the tablet, 73.1% always take the tablet in the presence of the teacher (Table 2). 3.2. Compliance with the IFAS. Overall compliance with the A Pearson’s chi-square test with a significant threshold IFAS in this current study was 26.2%. Only 26.2% (111) of of p< 0.05 established that the mother’s level of education 2 2 the adolescent girls consumed 5 or more tablets in the past 7 (χ �15.65, p< 0.01) and mother’s occupation (χ �10.30, weeks prior to the data collection. Majority (90.1%) of the p � 0.02) were significantly associated with adolescent girls adolescent girls took the IFA tablet on the first day it was level of compliance (Table 3). Respondents whose mothers given by the teachers. About 82.5% of the adolescent girls are had secondary education were 2.1 times more likely to still consuming the IFA tablet in school while the rest comply with the IFAS as compared to those respondents (17.4%) stopped consuming the IFA tablet. Among those whose mothers had no formal education (OR � 2.14 (95% CI: currently taking the IFA tablet in school, most (48.3%) cited 1.17, 3.29) p � 0.01). (e odds of compliance with the IFAS the prevention of anaemia as the reason for taking the IFA among respondents whose mothers were traders were 56% tablet while another 41.1% cited advice from their teacher. times lower compared to those respondents whose mothers Among those who stopped taking the IFA tablet in school, were unemployed (AOR � 0.44 (95% CI: 0.23, 0.85) 90.5% (67) cited the fact that their parents ask them not to p � 0.01) (Table 4). Good knowledge of anaemia (OR � 1.82 take the tablet while another 5.4% (4) cited side effects as the (95% CI: 1.17, 2.81) p � 0.01) and good knowledge of the Journal of Nutrition and Metabolism 5 Table 2: Compliance with IFAS among adolescent girls. mention anaemia as low blood level and hence were considered aware of anaemia. About 67.9% of the adolescent girls have Frequency, Percent Variables never received education on anaemia. (ose (32.1%) who have N � 424 (%) ever received education on anaemia cited teachers (85.3%) and Took IFA tablet on the first day health workers (14.7%) as their sources of anaemia education. No 42 9.9 Yes 382 90.1 Currently taking IFA tablet in school 3.5. Factors Associated with Adolescent Girls’ Level of No 74 17.5 Knowledge on Anaemia. In this current study, it was shown Yes 350 82.5 that more than half (56.8%) of the adolescent girls had poor Reasons for taking IFA tablet knowledge on anaemia while 43.2% had good knowledge of Advice from teacher 144 41.1 anaemia (Figure 2). Pearson chi-square test with a significance Because it is free 12 3.4 threshold of p< 0.05 found no statistically significant asso- Friends are taking it 25 7.1 ciation between respondent sociodemographic characteristics It prevents anaemia 169 48.3 and knowledge on anaemia except for the occupation of Reasons for not taking the tablet 2 fathers of the respondents (χ �11.46, p< 0.01). Respondents Fear of side effects 4 5.4 whose fathers were public/civil servants were found to be 4.4 My parents ask me not to take the 67 90.5 times more likely to have good knowledge on anaemia as tablet compared to those pupils whose fathers were unemployed l feel healthy 3 4.1 (OR � 4.4 (95% CI: 1.4, 13.5) p � 0.01) (Table 6). Number of IFA tablets taken in the past 7 weeks <5 tablets 313 73.8 3.6. Adolescent Girls’ Level of Knowledge on the IFAS Program. ≥5 tablets 111 26.2 Most (64.9%) of the adolescent girls were found to have poor Always takes IFA tablet under knowledge of the IFAS program while 35.1% were found to supervision have good knowledge of the IFAS program (Figure 3). No 114 26.9 Pearson chi-square test with a significance threshold of Yes 310 73.1 p< 0.05 found out that mother’s level of education (χ � 9.92, Ever missed taking IFA tablet in p< 0.02), mother’s occupation (χ � 8.39, p< 0.04), and fa- school ther’s occupation (χ �10.88, p< 0.01) of the respondents No 74 17.5 were statistically significant with adolescent girls’ level of Yes 350 82.5 knowledge on the IFAS program (Table 7). Respondents Reasons for missing whose mothers had secondary education were 2.1 times more Bad taste of tablet 23 6.6 likely to have good knowledge of the IFAS as compared with I was absent 101 28.9 those whose mothers had no formal education (OR � 2.1 (95% Side effects 16 4.6 CI: 1.16, 3.77) p � 0.01). Again, respondents whose fathers I was not given IFA tablet 210 60.0 were unemployed were 75% times less likely to have good knowledge of the IFAS program as compared to those re- IFAS program (OR � 2.29 (95% CI: 1.47, 3.57) p< 0.01) were spondents whose fathers were public/civil servants (OR � 0.25 also significant determinants of compliance with the IFAS. A (95% CI: 0.07, 0.88) p � 0.03). logistic regression analysis found out that the odds of After adjusting for the effect of all confounding variables compliance with the IFAS were 3.6 times more likely among in a logistic regression model, the mother’s education adolescent girls who were aware of anaemia compared to remained statistically significant. Respondents whose adolescent girls who were not aware of anaemia (AOR � 3.57 mothers had secondary education were 2.2 times more likely (95% CI: 1.96, 6.51) p< 0.01) (Table 5). to have good knowledge of the IFAS program as compared to those respondents whose mothers had no formal edu- cation (OR � 2.19 (95% CI: 1.81, 4.07) p � 0.01) (Table 8). 3.3. Perceived Benefits of Taking the IFA Tablet as Reported by Adolescent Girls. With multiple responses possible, majority (81.8%) of the adolescent girls cited regulation of men- 3.7. Side Effects Reported by the Adolescent Girls. With struation as the benefit they have gotten from taking the IFA multiple responses possible, most (78.8%) of the re- tablet and 77.8% thinks the IFA tablet has helped to improve spondents reported that there were no side effects associated their concentration and performance in class while over with the consumption of the IFA tablet. Some (10.9%) stated 18.2% cited reduced dizziness as the benefit they have gotten stomach/abdominal pains as the side effect they experienced from taking the IFA tablet (Figure 1). with the consumption of the IFA tablet while few cited nausea (8.3%) (Figure 4). 3.4. Awareness of Anaemia among Adolescent Girls. About 247 (58.2%) of the respondents claimed they have ever 3.8. Challenges Faced by Teachers in Implementing the IFA heard of a disease where the affected person is said to have low Supplementation Program. At the time of our visit, about blood level, and only 30.7% (130) were able to correctly 70% of the schools had IFA tablets in stock with school health 6 Journal of Nutrition and Metabolism Table 3: Sociodemographic characteristics and compliance level among adolescent girls. Compliance with IFAS Dependent Chi-square variables Noncompliance Compliance Total, N � 424 (p value) Age group (years) 10–15 256 (75.7) 82 (24.3) 338 (100) 3.18 (0.08) 16–19 57 (66.3) 29 (33.7) 86 (100) Class JHS 1 143 (72.6) 54 (27.4) 197 (100) 0.29 (0.59) JHS 2 170 (74.9) 57 (25.1) 227 (100) Ethnicity Dagomba 212 (73.6) 76 (26.4) 288 (100) 0.03 (0.99) Mamprusi 18 (75) 6 (25) 24 (100) Others 83 (74.1) 29 (25.9) 112 (100) Religion Christianity 77 (68.8) 35 (31.3) 112 (100) 2.03 (0.16) Islam 236 (75.6) 76 (24.4) 312 (100) Mother’s level of education No formal education 153 (75) 51 (25) 204 (100) 15.65 (<0.01) Basic 85 (85) 15 (15) 100 (100) Secondary 35 (58.3) 25 (41.7) 60 (100) Tertiary 40 (66.7) 20 (33.3) 60 (100) Father’s level of education No formal education 145 (76.3) 45 (23.7) 190 (100) 6.03 (0.11) Basic 42 (84) 8 (16) 50 (100) Secondary 53 (67.9) 25 (32.1) 78 (100) Tertiary 73 (68.9) 33 (31.1) 106 (100) Mother’s occupation Unemployed 35 (62.5) 21 (37.5) 56 (100) 10.30 (0.02) Public/civil servant 94 (69.6) 41 (30.4) 135 (100) Trader 176 (80) 44 (20) 220 (100) Retired 8 (61.5) 5 (38.5) 13 (100) Father’s occupation Unemployed 18 (85.7) 3 (14.3) 21 (100) 7.81 (0.05) Public/civil servant 132 (67.7) 63 (32.3) 195 (100) Farmer 146 (78.9) 39 (21.1) 185 (100) Retired 17 (73.9) 6 (26.1) 23 (100) Table 4: Association between the odds of sociodemographic characteristics and compliance level among adolescent girls. Unadjusted Adjusted Independent variables Frequency (%) OR 95% CI p value OR 95% CI p value Mother’s education No formal education 204 (48.1) Reference Basic 100 (23.6) 0.53 0.28, 1.00 0.05 0.51 0.27, 0.96 0.04 Secondary 60 (14.2) 2.14 1.17, 3.29 0.01 1.96 1.06, 3.63 0.03 Tertiary 60 (14.2) 1.50 0.80, 2.80 0.20 1.24 0.62, 2.48 0.54 Mother’s occupation Unemployed 56 (13.2) Reference Public/civil servant 135 (31.8) 0.73 0.34, 0.38 0.34 0.69 0.34, 1.42 0.32 Trader 220 (51.9) 0.42 0.22, 0.79 0.01 0.44 0.23, 0.85 0.01 Retired 13 (3.1) 1.04 0.30, 3.60 0.95 1.08 0.30, 3.92 0.90 coordinators (95%) in charge of issuing the IFA tablet to the limited time as one of the reasons for their inability to educate adolescent girls. About 45% (9) of the school health co- the adolescent girls on anaemia and on the IFAS program. ordinators have never educated the adolescent girls on anaemia A significant number (70%, 14) of the school health and on the IFAS program. Among those who have never coordinators were not able to organize training for their educated the adolescent girls on anaemia, 77.8% (7) cited colleague teachers with half (50%, 7) of them citing the fact Journal of Nutrition and Metabolism 7 Table 5: Factors associated with IFAS compliance level among adolescent girls. Unadjusted Adjusted Independent variables Frequency (%) OR 95% CI p value OR 95% CI p value Awareness of anaemia No 294 (69.3) Reference Yes 130 (30.7) 4.04 2.25, 7.25 <0.01 3.57 1.96, 6.51 <0.01 Knowledge of anaemia Poor 241 (56.8) Reference Good 183 (43.7) 1.82 1.17, 2.81 0.01 1.12 0.63, 2.00 0.70 Knowledge of the IFAS program Poor 275 (64.9) Reference Good 149 (35.1) 2.29 1.47, 3.57 <0.01 1.67 0.94, 3.00 0.08 90.0 81.8 77.8 80.0 70.3 70.0 60.0 50.0 40.0 27.6 30.0 18.2 17.0 20.0 10.0 0.0 Regulation Improved Increased Feeling Reduced Reduced of concentration appetite stronger dizziness fatigue menstruation and performance Figure 1: Perceived benets of consuming IFA tablets. 