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Understanding barriers in implementation and scaling up WIFS from providers perspective: A mixed‐method study, Rishikesh, India

Context: Since the implementation of Weekly Iron and Folic acid Supplementation (WIFS) program in India in 2013, little effort has been made to comprehensively evaluate the program. Aims: This study was carried out to assess the coverage of WIFS among adolescent girls, explore implementation barriers, and suggest solutions to improve WIFS through public schools in Rishikesh, India (2018–19). Methods and Materials: This was a sequential explanatory mixed-methods study. Quantitative component was a community-based cross-sectional survey to determine the prevalence of anemia and coverage of WIFS. Qualitative component added an explanation to understand WIFS implementation through document review and nonparticipant observation of WIFS session. We invited stakeholders for nominal group discussion on barriers and solutions. Statistical Analysis Used: Variables were described as proportion and mean. Group discussion transcript was analyzed using content analysis. Results: Of 400 adolescent girls, 16% (95% CI: 12.4, 19.6) received weekly and 45% ever received iron tablets over the last 3 months and 79% were anemic. From ten schools, one school never implemented WIFS. There was iron-folic acid (IFA) stock out for 10 months last year. Major barriers identified were nonavailability of IFA, and irregularity in submitting IFA consumption report. Suggested solutions were ensuring IFA stock, strengthening supervision, ownership, training, and regular meetings of stakeholders. Conclusions: To conclude, in a setting with high anemia prevalence, WIFS was poorly implemented. Ownership and strengthening supervision is essential for the success of the program.


Introduction
Globally, India has the largest adolescent population amounting to 253 million that corresponds to 20% of the total adolescent population. [1] Adolescence is a transition phase; characterized by growth spurt with the increased requirement of nutrient dietary allowances making them more vulnerable to iron deficiency anemia (IDA), as this extra amount is usually not met by diet. [2] Although anemia is prevalent globally, India is one of the most severely affected. [3] Among adolescents, 51% girls and 20% boys are anemic. [4] Various studies from India found the varied prevalence of anemia among adolescent girls ranging from 40-80%. [2,[5][6][7][8][9][10] In 2013, to combat anemia in adolescents, Government of India implemented 'Weekly Iron and Folic acid Supplementation (WIFS)'. Adolescents (girls and boys) in class VI to XII, enrolled in government/municipal schools were covered. School dropouts were covered through Anganwadi centers (AWC) across all states in India. [11] Studies have already proven the efficacy of weekly WIFS over daily iron supplementation in preventing anemia. [12][13][14] During 2000-2005, UNICEF had pilot tested the WIFS before its nationwide scaling up. [15] The WIFS program has been rarely evaluated since its universalization in India. We could find only two evaluation studies related to coverage of WIFS in Puducherry, a union territory across the eastern coast in south India. [16,17] The consumption of iron tablets among adolescents in these studies varied from 47% to 85%. We did not find evaluation studies of WIFS in other parts of India after 2012. To comprehensively review WIFS, we need a mix of quantitative and qualitative research methods. Since anemia is a major problem among adolescent girls with implications on maternal and child health, [18] we focused on the implementation of WIFS among adolescent girls. Moreover, the findings of the present study will help to identify gaps and recommend further strategies for effective implementation.
Therefore, in this study, we aimed to assess the coverage of WIFS over last 3 months among adolescent girls in a city of north India. We also wanted to understand how the WIFS program is being implemented in public schools and explore providers' perspectives into barriers and suggested solutions to improve WIFS implementation.

Study design
We conducted a sequential explanatory mixed-methods study involving a quantitative phase followed by a descriptive qualitative phase. [19] Quantitative phase was a community-based cross-sectional survey to determine coverage of WIFS in last 3 months. Qualitative component included a document review and non-participant observation of WIFS sessions in public schools to understand WIFS implementation. To explain the results of cross-sectional survey, we followed it up by exploring the barriers and suggested solutions to improve WIFS from providers' perspective using nominal group technique (NGT). [20] Setting Study site We conducted the study in Rishikesh, Dehradun, Uttarakhand (India), with an estimated adolescent population of 14,099 (22%) of which adolescent girls population was 7135. [21] A number of public schools providing secondary and higher secondary educations were ten (2018). The medical superintendent at district level worked in coordination with schools and ensures screening of adolescents with the help of medical officer, Rashtriya Kishore Swasthya Karyakram (RKSK -national adolescent health program) counsellor, and auxiliary nurse-midwife.
Specific setting WIFS program was launched in Rishikesh in 2012. According to operational framework, IFA tablets should be given weekly to all students from class VI to XII under supervision of class teachers. Principal nominates one nodal teacher from a science background who will procure, dispense, monitor, and supervise the program. Cluster resource coordinator (CRC) had been given the responsibility to distribute tablets as per demand. WIFS session should also be accompanied by behavior change communication sessions and screening for anemia. Class teacher has to fill up individual compliance card, class register format and forward to nodal teacher. The nodal teacher will further compile reports in monthly school format and forward it to principal further to block (sub district administrative unit) education officer and chief medical officer.

