Social determinants and socioeconomic inequalities in adherence to antenatal iron-folic acid supplementation in urban and rural Indonesia

Full text

ORIGINAL RESEARCH
AUTHORS
Bunga A Paramashanti PhD, Researcher * [https://orcid.org/0000-0001-6066-2039]
Esti Nugraheny PhD, Researcher [https://orcid.org/0000-0001-9146-0755]
Suparmi Suparmi MSc, Researcher [https://orcid.org/0000-0002-1319-0961]
Tin Afifah MSc, Researcher [https://orcid.org/0000-0003-1057-6778]
Wahyu Pudji Nugraheni PhD, Researcher [https://orcid.org/0000-0002-7129-809X]
Yuni Purwatiningsih MSc, Researcher [https://orcid.org/0000-0002-1758-8803]
Oktarina Oktarina MSc, Researcher
Muhammad Agus Mikrajab MPH, Researcher [https://orcid.org/0000-0001-7774-476X]
Effatul Afifah PhD, Lecturer [https://orcid.org/0000-0002-1775-7822]
Yhona Paratmanitya PhD, Lecturer [https://orcid.org/0000-0002-0193-3641]
CORRESPONDENCE
*Dr Bunga A Paramashanti pshanti.bunga@gmail.com
AFFILIATIONS
Research Center for Public Health and Nutrition, National Research and Innovation Agency, West Java 16914, Indonesia
Alma Ata Graduate School of Public Health, Universitas Alma Ata, Yogyakarta 55183, Indonesia
Department of Nutrition, Faculty of Health Sciences, Universitas Alma Ata, Yogyakarta 55183, Indonesia
PUBLISHED
8 November 2024 Volume 24 Issue 4
Rural and Remote Health www.rrh.org.au
James Cook University ISSN 1445-6354
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HISTORY
RECEIVED: 12 September 2023
REVISED: 2 August 2024
ACCEPTED: 7 August 2024
CITATION
Paramashanti BA, Nugraheny E, Suparmi, S, Afifah T, Nugraheni WP, Purwatiningsih Y, Oktarina, O, Mikrajab MA, Afifah E, Paratmanitya
Y.Social determinants and socioeconomic inequalities in adherence to antenatal iron–folic acid supplementation in urban and rural
Indonesia. Rural and Remote Health 2024; 24: 8722. https://doi.org/10.22605/RRH8722
This work is licensed under a Creative Commons Attribution 4.0 International Licence
ABSTRACT:
Introduction: Adherence to iron–folic acid supplementation (IFAS)
has been linked with maternal anaemia. While findings about
determinants of IFAS adherence have been mixed across different
research, there is inadequate evidence in relation to
socioeconomic inequalities. This study aims to examine social
determinants and socioeconomic inequalities of adherence to IFAS
in urban and rural Indonesia.
Methods: We conducted a secondary analysis of the 2017
Indonesia Demographic and Health Survey by including a total of
12 455women aged 15–49years. The outcome was adherence to
IFAS for at least 90days. We used multiple logistic regression
analysis adjusted for the survey design to analyse factors
associated with IFAS adherence. We estimated socioeconomic
inequalities using the Wagstaff normalized concentration index
and plotted them using the concentration curve.
Results: About half of women consumed IFAS for at least 90days,
with a higher proportion in urban areas (59.0%) than in rural areas
(47.8%). Social determinants of adherence to IFAS were similar for
urban and rural women. Overall, being an older woman, having
weekly internet access, antenatal care for at least four visits, and
residing in Java and Bali were significantly linked to IFAS
adherence. Higher maternal education was significantly linked to
IFAS adherence in urban settings, but not in rural settings. There
were interactions between place of residence and woman’s
education (p<0.001) and household wealth (p<0.001).
Concentration indices by woman’s education and household
wealth were 0.102 (p<0.001) and 0.133 (p<0.001), respectively,
indicating pro-educated and pro-rich inequalities. However, no
significant education-related disparity was found among rural
women (p=0.126).