70.0 coordinators think educating parents and children on the 60.0 IFAS program, providing incentives to school health co- ordinators, and ensuring the availability of water in class- 50.0 rooms could help solve some of these challenges. 40.0 30.0 20.0 4. Discussion 10.0 In this study, we sought to investigate the compliance level of 0.0 Poor knowledge Good knowledge adolescent girls with the IFAS and its inƒuencing factors among adolescent girls in the Tamale Metropolis of Ghana. Figure 2: Respondents’ knowledge of anaemia. We included 424 adolescents girls with a mean age (SD) of 14.4 (±1.7) with the majority of the adolescent girls between that they can handle the work alone while another half re- 10 and 15 years. ported there was no time to organize the training for colleague Compliance with the IFAS in this study was found to be teachers. Fifty-ve percent of the school health coordinators low (26.2%). ‘is nding is in variance with a similar study do not always supervise the adolescent girls to ingest the tablet conducted in Iran [22] which found compliance rate to be with the majority 63.6% of them citing limited time for their 62.3% and another study conducted in rural India which also inability to supervise them. Unavailability of water in the found a compliance rate of 85.8% [20]. However, our study classroom (36.4%) was also cited as one of the reasons for nding is similar to that of Sajna and Jacob [23] which also their inability to always supervise the adolescent girls to ingest found compliance to be low (15%). Low compliance in this the tablet. About 80% of the school health coordinators admit study could be a result of stock-outs of the IFA tablet as some the fact that they face challenges in implementing the IFAS of the schools had no IFA tablet in stock at the time of our program. Adolescent girls refusing to take the IFA tablet visit. In addition, compliance with the IFAS was a—ected by because they perceived it as family planning medicine and absenteeism on the part of the adolescent girls and teachers lack of water to swallow the tablet were some of the challenges not issuing the IFA tablet to the adolescent girls. Hence, opined by the school health coordinators. School health adolescent girls who are regular in school can be used to Percent Percent 8 Journal of Nutrition and Metabolism Table 6: Association between respondents’ sociodemographic characteristics and knowledge on anaemia. Knowledge on anaemia Independent variables Unadjusted OR (95% CI) p value Poor knowledge Good knowledge Total, N  424 Chi-square (p value) Age group (years) 10–15 192 (56.8) 146 (43.2) 338 (100) 0.00 (0.98) 16–20 49 (57) 37 (43) 86 (100) Class JHS 1 114 (57.9) 83 (42.1) 197 (100) 0.16 (0.69) JHS 2 127 (55.9) 100 (44.1) 227 (100) Ethnicity Dagomba 168 (58.3) 120 (41.7) 288 (100) 0.82 (0.67) Mamprusi 13 (54.2) 11 (45.8) 24 (100) Others 60 (53.6) 52 (46.4) 112 (100) Religion Christianity 63 (56.3) 49 (43.8) 112 (100) 0.02 (0.88) Islam 178 (57.1) 134 (42.9) 312 (100) Mother’s level of education No formal education 124 (60.8) 80 (39.2) 204 (100) 5.16 (0.16) Basic 59 (59) 41 (41) 100 (100) Secondary 30 (50) 30 (50) 60 (100) Tertiary 28 (46.7) 32 (53.3) 60 (100) Father’s level of education No formal education 116 (61.1) 74 (38.9) 190 (100) 5.14 (0.16) Basic 31 (62) 19 (38) 50 (100) Secondary 37 (47.4) 41 (52.6) 78 (100) Tertiary 57 (53.8) 49 (46.2) 106 (100) Mother’s occupation Unemployed 28 (50) 28 (50) 56 (100) 6.41 (0.09) Public/civil servant 68 (50.4) 67 (49.6) 135 (100) Trader 136 (61.8) 84 (38.2) 220 (100) Retired 9 (69.2) 4 (30.8) 13 (100) Father’s occupation Unemployed 17 (81) 4 (19) 21 (100) 11.46 (0.01) Reference Public/civil servant 96 (49.2) 99 (50.8) 195 (100) 4.4 (1.4, 13.5) 0.01 Farmer 114 (61.6) 71 (38.4) 185 (100) 2.6 (0.9, 8.2) 0.09 Retired 14 (60.9) 9 (39.1) 23 (100) 2.7 (0.7, 10.8) 0.15 program to achieve its intended objectives [24]. Perhaps, low 80.0 70.0 compliance level in this current study might be a barrier for the 60.0 program to achieve its objective of addressing anaemia among 50.0 40.0 adolescent girls in the study area. 30.0 In this study, level of education and occupation of 20.0 mothers of adolescent girls, awareness of anaemia, and good 10.0 0.0 knowledge of anaemia and of the IFAS program were sta- Poor knowledge Good knowledge tistically associated with compliance with the IFAS. A similar Figure 3: Respondents’ knowledge of the IFAS program. study in Ethiopia also found good knowledge of anaemia and of the IFAS program as predictors of compliance [21]. always remind the teachers in charge of the IFAS program to Lack of knowledge or not receiving counselling on anaemia issue the IFA tablet to them every Wednesday. is associated with noncompliance with IFAS [25]. In this Prevention of anaemia and advice from teachers were study, the odds of complying with the IFAS were 2.1 times found to be the motivating factors for consuming the IFA tablet more likely among adolescent girls whose mothers had by the adolescent girls. ‘ese ndings agree with a cross- secondary education compared to adolescent girls whose sectional study conducted by Dhikale et al. [20] which also mothers had no formal education. ‘erefore, ensuring high found teachers as the motivating factor for the consumption of compliance in our study area will include the mounting of IFA tablets by schoolchildren. ‘erefore, educating adolescent e—ective health education strategies in the schools in order to girls and teachers on the IFAS program including its benets create awareness on anaemia, increase the adolescent girls’ will help facilitate regular consumption and compliance with level of knowledge of anaemia and of the IFAS program. the IFAS by the adolescent girls. It is important to note that Again, engaging mothers of adolescent girls will also con- compliance with the IFA regimen is very crucial for every IFAS tribute to the success of the IFAS program. Knowledge on IFA program Journal of Nutrition and Metabolism 9 Table 7: Association between sociodemographic characteristics and knowledge on the IFAS program. Knowledge on the IFAS program Independent variables Chi-square (p value) Poor knowledge Good knowledge Total, N � 424 Age group (years) 10–15 217 (64.2) 121 (35.8) 338 (100) 0.32 (0.57) 16–20 58 (67.4) 28 (32.6) 86 (100) Class JHS 1 122 (61.9) 75 (38.1) 197 (100) 1.39 (0.24) JHS 2 153 (67.4) 74 (32.6) 227 (100) Ethnicity Dagomba 190 (66) 98 (34) 288 (100) 4.04 (0.13) Mamprusi 11 (45.8) 13 (54.2) 24 (100) Others 74 (66.1) 38 (33.9) 112 (100) Religion Christianity 76 (67.9) 36 (32.1) 112 (100) 0.60 (0.44) Islam 199 (63.8) 113 (36.2) 312 (100) Mother’s level of education No formal education 141 (69.1) 63 (30.9) 204 (100) 9.92 (0.02) Basic 70 (70) 30 (30) 100 (100) Secondary 31 (51.7) 29 (48.3) 60 (100) Tertiary 33 (55) 27 (45) 60 (100) Father’s level of education No formal education 130 (68.4) 60 (31.6) 190 (100) 7.68 (0.05) Basic 38 (76) 12 (24) 50 (100) Secondary 47 (60.3) 31 (39.7) 78 (100) Tertiary 60 (56.6) 46 (43.4) 106 (100) Mother’s occupation Unemployed 38 (67.9) 18 (32.1) 56 (100) 8.39 (0.04) Public/civil servant 77 (57) 58 (43) 135 (100) Trader 154 (70) 66 (30) 220 (100) Retired 6 (46.2) 7 (53.8) 13 (100) Father’s occupation Unemployed 18 (85.7) 3 (14.3) 21 (100) 10.88 (0.01) Public/civil servant 117 (60) 78 (40) 195 (100) Farmer 129 (69.7) 56 (30.3) 185 (100) Retired 11 (47.8) 12 (52.2) 23 (100) Table 8: Association between the odds of good knowledge on the IFAS program and sociodemographic characteristics of respondents. Dependent variable: good knowledge on the IFAS program Unadjusted Adjusted Independent variables Frequency (%) OR 95% CI p value OR 95% CI p value Mother’s level of education No formal education 204 (48.1) Reference Basic 100 (23.6) 0.96 0.57, 1.61 0.88 1.00 0.59, 1.70 1.00 Secondary 60 (14.2) 2.09 1.16, 3.77 0.01 2.19 1.81, 4.07 0.01 Tertiary 60 (14.2) 1.83 1.02, 3.30 0.04 1.25 0.64, 2.42 0.51 Mother’s occupation Unemployed 56 (13.2) 0.63 0.33, 1.21 0.17 0.64 0.31, 1.31 0.22 Public/civil servant 135 (31.8) Reference Trader 220 (51.9) 0.57 0.36, 0.89 0.01 0.66 0.39, 1.10 0.11 Retired 13 (3.1) 1.55 0.49, 4.85 0.45 1.25 0.37, 4.29 0.72 Father’s occupation Unemployed 21 (5.0) 0.25 0.07, 0.88 0.03 0.29 0.08, 1.06 0.06 Public/civil servant 195 (46) Reference Farmer 185 (43.6) 0.65 0.43, 1.00 0.05 0.81 0.51, 1.29 0.37 Retired 23 (5.4) 1.64 0.69, 3.89 0.27 1.79 0.70, 4.60 0.22 10 Journal of Nutrition and Metabolism 90.0 78.8 