Study population and sampling
In a cross-sectional survey (July-November 2018), adolescent girls (10-19 years) residing in wards of Rishikesh irrespective of their enrolment in schools or type of schools were included. Considering 30% coverage of WIFS among adolescent girls, with 90% confidence interval, desired precision of 5%, correction of finite population (total number of adolescent girls 7135 approx.), adjusting for design effect of cluster sampling (1.5), and nonresponse rate of 10%, we determined a minimum sample size of 365. [22] We used cluster sampling considering population under coverage of each AWC as a cluster (n = 62). We selected twenty clusters using population proportional to size sampling. We selected 20 adolescent girls per cluster, totalling 400. If a particular household did not have an adolescent girl, we selected the next consecutive household on the list. In a household with more than one adolescent girl, we selected one randomly. We did not make revisits if an adolescent girl was absent at the time of the survey.
For the qualitative phase involving document review and observation of WIFS session (from Dec 2018 to Feb 2019), we included all ten public schools. For the qualitative phase involving NGT, we considered all stakeholders involved in the implementation of WIFS in schools in Rishikesh. We finalized a list of participants (n = 6) after brainstorming among investigators (purposive sampling) and it included block education officer, chief medical officer, CRC of the district, and child development project officer of the block, RKSK counsellor, and medical superintendent.

Data collection and sources of data
For the cross-sectional survey, we administered a structured questionnaire (Appendix 1) using a mobile data capture application called EpiCollect5 (Imperial College London). We assessed hemoglobin level using capillary blood drawn by finger prick and tested using digital hemoglobinometer, Hemocue 301, which is a point of care test.
For the qualitative phase involving document review and nonparticipant observation of WIFS session, we noted down observations in a semi-structured observation guide (Appendix 2).
The broad domains under which observations noted were i) logistics management ii) reporting, monitoring, and supervision and iii) process of dispensing of iron-folic acid (IFA) during sessions. Before the final observation, free observation for two to three visits was done to take care of the Hawthorne effect. [20] For qualitative phase involving NGT, all stakeholders (n = 6) attended discussion. At the start, moderator welcomed all group members, shared results of a cross-sectional survey, document review and nonparticipant observation of WIFS sessions, stated importance of discussion, and how the output will help to improve WIFS. Moderator also motivated group members to participate actively (see Appendix 3 for step by step procedure of NGT). We audio-recorded discussion and took field notes.
Qualitative research methods were applied by MK who is trained and experienced in qualitative research.

Data analysis
For cross-sectional survey, we exported the data in Microsoft Excel (Microsoft, Redmond, WA, USA) format and analyzed using EpiData analysis (version 2.2.2.183 EpiData Association, Odense, Denmark). We summarized the coverage of WIFS and prevalence of anemia (hemoglobin <11.5 g% for age group up to 11 years and <12 g% for 12-19 years) and severe anemia (hemoglobin <8 g%) [23] using proportion and 95% confidence interval (CI).
For the qualitative phase involving document review and nonparticipant observation of WIFS session, we summarized close-ended entries using frequency and proportions. For qualitative phase involving nominal group technique, after listing (of all problems and suggested solutions) and voting, we took a snapshot of tally sheet. Two independent trained researchers did a content analysis of nonparticipant observations' and NGT discussion transcripts (transcribed and translated from Hindi to English same day) and resolved discrepancies by discussion. [24] Ethics Institutional Ethics Committee, AIIMS Rishikesh, India (No. AIIMS/IEC/19/523) and Ethics Advisory Group of the International Union Against Tuberculosis and Lung Disease (The Union), Paris, France (No. 90/18) approved the study. We took relevant administrative approvals from state and school authorities prior to data collection. We took written informed consent (assent from adolescents and consent from parents in a cross-sectional survey and NGT participants) as applicable.

Document review and nonparticipant observation of WIFS session
Among 10 public schools, one school never implemented WIFS to date. Tables 1 and 2 depict implementation status of WIFS assessed through document review and nonparticipant observation of WIFS sessions.

