The Determinants Associated With Adherence to Iron-folic Acidsupplementation Among Adolescent Girls in Jhs: A Cross-sectional Study at Mawuli Junior High School, Volta Region

The Determinants Associated With Adherence to Iron-folic Acidsupplementation Among Adolescent Girls in Jhs: A Cross-sectional Study at Mawuli Junior High School, Volta Region | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Determinants Associated With Adherence to Iron-folic Acidsupplementation Among Adolescent Girls in Jhs: A Cross-sectional Study at Mawuli Junior High School, Volta Region Francisca Tsidih, Samuel Antwi, Daniel Aboagye, Juliana Yartey Enos This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8842850/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 16 You are reading this latest preprint version Abstract Background Iron and folic acid (IFA) supplementation is essential for improving the nutritional status of adolescent girls and preventing related health issues. However, adherence to IFA supplementation remains a significant challenge in many Ghanaian school settings. Objective This study aimed to provide insights into adherence to IFA supplementation among adolescent girls and identify strategies to improve their nutritional status. Method The study was conducted at Mawuli Junior High School in the Volta Region of Ghana, selected as a representative public junior high school with a large population of adolescent girls. The study involved girls aged 13 to 18 years in Forms 2 and 3. A sample of 350 participants was selected using simple random sampling. Data were collected through structured questionnaires and analysed using descriptive and inferential statistics. Results Awareness of IFA programs in school was strongly associated with receiving and taking supplements (AOR = 8.54, 95% CI: 3.12–23.36, p 0.05). A strong association was found between frequency of intake and adherence (AOR = 5.99, 95% CI: 2.45–14.65, p < 0.001). Logistic regression showed that hearing of IFA programs in school significantly predicted adherence (AOR = 8.78, 95% CI: 2.91–26.45, p = 0.003). Although knowledge of IFA benefits was not a significant predictor of supplement intake overall (p = 0.155), the perceived importance of adherence increased the likelihood of initiation (AOR = 8.54, 95% CI: 2.33–21.65, p = 0.003). Forgetfulness emerged as the most common barrier to regular intake, followed by fear of side effects, lack of knowledge, and unavailability of supplements. Conclusion Strategies to improve adherence should focus on enhancing knowledge and attitudes toward IFA supplementation, addressing practical barriers such as forgetfulness and side effects, and integrating supplementation into adolescents’ daily routines. The study provides valuable insights into factors influencing adherence and offers direction for strengthening school-based IFA programs. Iron-Folic Acid Supplementation Adolescent Girls Adherence Determinants Junior High School Nutrition School-Based Program Volta Region Ghana INTRODUCTION According to the World Health Organisation (WHO, 2023; Geneva & WHO, 2011), as cited by Gosdin et al. ( 2021 ), the main cause of mortality and morbidity among teenage girls aged 10 to 19 worldwide is iron deficiency anaemia. If the issue is not resolved, the burden of adolescent anaemia will carry over into the next generation (Silitonga et al., 2023 ; Ejara et al., 2023 ). The need for improved nutrition, particularly iron intake, increases during adolescence (Dubik et al., 2019 ; Angadi & Balu, 2019 ; Cohn, 2014 ). Anaemia caused by iron and folic acid deficiency accounts for 1.45% of all years of life lost to disability globally (Desta et al., 2019 ). Short-term consequences include reduced immunity, decreased metabolism, low aerobic capacity, increased susceptibility to disease, lethargy, exhaustion, and poor concentration (Balarajan et al., 2011 ; Beard, 2000 ; Nokes et al., 1998 ; Gosdin et al., 2021 ). Iron deficiency causes over half of all anaemia cases, affecting over two billion people worldwide, with 30–50% residing in developing countries (Lyoba et al., 2020 ). Adolescence is a critical developmental stage that forms the foundation for productivity and well-being later in life (Yidana et al., 2020 ). It is also considered an optimal period for anaemia prevention strategies, laying the nutritional groundwork for future reproductive health (Dubik et al., 2019 ; UNICEF & MoH, 2017). Iron deficiency anaemia (IDA) remains a major cause of disability-adjusted life years among adolescent girls globally and heightens risks during adolescent pregnancy (Antwi et al., 2025 ; WHO, 2011; WHO, 2023). In nations where anaemia prevalence exceeds 20%, the WHO recommends periodic iron supplementation for all adolescents (Silitonga et al., 2023 ), supported by evidence