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.9 8.3 6.8 10.0 2.8 2.6 1.4 0.0 No side Stomach Nausea Vomitting Black Headache Diarrhoea effect ache stool Figure 4: Respondents’ perceived side e—ects of IFA supplement. About 90.5% (67) of the adolescent girls stopped taking inadequate. ‘is was not surprising since the majority of the adolescent girls have never received education on anaemia. the IFA tablet in school because their parents asked them not to take the IFA tablet. ‘is nding agrees with a study Our ndings agree with studies conducted in Ethiopia (43.3%) [28] and Delhi (28.5%) [29] but di—er from a study conducted in India [1] which also identied parental re- sistance as one of the reasons for schoolchildren’s refusal to conducted in India (90.5%) [1]. Jalambo et al. in their study take IFA tablet. Perhaps, parents were not engaged before in Palestine also concluded that adolescent girls have poor enrolling in the IFAS program in the schools. Engaging knowledge of anaemia including its causes, prevention, and parents of the adolescent girls on the IFAS program during management [30]. Awareness and having good knowledge Parent Teacher Association (PTA) meetings in the schools of anaemia have the potential to inƒuence adolescent girls’ is crucial for the success of the program. Less than half of consumption of the IFA tablets [12]. Another study in the adolescent girls in this current study report taking the Ethiopia emphasized the fact that knowledge of anaemia is tablet without the supervision of teachers. ‘is deviates protective against the risk of anaemia among adolescent girls [28]. Further analysis revealed that the odds of having good from the IFAS program recommendation which requires teachers to directly supervise the adolescent girls to swallow knowledge of anaemia among adolescent girls whose fathers were public/civil servants were 4.4 times more likely as the IFA tablet. Supervising schoolchildren to ingest the IFA tablet is considered one of the most important aspects of compared to those adolescent girls whose fathers were the IFAS program in schools. Without supervision, the unemployed. ‘is might be due to the fact that public/civil possibility of schoolchildren throwing the tablet away is servants are mostly educated and might have discussed very high [26]. anaemia and its related programs with their adolescent girls Anaemia among adolescent girls can lead to problems at home. such as decreased concentration, poor school performance, We also found a poor level of knowledge of the ado- weakness, and irregular menstruation. Weekly IFAS is lescent girls on the IFAS program. A similar program therefore indicated to improve the iron status of adolescent evaluated in India also found poor knowledge of adolescent girls on IFAS pertaining to side e—ects of the IFA tablet girls and to counteract the negative e—ects of iron deciency anaemia [9]. Most of the adolescent girls in this study (29%) and unawareness of benets (32%) of taking the IFA tablet [26]. Poor level of knowledge on the IFAS program claimed intake of the IFA tablets has helped to improve their menstruation, concentration, and performance in school. might be due to adolescent girls not receiving education on ‘is nding agrees with the studies of Priya et al. [27] and the IFAS program from their teachers. As part of the Vishal et al. [15] conducted in an urban setting in India implementation of the IFAS program in the schools, school which also found improved menstruation, concentration, health coordinators were supposed to educate the adolescent and performance in school as positive e—ects of taking IFA girls on anaemia and on the IFAS program before the start of tablet. Girls with these positive experiences could be used as the program. role models to share their own experiences with their col- Majority of the adolescent girl report no side e—ects leagues in order to improve on the success of the IFAS associated with the consumption of the IFA tablet. However, popularly reported side e—ects were stomachache, nausea, program. We found a poor level of knowledge of the adolescent and vomiting. Stomach ache, nausea, and vomiting are popularly reported as side e—ects associated with the con- girls on anaemia. ‘is nding means that adolescent girls’ level of knowledge on meaning, causes, consequences, signs sumption of IFA tablets in other studies [7, 22, 26, 31]. Side and symptoms, and prevention of anaemia altogether was e—ects of the IFA tablet are one of the main reasons for Percent Journal of Nutrition and Metabolism 11 noncompliance with IFAS [7, 22]. (e success of the IFAS Conflicts of Interest program could be threatened by these side effects. (e authors declare no conflicts of interest. Unavailability of water in classrooms was seen as an obstacle for teachers to supervise the adolescent girls to ingest the tablet. (is finding disagrees with a study con- Acknowledgments ducted in Iran [22] where students had free and unlimited access to water to ingest the IFA tablet but agrees with a (e authors are thankful to the schools and the adolescent systematic review done by Apriani and Syafiq [24] which girls who participated in the study. found access to water as a challenge in implementing IFAS programs in schools. In the absence of water, adolescent girls References are given the IFA tablet to go in search of water in order to swallow it. [1] A. K. Sarada and S. A. (ilak, “Evaluation of weekly iron and According to the school health coordinators, the major folic acid supplementation programme for adolescents in challenge they face in implementing the IFAS program is the rural schools of Kannur, North Kerala, India: a cross-sectional refusal of adolescent girls to take the IFA tablet as the study,” International Journal of Medical Science and Public perceived tablet as family planning medicine. (is percep- Health, vol. 5, no. 11, pp. 2259–2263, 2016. [2] A. Gupta, S. Mohammed, A. Saxena, S. Rahi, and A. Mohan, tion may be due to the poor engagement of the adolescent Operational Framework: Weekly Iron and Folic Acid Sup- girls on the IFAS program. (e fact that the program does plementation Programme for Adolescents, Ministry of Health not include adolescent boys might also contribute to this and Family Welfare, New Delhi, India, 2012, http:// misconception about the IFAS. (is calls for effective ed- tripuranrhm.gov.in/Guidlines/WIFS.pdf. ucation on the IFAS program in order to enlighten the [3] UNICEF, WHO, and CDC, Iron & Folic Acid (IFA) Sup- adolescent girls on its intended benefits and to also debunk plementation for Adolescent Girls and Women. Participants the misconceptions the adolescent girls have about the IFA Manual for Health Workers, WHO, Geneva, Switzerland, tablet. 2017, https://www.unicef.org/ghana/media/1331/file/UN157895. pdf. [4] B. D. Benoist, E. McLean, I. Egll, and M. Cogswell, Worldwide 5. Conclusion Prevalence of Anaemia 1993–2005: WHO Global Database on Anaemia, WHO, Geneva, Switzerland, 2008. (ere was low compliance with the IFAS program among [5] World Health Organization, Global Health Observatory adolescent girls. Teachers not issuing the tablet to the ad- (GHO) Data Repository, WHO, Geneva, Switzerland, 2019, olescent girls and absenteeism on the part of the adolescent http://apps.who.int/gho/data/view.main.ANAEMIAWOMEN girls were seen as the major barriers to compliance. Mother’s NPWREG. level of education, mother’s occupation, awareness of [6] D. Walters, J. Kakietek, J. Dayton Eberwein, and M. Shekar, anaemia, and good knowledge of both anaemia and the IFAS An Investment Framework for Meeting the Global Nutrition program were found to be significant determinants of Target for Anemia, World Bank Group, Washington, DC, compliance. 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Meshram, “Factors as- (e data used to support the findings of this study are sociated with high compliance/feasibility during iron and folic available from the corresponding author upon request. acid supplementation in a tribal area of Madhya Pradesh, 12 Journal of Nutrition and Metabolism India,” Public Health Nutrition, vol. 16, no. 2, pp. 377–380, [27] S. H. Priya, S. S. Datta, Y. A. Bahurupi, K. A. Narayan, N. Nishanthini, and M. R. Ramya, “Factors influencing weekly [13] N. Roschnik, A. Parawan, M. A. B. Baylon, T. Chua, and iron folic acid supplementation programme among school children: where to focus our attention?,” Saudi Journal for A. Hall, “Weekly iron supplements given by teachers sustain the haemoglobin concentration of schoolchildren in the Health Sciences, vol. 5, no. 1, p. 28, 2016. [28] G. Mengistu, M. Azage, and H. Gutema, “Iron deficiency Philippines,” Tropical Medicine and International Health, anaemia among in-school adolescent girls in rural area of vol. 9, no. 8, pp. 904–909, 2004. Bahir Dar city administration, north west Ethiopia,” Anemia, [14] P. Horjus, V. M. Aguayo, J. A. Roley, M. C. Pene, and vol. 2019, Article ID 1097547, 8 pages, 2019. S. P. Meershoek, “School-based iron and folic acid supple- [29] M. Singh, O. P. Rajoura, and R. A. Honnakamble, “Anaemia- mentation for adolescent girls: findings from Manica prov- related knowledge, attitude, and practices in adolescent ince, Mozambique,” Food and Nutrition Bulletin, vol. 26, schoolgirls of Delhi: a cross-sectional study,” International no. 3, pp. 281–286, 2005. Journal of Health & Allied Sciences, vol. 8, no. 2, pp. 144–148, [15] S. R. Vishal, K. S. Sunil, P. Dipak Chandrakant, and C. Padmaja Hari, “Program effectiveness of school based [30] M. O. Jalambo, I. A. Naser, R. Sharif, and N. A. Karim, weekly iron and folic acid supplementation in urban setting,” “Knowledge, attitude and practice of iron deficient and iron International Journal of Current Research, vol. 7, no. 3, deficient anaemic adolescents in the Gaza Strip, Palestine,” pp. 13941–13944, 2015. Asian Journal of Clinical Nutrition, vol. 9, no. 1, pp. 51–56, [16] A. Arega Sadore, L. Abebe Gebretsadik, and M. Aman Hussen, “Compliance with iron folate supplement and as- [31] M. Joshi and R. Gumashta, “Weekly iron folate supplemen- sociated factors among antenatal care attendant mothers in tation in adolescent girls–an effective nutritional measure for Misha district, South Ethiopia: community based cross-sec- the management of iron deficiency anaemia,” Global Journal tional study,” Journal of Environmental and Public Health, of Health Science, vol. 5, no. 3, p. 188, 2013. vol. 2015, Article ID 781973, 7 pages, 2015. 