Logistics management
In two schools, nodal teachers were aware of estimating demand for IFA tablet. Stockout was present in all schools with a mean period of 10 months. Annual frequency of receipt of IFA from block-level varied from 0-2. No demand was initiated from school. Two schools threw 2-3 months' stock due to the expiry of tablets. There was discordance between school sessions (April to March) and IFA receipt (January to December). The nodal teacher demanded drug only until the end of the current school session i.e. till the end of April.

Reporting, monitoring, and supervision
Five schools sent a "nil" report in the monthly format while rest send annually. Five of ten nodal teachers had received training for implementation of WIFS. No records of behaviour change communication sessions were made available. Two schools had screened children for anemia in last session. There was no record of a visit by ANM, medical officers or RKSK counselor in the last session.

Dispensing of IFA during weekly WIFS sessions
In schools with large strength, nodal teacher distributed tablets on first week of month and informed class teachers to give it on Mondays. In schools with small strength, students assembled in-ground and were given a tablet (weekly). Time taken for distribution and supervision of IFA tablets was 30 min to 1 h. Most of the students readily took tablets as instructed by the teacher. Some of them who refused were given a tablet to take at home.
Tablet was given on fixed day in seven schools after lunch. In eight schools, absent students were noted and the tablet was given to them on the next working day. No students were screened for anemia during sessions.
Only two schools (22%) gave tablets to students during the vacation period and maintained a record. In other schools, the nodal teacher either was unaware of giving tablet on vacation or had concern over safety. We observed a positive attitude of teachers towards program though few felt it increased their reporting work. Very few students denied taking tablets due to gastrointestinal upset or not being allowed by parents. One school had an emergency contact number of a nearby public hospital.

Nominal group technique
Barriers and suggested solutions to improve WIFS are depicted in Tables 3 and 4. On discussion with stakeholders, the main problem identified was nonavailability of IFA tablets, irregularity in IFA consumption report from school, lack of information to the teacher, the trained teacher being transferred out, and CRC not being a regular staff. Solutions suggested for this problem were adequate availability of IFA, strengthen monitoring and supervision, ownership of the education department, training of support staff of teachers, and regular block-level meetings. The detailed content analysis of discussion is presented below.
The main barrier in the implementation of WIFS was the nonavailability of IFA tablet. The problem of nonavailability of IFA was mainly due to little knowledge of the procurement process at the district level.
Participant #3 said, "There is no definite time of procurement. We distribute as and when received from the state". In addition, communication between the health and education departments was very limited. No monitoring or supervision of the program was done so the teacher fails to submit monthly consumption reports.
Participant #4 said "Training of nodal teacher though was done in 2014, later on, no refresher training was done. No teaching material was provided to train other teachers. Trained teachers got transferred, and CRC did not receive any training." It was also suggested that the principal should be involved in training.
Block officers in health department too were not well oriented.
Participant #1: "When the tablet was given at block level, then they sent it to primary health centers and then to auxiliary nurse-midwife. It did not reach up to adolescents." All participants agreed that capacity building was needed at all levels from teacher to block education officer and RKSK WIFS -weekly iron-folic acid supplementation; IFA -iron-folic acid; BEO -block education officer; IEC -information education communication WIFS -weekly iron-folic acid supplementation; IFA -iron-folic acid counselor to the medical officer and state drug store in the health department. No department was taking ownership of the program. Participant #4 suggested health officials should visit schools biannually. This will increase the morale of teachers and students too will develop confidence in the program.

