Formative research in Ethiopia and Bangladesh: strengthening household survey measures of maternal micronutrient supplementation in low- and middle-income countries.

Background: As countries transition from implementing iron folic acid (IFA) to multiple micronutrient supplements (MMS) for pregnant women, they need accurate data on who is being reached with these interventions. The aim of our formative research in Ethiopia and Bangladesh was to design updated household survey questions, response options, and visual aids to measure coverage of prenatal micronutrient supplements. Methods: In phase I, we landscaped health providers and retailers to identify prenatal micronutrient products available in each country and interviewed currently pregnant women (CPW) and recently delivered women (RDW) about how they differentiated among micronutrient products. In phase II, we used these findings to draft survey questions and visual aids. In phase III, we iteratively tested and refined the draft tools through cognitive interviews with women. Results: We had 73 participants in Ethiopia and 132 in Bangladesh, encompassing CPW, RDW, healthcare workers, and retailers. Women in both contexts distinguished among micronutrient products based on colour, shape, packaging, and perceived purpose. In cognitive tests, women generally understood the English term 'iron' as a catch-all term for any iron-containing supplement. Women did not recognise any specific term for multivitamins or MMS. Shorter recalls of seven days or one month for adherence were feasible for respondents. Conclusions: It is challenging for the measurement community to identify terms and images that help women distinguish between supplement types. The final set of survey questions developed as part of this research is comprehensible and can be feasibly adapted and used in multi-topic surveys in MMS contexts, but requires validation.