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[22] S. Kheirouri and M. Alizadeh, “Process evaluation of a na- tional school-based iron supplementation program for ado- lescent girls in Iran,” BMC Public Health, vol. 14, no. 1, p. 959, [23] M. V. Sajna and S. A. Jacob, “Adherence to weekly iron and folic acid supplementation among the school students of (rissur corporation—a cross sectional study,” International Journal Of Community Medicine And Public Health, vol. 4, no. 5, pp. 1689–1694, 2017. [24] M. Apriani and A. Syafiq, “Adolescent compliance on iron tablet consumption: a systematic review,” Advanced Science Letters, vol. 24, no. 9, pp. 6371–6375, 2018. [25] B. Jikamo and M. 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Compliance with Weekly Iron and Folic Acid Supplementation and Its Associated Factors among Adolescent Girls in Tamale Metropolis of Ghana

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Copyright © 2019 S. Dajaan Dubik et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Hindawi Journal of Nutrition and Metabolism Volume 2019, Article ID 8242896, 12 pages https://doi.org/10.1155/2019/8242896 Research Article Compliance with Weekly Iron and Folic Acid Supplementation and Its Associated Factors among Adolescent Girls in Tamale Metropolis of Ghana 1 2 3 1 S. Dajaan Dubik , Kingsley E. Amegah, Amshawu Alhassan, Louis N. Mornah, and Loveland Fiagbe Department of Nutritional Sciences, University for Development Studies, Box TL 1350, Tamale, Northern Region, Ghana Department of Health Information, Hohoe Municipal Hospital, Hohoe, Volta Region, Ghana Savelugu/Nanton Municipal Health Directorate, Ghana Health Service, Savelugu, Northern Region, Ghana Kete-Krachi District Health Directorate, Ghana Health Service, Kete-Krachi, Volta Region, Ghana Correspondence should be addressed to S. Dajaan Dubik; stephendubik@gmail.com Received 6 August 2019; Revised 2 November 2019; Accepted 29 November 2019; Published 11 December 2019 Academic Editor: C. S. Johnston Copyright © 2019 S. Dajaan Dubik et al. (is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. In Ghana, anaemia is a severe public health problem among adolescent girls. In an attempt to deal with this phenomenon, Ghana Ministry of Health in collaboration with other development partners developed and launched weekly iron and folic acid supplementation program for adolescent girls in Ghanaian junior high schools. (erefore, the main aim of this study was to determine the level of compliance with iron and folic acid supplementation (IFAS) and its associated factors among adolescent girls in the Tamale Metropolis of Ghana. Methods. A cross-sectional study was conducted among 424 randomly sampled adolescent girls in the Tamale Metropolis of Ghana from April to July 2019 using an interviewer-administered structured questionnaire. Twenty school health coordinators were purposively selected to answer questions on the challenges they face in implementing the IFAS program at the school level. Bivariate logistic regression and multivariate logistic regression were used to determine associations and strength of associations, respectively, at a significant threshold of p< 0.05. Results. Compliance with the IFAS was low (26.2%). Adolescent girls who were aware of anaemia (AOR � 3.57 (95% CI: 1.96, 6.51) p< 0.01), had good knowledge of anaemia (AOR � 1.82 (95% CI: 1.17, 2.81) p � 0.01), and had good knowledge of the IFAS program (AOR � 2.29 (95% CI: 1.47, 3.57) p< 0.01) were significantly associated with compliance with the IFAS. (e majority (60%) of the adolescent girls have ever missed taking the iron and folic acid (IFA) tablet because it was not issued to them by the teacher’s concern while about 48.3% (169) of the adolescent girls are taking the tablet because it prevents anaemia. Adolescent girls perceiving the tablet as family planning medicine (88.8%) and unavailability of water in classrooms (18.8%) were cited as the major challenges by school health coordinators. Conclusion. Compliance with the IFAS among adolescent girls was low. Level of education and occupation of mothers of adolescent girls, awareness on anaemia, and good knowledge of anaemia and of the IFAS program were significant predictors of compliance with the IFAS. Educating the adolescent girls on anaemia and benefits of the IFAS, constant supply of the IFA tablet, and engaging parents of the adolescent girls on the program will help improve the compliance level of the adolescent girls with the IFAS. adulthood, is characterized by intense growth resulting in 1. Introduction behavioural and sexual maturity in an individual [2]. It is the In developing countries, anaemia is a major public health second growth spurt of life where girls undergo different problem of not only pregnant women or children but also experiences. During adolescence, there is an increased de- adolescent girls [1]. Adolescence, a period of transition to mand for nutrition especially iron requirements [2]. 2 Journal of Nutrition and Metabolism weekly IFAS program in order to meet the challenge of the Adolescence is also considered as a golden time for in- terventions to curb anaemia. It also presents the right time high prevalence of anaemia among adolescent girls in Ghana. However, the major problem with the IFAS program for building a nutrition foundation for child bearing in later life [3]. is compliance with several interacting factors that still re- Globally, anaemia is affecting about 1.62 billion people main unclear in our study area [16]. Furthermore, the IFAS worldwide and approximately half of all anaemia can be program is relatively new among adolescent girls in Ghana. attributed to iron deficiency. Children, pregnant women, (erefore, the aim of this study was to determine the level of and women of reproductive age are greatly affected [4]. (e compliance with the IFAS and its influencing factors among number of nonpregnant women of reproductive age affected adolescent girls in the Tamale Metropolis of Ghana. (e specific aims of the present study were to (1) determine by anaemia increased from 464 million in 2000 to 578 million in 2016 across the globe. Africa and Asia are the compliance level of the adolescent girls with the IFAS, (2) assess factors influencing compliance with the IFAS, (3) hardest hit with the prevalence of over 35% and therefore require increased efforts to curb the problem [5]. determine the adolescent girls’ level of knowledge on anaemia and the IFAS, and (4) assess challenges faced by Worldwide, it is estimated that the absence of investment in prevention of anaemia would result in 265 million more teachers in implementing the program at the school level. cases of anaemia in women including adolescent girls by 2025 and nearly 800,000 more child deaths and 7,000–14,000 2. Methods more maternal deaths [6]. Anaemia, a direct indication of undernutrition and poor 2.1. Study Area and Design. A cross-sectional study was dietary intake of iron, is a serious public health problem conducted using quantitative data collection methods from among adolescent girls [2]. Adolescent girls are at greater April to July 2019 among adolescent girls in twenty selected risk of iron deficiency and anaemia due to increased growth, junior high schools in the Tamale Metropolis of Ghana. poor dietary intake of iron, low bioavailability of dietary Tamale Metropolis is geographically located between lati- ° ° ° ° iron, and high rate of infectious diseases, parasitic infections, tude 9 16 and 9 34 North and longitudes 0 36 and 0 57 and menstrual blood loss [7]. Iron deficiency anaemia occurs West. Tamale Metropolis is one of the 14 Districts in the more often in adolescent girls than in adolescent boys. (is is Northern Region. It is located in the central part of the due to excessive loss of iron during menstruation. Moreover, region and shares boundaries with Sagnarigu, Mion, East the risk of anaemia in adolescent girls is increased by poor Gonja, and Central Gonja districts. (e Metropolis has a literacy, ignorance, and lack of knowledge about iron de- total estimated land size of 646.90180 km [17]. According to ficiency [8]. the Ghana 2010 population and housing census, Tamale Anaemia has serious consequences; it can lead to poor Metropolis has a population of 233,252 constituting 49.7% school performance among schoolchildren, impaired males and 50.3% females. Among those aged 3 years and physical growth, and poor cognitive development, thereby older and are currently attending school, 18.2% are in junior hindering development socially and economically [4]. high schools. (e metropolis has 112 junior high schools Anaemia can also leave adolescent girls physically inactive, [17]. hindering their progress in school and ultimately causing them to drop out of school [3]. (e ultimate aim of man- aging anaemia is to help elevate the haemoglobin level of the 2.2. 