Conclusion: Women (age, education, occupation, birth number,
internet access, involvement in decision-making), household
(husband’s education, household wealth), health care (antenatal
care visit) and community (place of residence, geographic region)
factors are associated with overall adherence to IFAS. These factors
influence the adherence to IFAS in a complex web of deep-seated
socioeconomic inequalities. Thus, programs and interventions to
improve adherence to IFAS should target women of reproductive
age and their families, particularly those from socioeconomically
disadvantaged groups residing in rural areas.
Keywords:
demographic and health survey, Indonesia, inequalities, iron–folic acid, socioeconomic inequality, supplementation, urban.
FULL ARTICLE:
Introduction
Anaemia is a prominent women’s health concern worldwide,
particularly in lower- and middle-income countries and it has also
been associated with adverse pregnancy outcomes . WHO
defines pregnancy anaemia as a haemoglobin concentration less
than 11.0g/dL. Anaemia becomes a serious public health issue
when its prevalence reaches greater than 5.0% of the
population .Globally, the prevalence of anaemia in pregnancy is
36.8%, with the highest prevalence in Africa (41.7%), followed by
Asia (40.0%) . A nationally representative survey in Indonesia, Basic
Health Research, reported that the prevalence of pregnancy
anaemia in the country increased from 37.1% in 2013 to 48.9% in
2018, and in 2018 the prevalence in pregnant women aged
15–24years was 84.6% .
Iron deficiency anaemia (IDA) is the most typical anaemia in
pregnancy. During this period, the risk of iron deficiency increases
following the increased demand for iron in the mother for the
formation of red blood cells, and placenta and fetus development.
IDA is associated with poor birth outcomes, including preterm
birth, cesarean delivery, blood transfusion, low birth weight and
low APGAR (appearance, pulse, grimace, activity, respiration)
score . In severe cases, IDA may increase the risk of maternal
death and adverse fetal development . Also, it has a long-term
impact on children’s psychomotor and neurocognitive
development, as well as mental health .
Following global recommendations , the Indonesian government
made several efforts to reduce IDA in pregnancy. One of these was
providing pregnant women with daily iron–folic acid
supplementation (IFAS) during antenatal care visits . IFAS
treatment for 90days every consecutive day during early
pregnancy has been linked to reduced maternal anaemia and
improved birth outcomes . However, such a program is not
without constraints. Various factors affect antenatal IFAS in low-
and middle-income countries. For example, an Ethiopian study
found that women did not take IFAS due to a lack of access to
health facilities during pregnancy and limited information on the
utilization of IFAS . Delays in pre-existing anaemia diagnosis and
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treatment, poor access to IFAS and limited antenatal care
counselling on IFAS recommendations are reported reasons for
IFAS underutilization in Niger . Poor access and quality of
antenatal care services (eg low IFAS supply, inadequate counselling
to encourage IFAS consumption) were barriers to antenatal IFAS in
seven African and Asian countries . In Indonesia, antenatal IFAS is
challenged by a lack of coverage, various brands in which iron–
folic acid content does not meet the standard, consumption that
does not start early in pregnancy, low quality of IFAS education
and lack of database .
Previous studies have identified factors influencing adherence to
taking IFAS, including antenatal care visits, previous history of
anaemia, knowledge of anaemia, knowledge of IFAS and
suggestions from husbands . A systematic review study
has shown that pregnant women who obtained information about
IFAS and had adequate knowledge about IFAS were twice as likely
to have good adherence to IFAS . IFAS can also be influenced by
socioeconomic factors such as maternal education and
household wealth . However, existing studies have shown
mixed results, including in Indonesia .
Socioeconomic inequalities may pose a significant challenge to
optimal IFAS adherence. While earlier studies have suggested
socioeconomic inequalities in IFAS , these were limited to the
analysis of determinants adjusted for socioeconomic strata, with
no particular analysis aiming to quantify socioeconomic inequality.
Some nationally representative Indonesian studies have been
conducted to identify factors associated with IFAS among pregnant
women. Nevertheless, there were differences in how the outcome
was measured, such as receiving iron tablets , the consumption of
iron tablets , the consumption of at least 90 iron tablets and the
non-utilization of IFAS . Other Indonesian studies only involved
small sample sizes and restricted geographic areas . To our
knowledge, no socioeconomic inequality study in adherence to
IFAS has been conducted in the Indonesian context. Therefore, the
present study aims to fill research gaps by examining social
determinants and socioeconomic inequality in adherence to
antenatal IFAS in rural and urban settings in Indonesia. Findings
from this study may contribute to formulating appropriate policies
and interventions to enhance antenatal IFAS adherence, thus
better maternal nutrition and health outcomes.