that iron and folic acid supplementation (IFAS) is a cost-effective strategy (Mhango, 2022 ). Despite these global recommendations, many adolescent girls, especially those in low- and middle-income settings, continue to face difficulties adhering to IFAS regimens. This situation poses a challenge to achieving meaningful anaemia reduction. Schools represent an ideal platform for reaching large numbers of adolescents, yet adherence to supplementation within school settings remains inconsistent. These ongoing gaps highlight the need to better understand the specific determinants that influence adherence in Ghanaian junior high schools, particularly in the Volta Region, where contextual factors, behavioural barriers, and supply-side constraints may shape supplementation practices. Generating such evidence is essential for strengthening school-based interventions and improving the nutritional well-being of adolescent girls. METHODS Study Design, Population and Setting A cross-sectional design was employed, a methodological approach widely utilised in epidemiology and public health research to examine the prevalence of health-related outcomes and investigate associations between variables at a single point in time (Abduh et al., 2023 ). This design was appropriate for assessing adherence to iron–folic acid supplementation (IFAS) among adolescent girls in Junior High Schools (JHSs) in the Volta Region because it enabled the collection of data at a single time point, providing a snapshot of adherence behaviours and their associated determinants. Through this approach, the study captured information on demographic characteristics, knowledge, attitudes, accessibility of supplementation programs, and potential barriers to adherence, thereby facilitating a comprehensive understanding of factors influencing IFAS uptake among adolescent girls. The study was conducted at Mawuli E.P. Junior High School, located in the Ho Municipality of the Volta Region of Ghana. The school, established by the Evangelical Presbyterian Church, has a total student population of 1,034, of whom 548 are girls across Forms 1 to 3. The school is situated within an educational enclave that includes Mawuko E.P. Senior High School and the Evangelical Presbyterian Church Cathedral, and it serves students from diverse socioeconomic backgrounds. Mawuli JHS was selected as the study site because it is representative of a typical public junior high school in Ghana and has a substantial number of adolescent girls, making it a suitable setting for investigating adherence to IFAS. The study population consisted of adolescent girls aged 13 to 18 years enrolled in Forms 2 and 3 who had been receiving iron–folic acid supplements continuously for more than one year. This population group was selected because adolescent girls experience increased iron requirements due to rapid growth and menstruation, placing them at higher risk of iron deficiency and anaemia. Focusing on this group allowed the study to explore adherence patterns within a population particularly vulnerable to micronutrient deficiencies and essential to improved nutritional and health outcomes. Sampling and Sample Size The sampling frame for this study, obtained from the school’s records, consisted of the total population of 1,034 students. The sample size was determined using the Cochran formula to ensure statistical reliability. The formula, applied with a 95% confidence level (Z-score of 1.96), a 5% margin of error (e = 0.05), and an estimated proportion (p) of 0.5 (to maximise variability and ensure a conservative sample size), is presented below: $$\:\text{n}=\frac{N*{Z}^{2}*p*(1-p)}{\left(N-1\right)*{e}^{2}+{Z}^{2}*p*(1-p)}$$ where n is required sample, N is total population size, Z is Z-score corresponding to the desired confidence level (for a 95% confidence level, 𝑍 is approximately 1.96), p is estimated proportion of the population with the attribute of interest (assumed to be 0.5 for maximum variability) and e is margin of error (set at 0.05 for a 5% margin of error). $$\:\text{s}\text{o}\text{l}\text{v}\text{e}\left(n=\frac{1034{\left(1.96\right)}^{2}\left(0.5\right)\left(1-0.5\right)}{\left(1034\right){\left(0.05\right)}^{2}+{\left(1.96\right)}^{2}\left(0.5\right)\left(1-0.5\right)},n\right)$$ $$\:\text{n}=\frac{4965268}{17727}$$ $$\:\text{n}=280.09635$$ $$\:\text{n}=280$$ The sampling frame was obtained from the school’s updated enrolment records, and participants were selected using a random number generator to ensure each eligible student had an equal chance of being included. The study population consisted of adolescent girls aged 13 to 18 years who were currently enrolled students at Mawuli Junior High School and were willing and able to provide informed consent and complete the questionnaire. Only those present during