0e Weekly IFAS Program among Adolescent Girls in individual concern, and this is mostly done through iron Ghana. In Ghana, IFAS has been for only pregnant women therapy and blood transfusion [9]. However, at the pop- neglecting adolescent girls [3]. Weekly IFAS program which ulation level, iron deficiency anaemia can be tackled through is the first of its kind in Ghana among adolescent girls was deworming, iron supplementation, fortification of foods launched in 2017 by Ghana Ministry of Health with support with micronutrients, and proper dietary education with from development partners such as UNICEF and WHO. (e improved food security [3, 10]. initiative is expected to reach about 360,000 girls in junior In Ghana, the prevalence of anaemia among adolescent and senior high schools and 600,000 girls who are out of girls is unacceptably high. Data from the Ghana De- school [18]. mographic Health Survey (GDHS) indicate a high preva- (e IFAS program is in the pilot phase in four of the ten lence of 48% among adolescent girls [11]. Iron and folic acid regions, namely, Northern Region, Brong Ahafo Region, and supplementation are known as the most cost-effective way of Upper West and Upper East regions with the main aim of improving the iron status of adolescent girls in developing contributing to the reduction of anaemia among adolescent countries [8]. (erefore, constant use of iron and folic acid girls. About 4,500 school health coordinators who are supplements together with a diet rich in micronutrients is teachers in the participating schools and 3,000 health essential for the prevention of iron deficiency anaemia workers have been trained to support the implementation of among adolescent girls [2]. In addition, the effectiveness of the program [18]. Teachers are expected to encourage ad- weekly supplementation of IFA in preventing anaemia olescent girls in school to take one supplement (60 mg of among adolescent girls has been documented in several elemental iron and 400 μg (0.4 mg) of folic acid) every studies [12–15]. Taking cognizance of this, Ghana Ministry Wednesday in a week at noon. Community health workers of Health in 2017 with support from the Ministry of Edu- are expected to assist girls who are out of school to take the cation and other development partners has launched a tablet [3]. Journal of Nutrition and Metabolism 3 questionnaires which were mostly closed-ended with mul- 2.3. Study Population. All Adolescent girls attending junior high school in Tamale Metropolis were the source population. tiple choice and dichotomous responses were divided into sections and administered to both adolescent girls and (e study population consisted of randomly sampled girls who were attending junior high school in the study area in the teachers. Section A consisted of 8 questions to elicit in- third term of the 2018/2019 academic year. Girls who were formation on sociodemographic characteristics of the ad- absent and those who declined to answer the research olescent girls and section B was made of 9 questions to questions were excluded from the study. School health co- determine compliance level of the adolescent girls with the ordinators of the 20 schools also participated in the study. IFAS whereas section C consisted of 16 questions which sought to assess the level of knowledge of the adolescent girls of anaemia and of the IFAS program. Section C also sought 2.4. Sample Size Determination and Sampling Procedures. to find out the side effects experienced by adolescent girls. (e sample size was determined using Cochran’s formula Section D which was the only section administered to the N � (Z2 × p(1 − p))/d2 [19] with 95% confidence interval teachers sought to determine the challenges faced by and 5% margin error with assumed compliance rate of 50%, teachers in implementing the IFAS program at the school where N is the sample size, Z (statistic) � 1.96, p (compliance level. Data collection was done by two community health rate) � 0.5, and d (margin of error) � 0.05: nurses and two masters students in public health nutrition. (1.96)2 × 0.5(1 − 0.5) One-day training was organized for the data collectors by the (1) n � � 384.16. (0.05)2 principal investigator. (ey were trained on objectives of the study, how to ensure confidentiality of the data, and how to (e IFAS program is relatively a new program among fill the questionnaires. (ey were also trained on how to adolescent girls in Ghana, hence the justification for the initiate the interview process by reading the informed assumed compliance rate for the sample size calculation. (e consent to every respondent for voluntary participation. calculated sample size was therefore 385. After adding a 10% After data collection, the principal investigator reviewed nonresponse rate, the final sample size obtained was 424 each questionnaire in order to ensure the accuracy and research participants. completeness of the data collected. Simple random sampling was used to select the schools and the adolescent girls while purposive sampling was used to select the school health coordinators. Twenty schools were 2.6. Statistical Analysis. (e quantitative data were coded selected using lottery method. (e names of all junior high and analysed using STATA 14.1. Sociodemographic char- schools in the metropolis were written on pieces of papers acteristics, level of compliance, and knowledge of anaemia and placed in a bowl. With blind draw, the schools were and of the IFAS program were first presented in text, figures, randomly picked one by one without replacement until 20 and tables using descriptive statistics such as frequencies and schools were reached. (e final sample size of 424 was percentages. Bivariate logistic regression test was done to proportionally allocated to the 20 schools based on the determine the association between the sociodemographic enrolment of girls in each school. (e study participants characteristics and the outcome variables (compliance level, were selected from each class through simple random knowledge of anaemia, and knowledge of the IFAS pro- sampling using random numbers generated for each class gram). Logistic regression analysis was also done to de- using the girls attendance register. Twenty school health termine the effect of awareness of anaemia, knowledge of coordinators in the selected schools were purposively anaemia, and knowledge of the IFAS program on compli- sampled to participate in the study. ance level. Multivariate logistic regression was further done for variables that were statistically significant after the bi- 2.5. Data Collection. (e data collection tool used in col- variate analysis. Crude and adjusted odds ratios with their respective confidence intervals (95%) were computed to lecting the research data was structured pretested ques- determine the strength of association of each variable. tionnaires while data collection was done with the help of IFAS compliance level was measured based on the interviewer-assisted questionnaire administration. Pretest- number of tablets consumed in the past 7 weeks. Adolescent ing of the data collection tool was done in Sagnerigu Mu- girls who consumed at least five tablets of the expected dose nicipality since it shares similar characteristics with the study in the previous 7 weeks (1 tablet per week) which is area. (e data collection tool was adapted and modified from similar published studies [1, 2, 7, 20]. (e adoption of the equivalent to consuming 70% of the expected dose before the day of the data collection was considered compliant. Ado- data collection tool from similar published studies was to ensure the validity of the data collection tool. (irty ado- lescent girls who consumed less than five tablets were considered noncompliant [16]. Records kept by the school lescent girls were conveniently chosen in one school for the pretesting of the data collection tool. Pretesting was done to health coordinators were used to validate each respondent’s compliance status. ensure the reliability of the data collection tool. Questions Knowledge on anaemia was measured by summing up that gave responses that were not certain were reframed and 19 relevant knowledge items on anaemia (1 item on the tested again on the same respondents to ensure their meaning of anaemia, 4 items on causes of anaemia, 6 items reliability. on signs and symptoms of anaemia, 4 items on consequences A prior appointment was taken from headmasters and of anaemia, and 4 items on prevention of anaemia). A correct health coordinators of the selected schools. (e 4 Journal of Nutrition and Metabolism Table 1: Sociodemographic characteristics of respondents. response was scored “1” and an incorrect response was scored “0” with a maximum score of 19. (ose who scored above the Variables Frequency, N � 424 Percent (%) median mark were considered as having good knowledge of Mean age (SD) 14.4 (1.7) anaemia while those who scored below the median mark were Age group (years) considered as having poor knowledge [16]. 