Methods
Data source and study population
We used nationally representative data from the 2017 Indonesia
Demographic and Health Survey (IDHS), the most updated DHS
data for Indonesia. Administratively, Indonesia consisted of 34
provinces in 2017. Provinces are the largest subdivisions, followed
by municipalities/districts and rural–urban villages. Using a two-
stage stratified sampling design, the survey applied probability
proportional to size to select primary sampling units or census
blocks. The unit size was the number of households based on the
2010 population census. The census block was then stratified by
rural–urban villages with implicit stratification in each stratum by
sorting the census block based on the wealth index category. After
that, 25 households were chosen systematically from each census
block. Finally, the present study included all women aged
15–49years with a child born in the 5years preceding the survey.
IDHS provides detailed information on sampling procedures
elsewhere .
Outcome variable
The outcome variable was antenatal IFAS adherence. We used two
IDHS questions to determine the utilization of IFAS: ‘During this
pregnancy, were you given or did you buy any iron tablets or iron
syrup?’ and ‘During the whole pregnancy, for how many days did
you take the tablets or syrup?’ . We then categorized the
adherence to IFA supplementation as ‘less than 90 tablets’ or ‘90 or
more tablets’.
Explanatory variables
We included several social determinants of health as our
explanatory variables based on WHO’s theoretical framework of
social determinants of health , previous research findings of
factors of IFAS adherence and the availability of variables in
the 2017 IDHS . We then grouped these variables by several
characteristics of the women (age, educational level, occupation,
birth number of current pregnancy, weekly media exposure,
weekly internet access, involvement in decision-making),
household factors (husband’s educational level, household wealth),
healthcare factors (antenatal care visits) and community factors
(urban or rural residence, geographic region). Household wealth
was estimated using the principal component analysis on a
cumulative wealth score for each household based on assets,
including amenities and infrastructure. Based on these scores,
households were then ranked in five equal categories, each with
20% of the population: poorest, poorer, middle, richer and
richest .
Statistical analysis
First, we used descriptive statistics to obtain the proportion of IFAS
adherence across the explanatory variables. Taylor series linear
approximation was applied to estimate the 95% confidence
interval (CI) around its proportion.Second, we performed
univariate logistic regression to examine the relationship between
each explanatory variable and the IFAS adherence measured by
crude odds ratios (OR). Third, we included variables with p<0.25 to
multiple logistic regression to create a full baseline model. We kept
the mother’s age , mother’s educational level , maternal
involvement in decision-making , household wealth and
place of residence as fixed variables in the multivariate
analysis, regardless of their significance. We used a manual
backward elimination method to remove the least important
variables one by one beginning with the baseline model. We
presented adjusted odds ratios (AOR) in the final model.
Last, we used maternal education and household wealth as
indicators of socioeconomic inequalities . We determined the
socioeconomic inequalities in IFAS adherence using the Wagstaff
normalized concentration index for the binary outcome . We
also plotted the concentration curve to present the cumulative
proportion of IFAS adherence (y-axis) against the cumulative
proportion of the women, sorted by their education and
household wealth (x-axis) . A positive value for concentration
index or a curve below the line of equality means that IFAS
adherence is more concentrated among higher socioeconomic
groups. Conversely, a negative concentration index or a curve
above the line of equality suggests that IFAS adherence is more
concentrated among lower socioeconomic groups. A zero value
indicates the absence of socioeconomic inequalities .
We used Stata v17.0 (StataCorp, https://www.stata.com) for all
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statistical testing and applied ‘svy’ commands to adjust the
complex sampling design by including sampling weight, strata and
cluster. We set the level of significance at p<0.05.
Ethics approval
The 2017 IDHS received ethics approval from the Institutional
Review Board of ICF International (reference number:
FWA00000845) and was conducted after acquiring the written
informed consent of the study participants, adhering to the
principles of the Declaration of Helsinki. The present study uses
publicly available data for scientific use with de-identified
information and was thus exempt from ethics approval.