the designated data collection period and able to understand the study procedures were included. Girls below 13 or above 18 years, those unable to provide informed consent, those with cognitive or language limitations, and those absent during the data collection period were excluded from the study. This sampling approach ensured that the selected participants accurately represented the target population and enhanced the validity of the study findings. Data Collection and Instruments Data were collected using structured questionnaires designed to gather quantitative data on demographic characteristics, accessibility of IFA programs, adherence, knowledge, attitudes, and perceived barriers. Trained research assistants administered the questionnaires after explaining the study and ensuring informed consent. Completed questionnaires were checked for accuracy, completeness, and consistency. A pilot test was conducted using 28 respondents (10% of the sample) to refine the questionnaire and ensure clarity, linguistic appropriateness, and reliability. Data Management and Analysis Data management procedures ensured accuracy, consistency, and completeness before analysis. Completed questionnaires were manually checked for errors and missing responses. The data were then coded and entered into Microsoft Excel, utilising built-in verification checks to minimise entry errors. The cleaned dataset was then exported to SPSS for statistical analysis. Descriptive statistics, including frequencies, percentages, means, and standard deviations, were used to summarise participant characteristics and key study variables. Inferential statistical tests such as chi-square tests, t-tests, and logistic regression were conducted to examine associations between independent variables (demographic characteristics, knowledge, attitudes, accessibility, and barriers) and the dependent variable (adherence to IFAS). Odds ratios with 95% confidence intervals were generated for regression models. A significance level of p < 0.05 was used to determine statistical significance. Findings were presented using tables and figures to enhance clarity and facilitate interpretation. Ethical Considerations and Confidentiality Ethical clearance for the study was granted by the Ghana Health Service Ethics Review Committee (GHS-ERC: 050/05/24). Additional authorisation was obtained from the Ho Municipal Health Directorate and the administration of Mawuli JHS. Informed consent was obtained from all participants or their guardians. The study was conducted in accordance with the ethical principles of the Declaration of Helsinki . Participation was voluntary, and respondents were assured of the right to withdraw at any time without consequences. Confidentiality was ensured by using anonymous identifiers instead of names. All data were securely stored, and participants’ privacy was protected throughout the study. Support or referral mechanisms were provided for participants who experienced discomfort or required additional assistance. RESULTS Sociodemographic Characteristics of Study Participants The majority of participants were aged 14–16 years (76.4%), with the largest proportions in JHS 2 and JHS 3. Most participants were Christian (70%) and from middle-class families (56.8%). Over half (51.1%) lived with both parents. Regarding parental education, most mothers had completed SHS (42.5%), and most fathers had a tertiary education (45.7%). Table1: Demographic Information of Participants (N = 280) Variable Frequency (N) Percentage (%) Age (years) 13 38 13.6 14 76 27.1 15 78 27.9 16 60 21.4 17 26 9.3 18 2 0.7 Grade Level JHS 1 55 19.6 JHS 2 112 40 JHS 3 113 40.4 Religion Christian 196 70 Muslim 53 19 Traditional 28 10 Other 3 1.1 Family Socioeconomic Status High 76 27.1 Middle 159 56.8 Low 45 16.1 Living Arrangement Both parents 143 51.1 One parent 28 10 Relatives 109 38.9 Mother’s Education No education 13 4.6 Primary 44 15.7 JHS 42 15 SHS 119 42.5 Tertiary 55 19.6 Vocational/Training 7 2.5 Father’s Education No education 17 6.1 Primary 61 21.8 JHS 20 7.1 SHS 46 16.4 Tertiary 128 45.7 Vocational/Training 8 2.9 Awareness of the IFA Program and Frequency of Receipt in Schools Table 2 presents the distribution of respondents based on their awareness of the Iron and Folic Acid (IFA) program and the frequency with which they received IFA supplements in school. Among the 280 respondents, 216 (77.1%) reported having heard of IFA programs in their schools, while 64 (22.9%) had not. Regarding receipt of IFA supplements, 216 (77.1%) reported receiving them in school, whereas 64 (22.9%) did not. A chi-square test was conducted to assess the association between awareness of IFA programs and receipt of IFA supplements in school. The results indicated a statistically significant association (χ² = 137.108, df = 1, p < 