10–15 338 79.7 Knowledge of the IFAS program was scored by summing 16–20 86 20.3 up 15 relevant knowledge items on the IFAS program: one item Class on why they are given the tablet, 4 items on benefits of taking JHS 1 197 46.5 IFA tablet, 3 items on food that inhibits iron and folic acid JHS 2 227 53.5 absorption, 5 items on side effects of taking IFA tablets, and 2 Ethnicity items on why girls are given the iron and folic acid tablet. A Dagomba 288 67.9 correct answer was scored “1” and an incorrect answer was Mamprusi 24 5.7 scored “0”. With a maximum score of 15, those who scored Others 112 26.4 above the median mark were considered having good knowl- Religion edge on the IFAS program while those who scored below the Christianity 112 26.4 median mark were considered as having poor knowledge [21]. Islam 312 73.6 Mother’s level of education No formal education 204 48.1 2.7. Ethical Consideration. Ethical clearance for the study Basic 100 23.6 was sought from the University for Development Studies. Secondary 60 14.2 Approval letter for the study was granted by Ghana Health Tertiary 60 14.2 Service while permission to go into the school was obtained Father’s level of education from the Tamale Metropolitan Education Office. Informed No formal education 190 44.8 assent was obtained from underaged participants in their Basic 50 11.8 schools while informed consent was obtained from the Secondary 78 18.4 parents of the girls. Selected girls were given informed Tertiary 106 25.0 consent forms for their parents to thumbprint/sign signalling Mother’s occupation their agreement for their child to participate in the study. Unemployed 56 13.2 Public/civil servant 135 31.8 Trader 220 51.9 3. Results Retired 13 3.1 3.1. Sociodemographic Characteristics of the Adolescent Girls. Father’s occupation (e total number of respondents in this current study was Unemployed 21 5.0 424 with a mean age (SD) of 14.4 (±1.7). Majority (79.7%) of Public/civil servant 195 46.0 Farmer 185 43.6 the respondents had their ages ranging between 10 and 15 Retired 23 5.4 years with over half (53.5%) in junior high school two. Majority (67.9%) of the adolescent girls were Dagombas with 73.6% of them affiliated to the Islamic religion. Most (48.1%) reason for ceasing to take the IFA tablet. About 82.5% of the of the respondents’ mothers had no formal education while adolescent girls have ever missed taking the IFA tablet in very few (14.2%) had tertiary education, and about half school. Most (60%) of the adolescent girls have ever missed (51.9%) of the respondents’ mothers were petty traders. taking the IFA tablet because it was not issued to them by the Twenty-five percent of the respondents’ fathers had tertiary teacher’s concern while another 28.9% cited the fact that education while most (44.8%) of them had no formal edu- they were absent from school. Among those who have ever cation with 46% of them being public/civil servants (Table 1). taken the tablet, 73.1% always take the tablet in the presence of the teacher (Table 2). 3.2. Compliance with the IFAS. Overall compliance with the A Pearson’s chi-square test with a significant threshold IFAS in this current study was 26.2%. Only 26.2% (111) of of p< 0.05 established that the mother’s level of education 2 2 the adolescent girls consumed 5 or more tablets in the past 7 (χ �15.65, p< 0.01) and mother’s occupation (χ �10.30, weeks prior to the data collection. Majority (90.1%) of the p � 0.02) were significantly associated with adolescent girls adolescent girls took the IFA tablet on the first day it was level of compliance (Table 3). Respondents whose mothers given by the teachers. About 82.5% of the adolescent girls are had secondary education were 2.1 times more likely to still consuming the IFA tablet in school while the rest comply with the IFAS as compared to those respondents (17.4%) stopped consuming the IFA tablet. Among those whose mothers had no formal education (OR � 2.14 (95% CI: currently taking the IFA tablet in school, most (48.3%) cited 1.17, 3.29) p � 0.01). (e odds of compliance with the IFAS the prevention of anaemia as the reason for taking the IFA among respondents whose mothers were traders were 56% tablet while another 41.1% cited advice from their teacher. times lower compared to those respondents whose mothers Among those who stopped taking the IFA tablet in school, were unemployed (AOR � 0.44 (95% CI: 0.23, 0.85) 90.5% (67) cited the fact that their parents ask them not to p � 0.01) (Table 4). Good knowledge of anaemia (OR � 1.82 take the tablet while another 5.4% (4) cited side effects as the (95% CI: 1.17, 2.81) p � 0.01) and good knowledge of the Journal of Nutrition and Metabolism 5 Table 2: Compliance with IFAS among adolescent girls. mention anaemia as low blood level and hence were considered aware of anaemia. About 67.9% of the adolescent girls have Frequency, Percent Variables never received education on anaemia. (ose (32.1%) who have N � 424 (%) ever received education on anaemia cited teachers (85.3%) and Took IFA tablet on the first day health workers (14.7%) as their sources of anaemia education. No 42 9.9 Yes 382 90.1 Currently taking IFA tablet in school 3.5. Factors Associated with Adolescent Girls’ Level of No 74 17.5 Knowledge on Anaemia. In this current study, it was shown Yes 350 82.5 that more than half (56.8%) of the adolescent girls had poor Reasons for taking IFA tablet knowledge on anaemia while 43.2% had good knowledge of Advice from teacher 144 41.1 anaemia (Figure 2). Pearson chi-square test with a significance Because it is free 12 3.4 threshold of p< 0.05 found no statistically significant asso- Friends are taking it 25 7.1 ciation between respondent sociodemographic characteristics It prevents anaemia 169 48.3 and knowledge on anaemia except for the occupation of Reasons for not taking the tablet 2 fathers of the respondents (χ �11.46, p< 0.01). Respondents Fear of side effects 4 5.4 whose fathers were public/civil servants were found to be 4.4 My parents ask me not to take the 67 90.5 times more likely to have good knowledge on anaemia as tablet compared to those pupils whose fathers were unemployed l feel healthy 3 4.1 (OR � 4.4 (95% CI: 1.4, 13.5) p � 0.01) (Table 6). Number of IFA tablets taken in the past 7 weeks <5 tablets 313 73.8 3.6. Adolescent Girls’ Level of Knowledge on the IFAS Program. ≥5 tablets 111 26.2 Most (64.9%) of the adolescent girls were found to have poor Always takes IFA tablet under knowledge of the IFAS program while 35.1% were found to supervision have good knowledge of the IFAS program (Figure 3). No 114 26.9 Pearson chi-square test with a significance threshold of Yes 310 73.1 p< 0.05 found out that mother’s level of education (χ � 9.92, Ever missed taking IFA tablet in p< 0.02), mother’s occupation (χ � 8.39, p< 0.04), and fa- school ther’s occupation (χ �10.88, p< 0.01) of the respondents No 74 17.5 were statistically significant with adolescent girls’ level of Yes 350 82.5 knowledge on the IFAS program (Table 7). Respondents Reasons for missing whose mothers had secondary education were 2.1 times more Bad taste of tablet 23 6.6 likely to have good knowledge of the IFAS as compared with I was absent 101 28.9 those whose mothers had no formal education (OR � 2.1 (95% Side effects 16 4.6 CI: 1.16, 3.77) p � 0.01). Again, respondents whose fathers I was not given IFA tablet 210 60.0 were unemployed were 75% times less likely to have good knowledge of the IFAS program as compared to those re- IFAS program (OR � 2.29 (95% CI: 1.47, 3.57) p< 0.01) were spondents whose fathers were public/civil servants (OR � 0.25 also significant determinants of compliance with the IFAS. A (95% CI: 0.07, 0.88) p � 0.03). logistic regression analysis found out that the odds of After adjusting for the effect of all confounding variables compliance with the IFAS were 3.6 times more likely among in a logistic regression model, the mother’s education adolescent girls who were aware of anaemia compared to remained statistically significant. Respondents whose adolescent girls who were not aware of anaemia (AOR � 3.57 mothers had secondary education were 2.2 times more likely (95% CI: 1.96, 6.51) p< 0.01) (Table 5). to have good knowledge of the IFAS program as compared to those respondents whose mothers had no formal edu- cation (OR � 2.19 (95% CI: 1.81, 4.07) p � 0.01) (Table 8). 3.3. Perceived Benefits of Taking the IFA Tablet as Reported by Adolescent Girls. With multiple responses possible, majority (81.8%) of the adolescent girls cited regulation of men- 3.7. Side Effects Reported by the Adolescent Girls. With struation as the benefit they have gotten from taking the IFA multiple responses possible, most (78.8%) of the re- tablet and 77.8% thinks the IFA tablet has helped to improve spondents reported that there were no side effects associated their concentration and performance in class while over with the consumption of the IFA tablet. Some (10.9%) stated 18.2% cited reduced dizziness as the benefit they have gotten stomach/abdominal pains as the side effect they experienced from taking the IFA tablet (Figure 1). with the consumption of the IFA tablet while few cited nausea (8.3%) (Figure 4). 