Results
Characteristics of study participants and proportion of iron–
folic acid supplement adherence
Table1 presents the distribution of adherence to antenatal IFAS
across different determinants. We included a total of 12
455women aged 15–49years in the analysis. Overall, the
percentage of adherence to antenatal IFAS was 53.4%. The
proportion of adherence to taking at least 90 tablets was lower
among women with the following characteristics: aged 15–19years
(45.0%), no or incomplete primary school (43.1%), working in the
agricultural sector (39.4%), without weekly internet access (47.5%),
not involved in decision-making (46.8%), whose husbands had
none or incomplete primary school (41.3%), from the poorest
families (43.0%), with fewer than four antenatal care visits (20.0%).
The proportion of IFAS adherence was higher among those who
lived in urban areas (59.0%), and in Java and Bali (63.5%). Table2
shows detailed proportions of adherence to antenatal IFAS in
urban and rural areas.
Table1:Characteristics of study participants and proportions of antenatal IFAS adherence in Indonesia (n=12 455), based on
data from 2017 Indonesia Demographic and Health Survey

Table2:Characteristics of study participants and proportions of antenatal IFAS adherence in urban and rural Indonesia (n=12
455), based on data from 2017 Indonesia Demographic and Health Survey
Social determinants of iron–folic acid supplement adherence
Tab l e 3 presents crude and adjusted odds ratios of IFAS adherence
determinants. Overall, the likelihood of IFAS adherence increases
with the women’s age. In other words, the results showed that a
1-year increase in maternal age was associated with a 1%
improvement in relative risk for overall IFAS adherence (AOR 1.01;
95%CI 1.00–1.02, p=0.009). However, we found no association
between the woman’s age and IFAS adherence when analysing the
relationship based on urban (AOR 1.01; 95%CI 0.99–1.02, p=0.082)
and rural (AOR 1.01; 95%CI 0.99–1.02, p=0.075) areas. There was
no significant relationship between the woman’s educational level
and IFAS adherence, except in urban areas indicating that
completing secondary school (AOR 1.49; 95%CI 1.03–2.16,
p=0.033) and higher education (AOR 1.66; 95%CI 1.09–2.53,
p=0.019) was associated with IFAS adherence among urban
women. Our study shows that weekly internet access was
significantly related to IFAS adherence across the living areas.
Altogether, although Table3 shows that women whose husbands
completed higher education had 34% greater odds of consuming
IFAS (95%CI 1.03–1.75, p=0.031), particularly, urban women whose
husbands completed higher education had 55% higher odds of
taking IFAS (95%CI 1.06–2.28, p=0.025). No significant association
could be identified between the husband’s education at all levels
and IFAS adherence in rural areas. Despite a dose–response
relationship between household wealth and IFAS adherence in
bivariate analysis, we found no significant association between
these variables after adjusting for other variables.Women with a
history of antenatal care for at least four visits were three to four
times more likely to take IFAS across the place of residence.
Compared to those who lived in Java and Bali, women in all

regions were less likely to consume IFAS, except for urban women
who lived in Kalimantan (AOR 0.75; 95%CI 0.56–1.00, p=0.052).
Furthermore, we performed interaction analyses between woman’s
education and place of residence, and household wealth and place
of residence. Figure1 depicts that the probability of IFAS
adherence generally increases with the level of education among
women residing in urban areas but remains stagnated in rural
areas. In urban areas, the probability of IFAS adherence is higher
for those who completed secondary school or above. Likewise,
Figure2 presents the probability of IFAS which gradually increases
with household wealth in urban areas but shows no considerable
change across household wealth in rural areas. The probability of
IFAS adherence in urban is higher for women with middle income
and above. Overall, the difference in probabilities of IFAS
adherence across place of residence changes across women’s
educational attainment and household wealth, suggesting
interaction effects.
