Using an experience-based co-design approach to identify touchpoints and develop strategies for implementing an intravenous iron intervention for pregnant women with moderate and severe anaemia in Malawi

Abstract

Abstract Background In low- and middle-income countries, women experiencing anaemia during pregnancy are recommended to take 30 mg to 60 mg of oral iron daily throughout pregnancy. However, oral iron tablets are often poorly tolerated, resulting in low adherence. An alternative to oral iron is intravenous (IV) iron, which is commonly used in high-income countries to enable the rapid restoration of the body’s iron stores. A randomised controlled trial in Malawi is underway to investigate the effectiveness and safety of IV iron compared to standard of care oral iron supplementation to pregnant women with moderate and severe anaemia in in the third trimester (REVAMP-TT). However, strategies for informing the successful implementation of REVAMP-TT trial remain largely unknown. This study used a co-design approach to address this gap. Methodology: The co-design process involved two phases: 1) Information gathering—which included conducting interviews with key informants and gathering previous findings from a qualitative formative study on the perceptions and experiences of IV iron treatment for pregnant women experiencing anaemia in Malawi (n = 52) to identify the touchpoints; 2) Two co-design workshops with end-users (n = 20) and healthcare providers (n = 20) to develop strategies for the implementation of REVAMP-TT trial. We mapped the touchpoints to the Consolidated Framework for Implementation Research 2.0 (CFIR 2.0) and matched the strategies to Expert Recommendations for Implementing Change (ERIC) according to the CFIR-ERIC matching tool. Results The following touchpoints were identified: cost of IV iron, lack of available resources and knowledge, local attitudes including myths and misconceptions of IV iron, local conditions affecting access to antenatal care, lack of political will and buy-in from high-level leaders, lack of capability from healthcare providers to deliver IV iron and lack of male involvement to support pregnant women accessing care. The suggested strategies included: providing financial strategies, developing stakeholder relationships, training and educating stakeholders, supporting clinicians, and engaging end-users. Conclusion We found that the ability of pregnant women in Malawi to access anaemia screening and treatment depends on the ability to address the perceived obstacles. We developed information, education and communication materials about the risks and consequences of anaemia during pregnancy and treatment to improve the recruitment of pregnant women with anaemia in REVAMP-TT trial. Engaging end-users and relevant stakeholders ensured that the IV iron intervention is tailored to meet their needs, and the implementation strategies are culturally appropriate.