3.4. Awareness of Anaemia among Adolescent Girls. About 247 (58.2%) of the respondents claimed they have ever 3.8. Challenges Faced by Teachers in Implementing the IFA heard of a disease where the affected person is said to have low Supplementation Program. At the time of our visit, about blood level, and only 30.7% (130) were able to correctly 70% of the schools had IFA tablets in stock with school health 6 Journal of Nutrition and Metabolism Table 3: Sociodemographic characteristics and compliance level among adolescent girls. Compliance with IFAS Dependent Chi-square variables Noncompliance Compliance Total, N � 424 (p value) Age group (years) 10–15 256 (75.7) 82 (24.3) 338 (100) 3.18 (0.08) 16–19 57 (66.3) 29 (33.7) 86 (100) Class JHS 1 143 (72.6) 54 (27.4) 197 (100) 0.29 (0.59) JHS 2 170 (74.9) 57 (25.1) 227 (100) Ethnicity Dagomba 212 (73.6) 76 (26.4) 288 (100) 0.03 (0.99) Mamprusi 18 (75) 6 (25) 24 (100) Others 83 (74.1) 29 (25.9) 112 (100) Religion Christianity 77 (68.8) 35 (31.3) 112 (100) 2.03 (0.16) Islam 236 (75.6) 76 (24.4) 312 (100) Mother’s level of education No formal education 153 (75) 51 (25) 204 (100) 15.65 (<0.01) Basic 85 (85) 15 (15) 100 (100) Secondary 35 (58.3) 25 (41.7) 60 (100) Tertiary 40 (66.7) 20 (33.3) 60 (100) Father’s level of education No formal education 145 (76.3) 45 (23.7) 190 (100) 6.03 (0.11) Basic 42 (84) 8 (16) 50 (100) Secondary 53 (67.9) 25 (32.1) 78 (100) Tertiary 73 (68.9) 33 (31.1) 106 (100) Mother’s occupation Unemployed 35 (62.5) 21 (37.5) 56 (100) 10.30 (0.02) Public/civil servant 94 (69.6) 41 (30.4) 135 (100) Trader 176 (80) 44 (20) 220 (100) Retired 8 (61.5) 5 (38.5) 13 (100) Father’s occupation Unemployed 18 (85.7) 3 (14.3) 21 (100) 7.81 (0.05) Public/civil servant 132 (67.7) 63 (32.3) 195 (100) Farmer 146 (78.9) 39 (21.1) 185 (100) Retired 17 (73.9) 6 (26.1) 23 (100) Table 4: Association between the odds of sociodemographic characteristics and compliance level among adolescent girls. Unadjusted Adjusted Independent variables Frequency (%) OR 95% CI p value OR 95% CI p value Mother’s education No formal education 204 (48.1) Reference Basic 100 (23.6) 0.53 0.28, 1.00 0.05 0.51 0.27, 0.96 0.04 Secondary 60 (14.2) 2.14 1.17, 3.29 0.01 1.96 1.06, 3.63 0.03 Tertiary 60 (14.2) 1.50 0.80, 2.80 0.20 1.24 0.62, 2.48 0.54 Mother’s occupation Unemployed 56 (13.2) Reference Public/civil servant 135 (31.8) 0.73 0.34, 0.38 0.34 0.69 0.34, 1.42 0.32 Trader 220 (51.9) 0.42 0.22, 0.79 0.01 0.44 0.23, 0.85 0.01 Retired 13 (3.1) 1.04 0.30, 3.60 0.95 1.08 0.30, 3.92 0.90 coordinators (95%) in charge of issuing the IFA tablet to the limited time as one of the reasons for their inability to educate adolescent girls. About 45% (9) of the school health co- the adolescent girls on anaemia and on the IFAS program. ordinators have never educated the adolescent girls on anaemia A significant number (70%, 14) of the school health and on the IFAS program. Among those who have never coordinators were not able to organize training for their educated the adolescent girls on anaemia, 77.8% (7) cited colleague teachers with half (50%, 7) of them citing the fact Journal of Nutrition and Metabolism 7 Table 5: Factors associated with IFAS compliance level among adolescent girls. Unadjusted Adjusted Independent variables Frequency (%) OR 95% CI p value OR 95% CI p value Awareness of anaemia No 294 (69.3) Reference Yes 130 (30.7) 4.04 2.25, 7.25 <0.01 3.57 1.96, 6.51 <0.01 Knowledge of anaemia Poor 241 (56.8) Reference Good 183 (43.7) 1.82 1.17, 2.81 0.01 1.12 0.63, 2.00 0.70 Knowledge of the IFAS program Poor 275 (64.9) Reference Good 149 (35.1) 2.29 1.47, 3.57 <0.01 1.67 0.94, 3.00 0.08 90.0 81.8 77.8 80.0 70.3 70.0 60.0 50.0 40.0 27.6 30.0 18.2 17.0 20.0 10.0 0.0 Regulation Improved Increased Feeling Reduced Reduced of concentration appetite stronger dizziness fatigue menstruation and performance Figure 1: Perceived benets of consuming IFA tablets. 70.0 coordinators think educating parents and children on the 60.0 IFAS program, providing incentives to school health co- ordinators, and ensuring the availability of water in class- 50.0 rooms could help solve some of these challenges. 40.0 30.0 20.0 4. Discussion 10.0 In this study, we sought to investigate the compliance level of 0.0 Poor knowledge Good knowledge adolescent girls with the IFAS and its inƒuencing factors among adolescent girls in the Tamale Metropolis of Ghana. Figure 2: Respondents’ knowledge of anaemia. We included 424 adolescents girls with a mean age (SD) of 14.4 (±1.7) with the majority of the adolescent girls between that they can handle the work alone while another half re- 10 and 15 years. ported there was no time to organize the training for colleague Compliance with the IFAS in this study was found to be teachers. Fifty-ve percent of the school health coordinators low (26.2%). ‘is nding is in variance with a similar study do not always supervise the adolescent girls to ingest the tablet conducted in Iran [22] which found compliance rate to be with the majority 63.6% of them citing limited time for their 62.3% and another study conducted in rural India which also inability to supervise them. Unavailability of water in the found a compliance rate of 85.8% [20]. However, our study classroom (36.4%) was also cited as one of the reasons for nding is similar to that of Sajna and Jacob [23] which also their inability to always supervise the adolescent girls to ingest found compliance to be low (15%). Low compliance in this the tablet. About 80% of the school health coordinators admit study could be a result of stock-outs of the IFA tablet as some the fact that they face challenges in implementing the IFAS of the schools had no IFA tablet in stock at the time of our program. Adolescent girls refusing to take the IFA tablet visit. In addition, compliance with the IFAS was a—ected by because they perceived it as family planning medicine and absenteeism on the part of the adolescent girls and teachers lack of water to swallow the tablet were some of the challenges not issuing the IFA tablet to the adolescent girls. Hence, opined by the school health coordinators. School health adolescent girls who are regular in school can be used to Percent Percent 8 Journal of Nutrition and Metabolism Table 6: Association between respondents’ sociodemographic characteristics and knowledge on anaemia. Knowledge on anaemia Independent variables Unadjusted OR (95% CI) p value Poor knowledge Good knowledge Total, N  424 Chi-square (p value) Age group (years) 10–15 192 (56.8) 146 (43.2) 338 (100) 0.00 (0.98) 16–20 49 (57) 37 (43) 86 (100) Class JHS 1 114 (57.9) 83 (42.1) 197 (100) 0.16 (0.69) JHS 2 127 (55.9) 100 (44.1) 227 (100) Ethnicity Dagomba 168 (58.3) 120 (41.7) 288 (100) 0.82 (0.67) Mamprusi 13 (54.2) 11 (45.8) 24 (100) Others 60 (53.6) 52 (46.4) 112 (100) Religion Christianity 63 (56.3) 49 (43.8) 112 (100) 0.02 (0.88) Islam 178 (57.1) 134 (42.9) 312 (100) Mother’s level of education No formal education 124 (60.8) 80 (39.2) 204 (100) 5.16 (0.16) Basic 59 (59) 41 (41) 100 (100) Secondary 30 (50) 30 (50) 60 (100) Tertiary 28 (46.7) 32 (53.3) 60 (100) Father’s level of education No formal education 116 (61.1) 74 (38.9) 190 (100) 5.14 (0.16) Basic 31 (62) 19 (38) 50 (100) Secondary 37 (47.4) 41 (52.6) 78 (100) Tertiary 57 (53.8) 49 (46.2) 106 (100) Mother’s occupation Unemployed 28 (50) 28 (50) 56 (100) 6.41 (0.09) Public/civil servant 68 (50.4) 67 (49.6) 135 (100) Trader 136 (61.8) 84 (38.2) 220 (100) Retired 9 (69.2) 4 (30.8) 13 (100) Father’s occupation Unemployed 17 (81) 4 (19) 21 (100) 11.46 (0.01) Reference Public/civil servant 96 (49.2) 99 (50.8) 195 (100) 4.4 (1.4, 13.5) 0.01 Farmer 114 (61.6) 71 (38.4) 185 (100) 2.6 (0.9, 8.2) 0.09 Retired 14 (60.9) 9 (39.1) 23 (100) 2.7 (0.7, 10.8) 0.15 program to achieve its intended objectives [24]. Perhaps, low 80.0 70.0 compliance level in this current study might be a barrier for the 60.0 program to achieve its objective of addressing anaemia among 50.0 40.0 adolescent girls in the study area. 30.0 In this study, level of education and occupation of 20.0 mothers of adolescent girls, awareness of anaemia, and good 10.0 0.0 knowledge of anaemia and of the IFAS program were sta- Poor knowledge Good knowledge tistically associated with compliance with the IFAS. A similar Figure 3: Respondents’ knowledge of the IFAS program. study in Ethiopia also found good knowledge of anaemia and of the IFAS program as predictors of compliance [21]. always remind the teachers in charge of the IFAS program to Lack of knowledge or not receiving counselling on anaemia issue the IFA tablet to them every Wednesday. is associated with noncompliance with IFAS [25]. In this Prevention of anaemia and advice from teachers were study, the odds of complying with the IFAS were 2.1 times found to be the motivating factors for consuming the IFA tablet more likely among adolescent girls whose mothers had by the adolescent girls. ‘ese ndings agree with a cross- secondary