Tab l e3:Determinants of antenatal iron–folic acid supplementation adherence among women aged 15–49years in Indonesia
showing crude and adjusted odds ratio, based on data from 2017 Indonesia Demographic and Health Survey

Figure1:Combined effect of woman’s educational level and place of residence (p<0.001), based on data from 2017 Indonesia
Demographic and Health Survey.
Figure2:Combined effect of household wealth and place of residence (p<0.001), based on data from 2017 Indonesia
Demographic and Health Survey.
Socioeconomic inequalities in iron–folic supplement adherence
As shown in Table4, the concentration indices for antenatal IFAS
adherence, ranked by the woman’s education, were estimated at
0.102 (standard error (SE) 0.013, p<0.001) overall in both settings
and 0.132 (SE 0.018, p<0.001) in women living in urban areas. The
positive value of concentration indices indicates that educated
women had higher adherence to antenatal IFAS. Nevertheless,
there was a non-significant concentration of IFAS uptake among
the more highly educated population in rural areas (p=0.126).
Similarly, the positive value of concentration indices ranked by
household wealth suggests that women from richer families had

greater adherence to antenatal IFAS in all locations.
Figures 3 and 4 present the concentration curves for IFAS
adherence among women aged 15–49years, ranked by woman’s
education and household wealth, respectively. As illustrated, all
concentration curves lie below the line of equality, confirming that
the percentage of IFAS adherence is greater in women with higher
education and in wealthier households. It means that there were
pro-educated and pro-rich inequalities in the adherence to IFAS.
The greater the degree of disparity, the further the curves depart
from the line of equality. However, following the results from
Table4, the concentration curve for IFAS adherence ranked by
woman’s education in rural areas does not show substantial
inequality (Fig3).
Table4:Wagstaff normalized concentration index of antenatal iron–folic acid supplementation adherence by woman’s
education and household wealth), based on data from 2017 Indonesia Demographic and Health Sur vey
Figure3:Concentration curves of antenatal iron–folic acid supplementation adherence ranked by woman’s education overall,
and in urban and rural areas, based on data from 2017 Indonesia Demographic and Health Survey.
Figure4:Concentration curves of antenatal iron–folic acid supplementation adherence ranked by household wealth overall, and
in urban and rural areas, based on data from 2017 Indonesia Demographic and Health Survey.
Discussion
The present study examined social determinants and
socioeconomic inequalities in adherence to IFAS in 12 455
Indonesian women aged 15–49years with a child born in the
5years preceding the 2017 IDHS. The current analysis reported
approximately half of these women took daily IFAS for a minimum
of 90days. Adherence to at least 90days of IFAS was linked to
maternal age, access to the internet, frequency of antenatal care
visits and geographic location.Moreover, the proportion of
women with adherence to IFAS was more concentrated among
educated women and in wealthier households.
Woman’s age was significantly associated with adherence to IFAS.
This finding aligned with previous studies conducted in Ethiopia,
Indonesia, and other low- and middle-income countries in Asia,
Africa, Latin America and the Caribbean where the odds of
adherence were higher among older women . Older women
had a higher risk of anaemia or iron deficiencies; therefore, they
were more compliant in taking IFAS during pregnancy and
particularly being targeted by health workers during the anaemia
prevention program . Older women tend to have better
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knowledge and awareness about IFAS importance . While these
findings support the need for targeted IFAS to specific vulnerable
groups, it is also important to note that IFAS should cover all
pregnant women across the nation to reduce pregnancy anaemia.
Maternal weekly access to the internet was also related to IFAS
adherence. Following previous studies, the internet has become a
valuable tool for accessing information, including about IFAS .
Also, internet access could provide opportunities to connect with
online communities and support groups who had similar concerns,
including sharing personal experiences and emotional support for
women . Thus, internet-based education can be an alternative to
delivering information on pregnancy nutrition and health,
including anaemia and IFAS.
The present study indicated a significant relationship between the
husband’s education and IFAS adherence, particularly for those
men with higher education overall and in urban areas. Our result
was in line with previous research suggesting that husbands with
low educational attainment were a predictor for non-utilization of
IFAS . Husbands with better education tend to understand
pregnancy risks and be more engaged with pregnancy health .
Nevertheless, we found no significant association between the
husband’s education at all levels and IFAS adherence in rural areas.