0.001), suggesting that students who were aware of IFA programs were more likely to receive supplements (Table 2.1) Table 2: Awareness of the IFA program in schools and the frequency received in school. Received IFA in School? Heard of IFA Programs in School? No Yes No 40 4 Yes 24 212 Total 64 216 Chi-Square Test Results Test Value df Asymptotic Significance (2-sided) Pearson Chi-Square 137.108 1 .000 Continuity Correction 132.567 1 .000 Likelihood Ratio 119.027 1 .000 Fisher's Exact Test .000 Notes • N of Valid Cases: 280 • 0 cells (0.0%) have expected count less than 5. The minimum expected count is 10.06. • Computed only for a 2x2 table Source: Field Data Table 2.1: Association between Awareness of IFA Programs and Receipt of IFA Supplements in School Received IFA in School? Total Heard of IFA Programs in School? No Yes No 40 4 Yes 24 212 Total 64 216 Chi-Square Test Results Test Value df Asymptotic Significance (2-sided) Pearson Chi-Square 137.108 1 .000 Continuity Correction 132.567 1 .000 Likelihood Ratio 119.027 1 .000 Fisher's Exact Test .000 Notes • N of Valid Cases: 280 • 0 cells (0.0%) have expected count less than 5. The minimum expected count is 10.06. • Computed only for a 2x2 table Source: Field Data Adherence to IFA Supplementation by Grade Level and Living Arrangement T-test analyses were conducted to examine differences in adherence to IFA supplementation by grade level and living arrangement. For grade level, students in grade ≥3 had a mean adherence score of 1.99 (SD = 0.090), while those in grades <3 had a mean of 1.98 (SD = 0.138). There was no statistically significant difference in adherence between the groups (t = 0.780, df = 278, p = 0.436), indicating similar adherence across grade levels (Table 4). When adherence was analyzed by living arrangement, students living in grade ≥4 hostels had a mean adherence score of 2.00 (SD = 0.000), compared to 1.98 (SD = 0.130) for those in grade <4 hostels. The difference was not statistically significant under equal variance assumptions (t = 0.903, df = 278, p = 0.367); however, using unequal variance assumptions, a small but significant difference was observed (t = 2.013, df = 232, p = 0.045), suggesting that living arrangement may have a marginal effect on adherence (Table 4.1). Table 3: T-test analysis for adherence to IFA supplementation Group Statistics and Independent Samples Test for IFA Supplement Usage by Grade Level Grade Level N Mean Std. Deviation Std. Error Mean >= 3 124 1.99 0.090 0.008 < 3 156 1.98 0.138 0.011 Independent Samples Test Test Value df Sig. (2-tailed) Mean Difference Std. Error Difference 95% Confidence Interval of the Difference Levene's Test for Equality of Variances 2.462 0.118 t-test for Equality of Means (Equal variances assumed) 0.780 278 0.436 0.011 0.014 -0.017 to 0.039 t-test for Equality of Means (Equal variances not assumed) 0.817 268.360 0.415 0.011 0.014 -0.016 to 0.038 Table 3.1: T-test Analysis for adherence to IFA and living arrangement. Group Statistics and Independent Samples Test for IFA Supplement Usage by Grade Level Grade Level N Mean Std. Deviation Std. Error Mean >= 4 47 2.00 0.000 0.000 < 4 233 1.98 0.130 0.009 Independent Samples Test Test Value df Sig. (2-tailed) Mean Difference Std. Error Difference 95% Confidence Interval of the Difference Levene's Test for Equality of Variances 3.377 0.067 t-test for Equality of Means (Equal variances assumed) 0.903 278 0.367 0.017 0.019 -0.020 to 0.055 t-test for Equality of Means (Equal variances not assumed) 2.013 232.000 0.045 0.017 0.009 0.000 to 0.034 Source: Field Data Perceived Barriers to IFA Adherence Descriptive statistics were used to identify perceived barriers to IFA adherence (Table 6). The mean score for reasons for not taking IFA regularly was 4.54 (SD = 2.897), while 39% of respondents reported experiencing side effects, with an average severity score of 5.99 (SD = 3.354). Cross-tabulation analysis revealed a significant relationship between knowledge of IFA benefits and reasons for non-adherence (χ² = 265.587, df = 21, p < 0.001). Forgetfulness was the most commonly reported barrier among students with “a lot” of knowledge (40 respondents), while fear of side effects was more common among those with limited knowledge (Table 6.1). Table 4: Descriptive analysis in identifying perceived barriers to IFA adherence. Descriptive Statistics N Minimum Maximum Mean Std. Deviation Reasons for not taking IFA regularly 280 1 8 4.54 2.897 Experienced side effects? 