education compared to adolescent girls whose sectional study conducted by Dhikale et al. [20] which also mothers had no formal education. ‘erefore, ensuring high found teachers as the motivating factor for the consumption of compliance in our study area will include the mounting of IFA tablets by schoolchildren. ‘erefore, educating adolescent e—ective health education strategies in the schools in order to girls and teachers on the IFAS program including its benets create awareness on anaemia, increase the adolescent girls’ will help facilitate regular consumption and compliance with level of knowledge of anaemia and of the IFAS program. the IFAS by the adolescent girls. It is important to note that Again, engaging mothers of adolescent girls will also con- compliance with the IFA regimen is very crucial for every IFAS tribute to the success of the IFAS program. Knowledge on IFA program Journal of Nutrition and Metabolism 9 Table 7: Association between sociodemographic characteristics and knowledge on the IFAS program. Knowledge on the IFAS program Independent variables Chi-square (p value) Poor knowledge Good knowledge Total, N � 424 Age group (years) 10–15 217 (64.2) 121 (35.8) 338 (100) 0.32 (0.57) 16–20 58 (67.4) 28 (32.6) 86 (100) Class JHS 1 122 (61.9) 75 (38.1) 197 (100) 1.39 (0.24) JHS 2 153 (67.4) 74 (32.6) 227 (100) Ethnicity Dagomba 190 (66) 98 (34) 288 (100) 4.04 (0.13) Mamprusi 11 (45.8) 13 (54.2) 24 (100) Others 74 (66.1) 38 (33.9) 112 (100) Religion Christianity 76 (67.9) 36 (32.1) 112 (100) 0.60 (0.44) Islam 199 (63.8) 113 (36.2) 312 (100) Mother’s level of education No formal education 141 (69.1) 63 (30.9) 204 (100) 9.92 (0.02) Basic 70 (70) 30 (30) 100 (100) Secondary 31 (51.7) 29 (48.3) 60 (100) Tertiary 33 (55) 27 (45) 60 (100) Father’s level of education No formal education 130 (68.4) 60 (31.6) 190 (100) 7.68 (0.05) Basic 38 (76) 12 (24) 50 (100) Secondary 47 (60.3) 31 (39.7) 78 (100) Tertiary 60 (56.6) 46 (43.4) 106 (100) Mother’s occupation Unemployed 38 (67.9) 18 (32.1) 56 (100) 8.39 (0.04) Public/civil servant 77 (57) 58 (43) 135 (100) Trader 154 (70) 66 (30) 220 (100) Retired 6 (46.2) 7 (53.8) 13 (100) Father’s occupation Unemployed 18 (85.7) 3 (14.3) 21 (100) 10.88 (0.01) Public/civil servant 117 (60) 78 (40) 195 (100) Farmer 129 (69.7) 56 (30.3) 185 (100) Retired 11 (47.8) 12 (52.2) 23 (100) Table 8: Association between the odds of good knowledge on the IFAS program and sociodemographic characteristics of respondents. Dependent variable: good knowledge on the IFAS program Unadjusted Adjusted Independent variables Frequency (%) OR 95% CI p value OR 95% CI p value Mother’s level of education No formal education 204 (48.1) Reference Basic 100 (23.6) 0.96 0.57, 1.61 0.88 1.00 0.59, 1.70 1.00 Secondary 60 (14.2) 2.09 1.16, 3.77 0.01 2.19 1.81, 4.07 0.01 Tertiary 60 (14.2) 1.83 1.02, 3.30 0.04 1.25 0.64, 2.42 0.51 Mother’s occupation Unemployed 56 (13.2) 0.63 0.33, 1.21 0.17 0.64 0.31, 1.31 0.22 Public/civil servant 135 (31.8) Reference Trader 220 (51.9) 0.57 0.36, 0.89 0.01 0.66 0.39, 1.10 0.11 Retired 13 (3.1) 1.55 0.49, 4.85 0.45 1.25 0.37, 4.29 0.72 Father’s occupation Unemployed 21 (5.0) 0.25 0.07, 0.88 0.03 0.29 0.08, 1.06 0.06 Public/civil servant 195 (46) Reference Farmer 185 (43.6) 0.65 0.43, 1.00 0.05 0.81 0.51, 1.29 0.37 Retired 23 (5.4) 1.64 0.69, 3.89 0.27 1.79 0.70, 4.60 0.22 10 Journal of Nutrition and Metabolism 90.0 78.8 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.9 8.3 6.8 10.0 2.8 2.6 1.4 0.0 No side Stomach Nausea Vomitting Black Headache Diarrhoea effect ache stool Figure 4: Respondents’ perceived side e—ects of IFA supplement. About 90.5% (67) of the adolescent girls stopped taking inadequate. ‘is was not surprising since the majority of the adolescent girls have never received education on anaemia. the IFA tablet in school because their parents asked them not to take the IFA tablet. ‘is nding agrees with a study Our ndings agree with studies conducted in Ethiopia (43.3%) [28] and Delhi (28.5%) [29] but di—er from a study conducted in India [1] which also identied parental re- sistance as one of the reasons for schoolchildren’s refusal to conducted in India (90.5%) [1]. Jalambo et al. in their study take IFA tablet. Perhaps, parents were not engaged before in Palestine also concluded that adolescent girls have poor enrolling in the IFAS program in the schools. Engaging knowledge of anaemia including its causes, prevention, and parents of the adolescent girls on the IFAS program during management [30]. Awareness and having good knowledge Parent Teacher Association (PTA) meetings in the schools of anaemia have the potential to inƒuence adolescent girls’ is crucial for the success of the program. Less than half of consumption of the IFA tablets [12]. Another study in the adolescent girls in this current study report taking the Ethiopia emphasized the fact that knowledge of anaemia is tablet without the supervision of teachers. ‘is deviates protective against the risk of anaemia among adolescent girls [28]. Further analysis revealed that the odds of having good from the IFAS program recommendation which requires teachers to directly supervise the adolescent girls to swallow knowledge of anaemia among adolescent girls whose fathers were public/civil servants were 4.4 times more likely as the IFA tablet. Supervising schoolchildren to ingest the IFA tablet is considered one of the most important aspects of compared to those adolescent girls whose fathers were the IFAS program in schools. Without supervision, the unemployed. ‘is might be due to the fact that public/civil possibility of schoolchildren throwing the tablet away is servants are mostly educated and might have discussed very high [26]. anaemia and its related programs with their adolescent girls Anaemia among adolescent girls can lead to problems at home. such as decreased concentration, poor school performance, We also found a poor level of knowledge of the ado- weakness, and irregular menstruation. Weekly IFAS is lescent girls on the IFAS program. A similar program therefore indicated to improve the iron status of adolescent evaluated in India also found poor knowledge of adolescent girls on IFAS pertaining to side e—ects of the IFA tablet girls and to counteract the negative e—ects of iron deciency anaemia [9]. Most of the adolescent girls in this study (29%) and unawareness of benets (32%) of taking the IFA tablet [26]. Poor level of knowledge on the IFAS program claimed intake of the IFA tablets has helped to improve their menstruation, concentration, and performance in school. might be due to adolescent girls not receiving education on ‘is nding agrees with the studies of Priya et al. [27] and the IFAS program from their teachers. As part of the Vishal et al. [15] conducted in an urban setting in India implementation of the IFAS program in the schools, school which also found improved menstruation, concentration, health coordinators were supposed to educate the adolescent and performance in school as positive e—ects of taking IFA girls on anaemia and on the IFAS program before the start of tablet. Girls with these positive experiences could be used as the program. role models to share their own experiences with their col- Majority of the adolescent girl report no side e—ects leagues in order to improve on the success of the IFAS associated with the consumption of the IFA tablet. However, popularly reported side e—ects were stomachache, nausea, program. We found a poor level of knowledge of the adolescent and vomiting. Stomach ache, nausea, and vomiting are popularly reported as side e—ects associated with the con- girls on anaemia. ‘is nding means that adolescent girls’ level of knowledge on meaning, causes, consequences, signs sumption of IFA tablets in other studies [7, 22, 26, 31]. Side and symptoms, and prevention of anaemia altogether was e—ects of the IFA tablet are one of the main reasons for Percent Journal of Nutrition and Metabolism 11 noncompliance with IFAS [7, 22]. (e success of the IFAS Conflicts of Interest program could be threatened by these side effects. (e authors declare no conflicts of interest. Unavailability of water in classrooms was seen as an obstacle for teachers to supervise the adolescent girls to ingest the tablet. (is finding disagrees with a study con- Acknowledgments ducted in Iran [22] where students had free and unlimited access to water to ingest the IFA tablet but agrees with a (e authors are thankful to the schools and the adolescent systematic review done by Apriani and Syafiq [24] which girls who participated in the study. found access to water as a challenge in implementing IFAS programs in schools. In the absence of water, adolescent girls References are given the IFA tablet to go in search of water in order to swallow it. [1] A. K. Sarada and S. A. (ilak, “Evaluation of weekly iron and According to the school health coordinators, the major folic acid supplementation programme for adolescents in challenge they face in implementing the IFAS program is the rural schools of Kannur, North Kerala, India: a cross-sectional refusal of adolescent girls to take the IFA tablet as the study,” International Journal of Medical Science and Public perceived tablet as family planning medicine. 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