Discussion
In a setting with high prevalence of anemia among adolescent girls from a city in north India, we report poor uptake of WIFS. This is further validated by document reviews, nonparticipant observation, and nominal group technique that showed gaps in the procurement of IFA tablets due to poor monitoring and supervising mechanism in public schools. Studies done on evaluation of WIFS in India after nationwide scaling were limited to coverage of WIFS. Present study comprehensively evaluated WIFS program using a mixed-methods approach.
There were two limitations. Firstly, the Hawthorne effect during the nonparticipant observation was possible but we tried to limit it through initial free observations. Secondly, we limited our qualitative exploration to public schools only, as barriers to utilization of AWC services were explored in our earlier study. [25] This study shows poor coverage of WIFS which is consistent with findings of studies by Priya et al. and Dikhale et al. [16,17] This is especially important considering the high prevalence of anemia in our setting (71%). Many studies done on a smaller scale reported a higher prevalence of anemia among adolescent girls that is consistent with this study. [7,9,26] These children with anemia should have been screened and identified to receive therapy for anemia. Considering the high prevalence of anemia, we recommend that all adolescent girls in public schools be tested for hemoglobin once a year. Those with anemia should be treated for anemia followed by WIFS after treatment completion. Screening and referral for anemia referral were poorly implemented. Following were reasons for poor implementation.
At first, IFA stockout was a key barrier. Lack of training led to a lack of awareness about procedures for procurement of tablets.
Each school was expected to make a requisition to CRC; however,    none of the school made any requisitions and relied on whatever supplies it received. Teachers did not immediately address these stockouts, as they perceived their role was limited to distribution. This IFA stockout is despite the allocation of dedicated funds for WIFS program in-state annual plan. [27] Ensuring regular submission of IFA consumption report and requisition from schools is expected to solve the problem of IFA nonavailability. When IFA stocks were available, conduct of WIFS sessions was mostly satisfactory. The nodal teacher was expected to consume tablets in front of students to build faith among student about the program. In our observation, teachers consumed it infrequently.
Secondly, reporting, monitoring, and feedback mechanism were weak though the timeline for each was mentioned in the program. [11] School administration is not answerable to the department of health and there is a felt need for them to own program. Each sector has been working independently of each other, without any formal working mechanism. Lack of coordination resulted in ineffective and inefficient implementation. This could be addressed through regular meetings of stakeholders from both the department. There is a need for memorandum of understanding with clear roles and responsibilities at each level evolving to collaborative relationships. [28] Thirdly, there was a lack of effective training of teachers and health personnel involved in the program. The training was done during the inception of the program, 2013. One day training is not sufficient to make teacher competent in executing the program.
The program should also consider the attrition of teachers. A study from Cameroon reported that poor training of health workers, the presence of unqualified supervisors, and lack of supplies and material were important barriers to implementation of reproductive healthcare. [29] Therefore we suggest that communication should be strengthened by providing targeted training and retraining for school health coordinators and healthcare personnel (CRC).
Lastly, we did not observe any use of information, education, and communication materials, or any social marketing strategy for community acceptance and involvement. A strong communication component was responsible for successful uptake of WIFS amongst adolescent girls in Tanzania and India. [13,30] One Philippine study demonstrated how the social mobilization of local officials and health personnel was integral to the social marketing strategy of a WIFS program. [31] The role of peers should be considered for better acceptance and demand generation. [32] Supply-chain management system, communication strategy, indicators of effectiveness, and operating costs of program needs to be observed, analyzed, and documented to formulate recommendations for the program in future. We further recommend carrying on comprehensive evaluation studies of WIFS in various other parts of India.

Conclusion
We conclude that there is a high prevalence of anemia among adolescent girls (90% school going) in the community and poor coverage and implementation of school-based WIFS in public schools of Rishikesh, India. We strongly recommend maintaining records of hemoglobin level for all schools-going adolescents followed by appropriate management. Nonavailability of IFA was the main concern for poor implementation of WIFS which was found to be a due delay in receipt of the demand-consumption report and inadequate training of teachers. There is a gap in documentation, reporting, and monitoring with limited communication between stakeholders. There is need for targeted training for school authorities and health personnel. Collaborative efforts and sense of ownership from the health and education department are needed for successful implementation of the program. Optimum (proper) Storage condition of IFA tablet (dark, dry place away from direct sunlight, the packaging in good condition and not tempered) Completeness of Individual compliance card (last 3 months atleast 5% of total students selected randomly from each class)

Mention number of cards examined
Completeness of Class-wise monthly registers in last 3 months in aleast 5% of classes Mention total no classes Completeness of monthly school report in last 3 months Is the information consistent with all the reports Timely submission of monthly school report by 5 th of following month to BEO in last 3 months: Submission of copy of monthly school report to ANM in last 3 month Records of IEC/Awareness activities with students and parents in last 3 month (if available, then mention number) Records of Number of students screened for anemia by teacher (if available, then mention number)) Number of students referred for possible presence of anaemia to health facility in last 1 year (if available, then mention number) Visit by ANM in last 3 month Minutes of meeting regarding WIFS in school last year (mention frequency and note the details for content analysis) Any other observation:

Item
Yes No Remark Is WIFS session planned on fixed day i.e Monday every week Who gives a IFA tablet to students × × At what time the tablet is given (morning. After lunch or some other) × × Is it supervised by nodal teacher Do nodal teachers themselves consume the tablet in front of student Is session accompanied by nutrition and health education sessions Do teachers screen student for anaemia Do teacher keeps record of student taking tablet Is the attempt made to make the non-complaint or absent student to take the tablets Mechanism to give IFA to children during vacation period in last years Is phone number of health dept available for emergency