While knowledge can be gained from various sources, our findings
highlight the need for community-based education for husbands.
Thus, involving husbands in women’s nutrition and health
programs, including IFAS, will likely enhance the program’s impact.
Following previous studies , this study found that antenatal
care for at least four visits was significantly linked to IFAS
adherence. The possible reason is that IFAS is distributed during
the antenatal visits. Those who did not come for antenatal care
might not receive IFAS. Additionally, those who attended antenatal
care for at least four visits may have done so because they were
health conscious, and knew the importance of adhering to IFAS.
Another reason for this is that health providers would advise
pregnant women about IFAS during their antenatal visits, which
may enhance their knowledge and awareness, thus adhering to
IFAS and better managing its side effects . Therefore, increasing
the coverage and quality of antenatal care is required to improve
pregnant women’s adherence to IFAS.
Living in Java and Bali was associated with the likelihood of IFAS
adherence.Women who lived in the Java and Bali regions were
more advantaged than those living in other regions. The
explanation could be that the coverage of antenatal care services
in Java and Bali was higher than the national coverage and
among the highest of all other regions in Indonesia . Java and
Bali have also been recognized for their quality health facilities,
infrastructure and health professionals . Thus, despite the widely
spread geographic areas in the country, healthcare equity should
be implemented across Indonesia to reduce the burden of
accessing quality healthcare services.
Although there were no significant associations between woman’s
education and household wealth and adherence to IFAS, our study
suggests interaction effects between woman’s education and
household wealth and place of residence, indicating
socioeconomic inequalities in IFAS in rural and urban
areas.Moreover, while the concentration indices indicated
education- and wealth-related inequalities in IFAS, the magnitude
of inequalities between rural and urban was different. This could
be because women’s education in rural areas tends to be more
homogenous as shown in our interaction analyses, thus having
similar knowledge and adherence to IFAS. Supporting this finding,
Statistics of Indonesia has reported that the proportion of the
population with primary education was similar between rural
(96.9%) and urban (98.6%) areas, but differed in high school
education, with 55.5% in rural and 73.9% in urban areas . Thus,
enhancing household economic status may reduce the gap in IFAS
adherence between rural and urban areas of Indonesia. While
there is no significant relationship between the woman’s education
and IFAS adherence in rural areas, educating women about the
importance of IFAS and overall pregnancy health and nutrition
should be of importance. Such interventions should not be limited
to formal education, but also be in informal educational platforms,
including education based in health facilities, communities, and
through media.
To our knowledge, this is the first study in Indonesia to estimate
socioeconomic inequalities in IFAS. While existing international
studies assessed inequalities in IFAS adherence using analysis of
determinants , we performed specific inequality analysis using
concentration indices by woman’s education and household
wealth to quantify the socioeconomic inequality. Statistical
analyses throughout this study were adjusted for the IDHS survey
design, including sampling weight, clustering and stratification.
The use of various social determinants of IFAS adherence is useful
for identifying the immediate and root causes of IFAS. However,
the nature of this cross-sectional survey did not allow us to draw a
causal inference. Also, this study might have recall bias since the
number of days of IFAS consumption was purely based on the
women’s recall.
Conclusion
Overall adherence to antenatal IFAS was associated with various
factors: the women (age, education, occupation, birth number,
internet access, involvement in decision-making), household
(husband’s education, household wealth), health care (antenatal
care visit) and community (place of residence, geographic region).
There were also pro-educated and pro-rich inequalities in overall
adherence to antenatal IFAS. Nevertheless, there was no significant
association between woman’s education and adherence to
antenatal IFAS and no education-related disparity in adherence to
antenatal IFAS among women in rural areas. Thus, programs and
interventions to improve adherence to IFAS should target women
of reproductive age and their families, particularly those from
socioeconomically disadvantaged groups residing in rural areas.
Such efforts may include enhancing information, education and
counselling during antenatal care, and improving the use of the
internet and online social media for health information.
Acknowledgements
We thank the Demographic and Health Survey for providing access
to the 2017 Indonesia Demographic and Health Survey data for
this study.
Funding
No funding was received for this research
Conflicts of interest
The authors have no conflicts of interest to declare for this study.
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