280 1 3 1.39 .503 Side effects experienced 280 1 10 5.99 3.354 Valid N (listwise) 280 Source: Field Data Table 4.1: Cross-tabulation with Adherence Crosstabulation Reasons for Not Taking IFA Regularly Knowledge of IFA Benefits Total A lot Some Forgetfulness 40 43 Fear of side effects 22 10 Lack of knowledge 13 4 Not available 0 21 Not applicable 12 36 Total 93 117 Tests Value df Asymptotic Significance (2-sided) Pearson Chi-Square 265.587 21 .000 Likelihood Ratio 194.406 21 .000 Notes • N of Valid Cases: 280 • 15 cells (46.9%) have expected count less than 5. The minimum expected count is 0.20. Logistic Regression of Independence of respondent knowledge and attitudes Logistic regression was performed to evaluate the independence of respondents’ knowledge and attitudes toward IFA adherence (Table 7). The model correctly classified 98.6% of cases. Knowledge of IFA benefits (Wald = 12.212, p = 0.007) and the perceived importance of IFA adherence for adolescent girls (Wald = 8.697, p = 0.034) were significant predictors of adherence. Specifically, higher knowledge of IFA benefits and recognition of its importance were associated with increased likelihood of adherence. Table 5: Logistic Regression of Independence of respondent knowledge and attitudes Case Processing Summary Included in Analysis: 280 cases (100.0%) Missing Cases: 0 (0.0%) Total: 280 cases (100.0%) Dependent Variable Encoding No: 0 Yes: 1 Classification Table Observed Predicted Percentage Correct No 0 4 Yes 0 276 Overall Percentage 98.6% Variables in the Equation Variable B S.E. Wald df Sig. Exp(B) Constant 4.234 .504 70.686 1 .000 69.000 Variables not in the Equation Variable Score df Sig. Knowledge of IFA benefits 12.212 3 .007 Knowledge of IFA benefits (1) 2.018 1 .155 Knowledge of IFA benefits (2) 2.913 1 .088 Knowledge of IFA benefits (3) 8.784 1 .003 Importance of IFA adherence for adolescent girls 8.697 3 .034 Importance of IFA adherence for adolescent girls (1) 1.439 1 .230 Importance of IFA adherence for adolescent girls (2) .947 1 .330 Importance of IFA adherence for adolescent girls (3) 8.544 1 .003 Overall Statistics 32.603 6 .000 Source: Field Data DISCUSSION Introduction This chapter discusses the findings of the study in relation to the research objectives and questions, focusing on determinants associated with adherence to iron-folic acid (IFA) supplementation among adolescent girls. The discussion integrates participant characteristics, program accessibility, adherence patterns, barriers, and knowledge and attitudes towards IFA supplementation. By situating the findings within the broader literature, this section provides an understanding of the factors influencing IFA supplementation adherence and identifies potential strategies to improve program effectiveness in Ghanaian schools. The study sample was representative of adolescent girls in Junior High Schools (JHS) in the selected districts, capturing diverse religious, socioeconomic, and living arrangement backgrounds. Additionally, the inclusion of participants with varying levels of parental education allowed for a nuanced understanding of how family background influences health knowledge and behaviours, which are essential determinants of adherence to supplementation programs (Victora et al., 2010; Cohn, 2014). Participant Characteristics The demographic characteristics of the study participants provided important insights into the population under investigation and the generalizability of the study findings. Participants ranged in age from 13 to 18 years, with the majority between 14 and 15 years (27.1% and 27.9%, respectively). This age distribution aligns with the typical adolescent population in JHS and is consistent with previous research highlighting that older adolescent girls tend to exhibit better knowledge and attitudes towards IFA supplementation compared to younger peers (Aguilar-Palomo et al., 2019; Ejara et al., 2023). Regarding grade level, most participants were in JHS 2 (40%) and JHS 3 (40.4%), while fewer were in JHS 1 (19.6%). This distribution ensures the study captured the perspectives of girls across different academic stages. Grade level has been identified as a significant factor in health knowledge acquisition and attitudes toward supplementation, with higher grades often correlating with better awareness and adherence (Adanu et al., 2016). Religious affiliation was predominantly Christian (70%), followed by Muslim (19%), Traditional (10%), and other religions (1.1%), reflecting the national religious composition of Ghana (GSS, 2013). Religion is an important determinant of health behaviors, as it can influence attitudes towards interventions, including supplementation programs. Previous studies have demonstrated that religious affiliation is significantly associated with health-seeking behaviours, such as the use of modern contraceptives among women (Agyemang et al., 2012), suggesting similar effects could apply to adolescent health interventions like IFA supplementation. Family socioeconomic status also emerged as a notable determinant. In this study, most participants were from middle-income families (56.8%), followed by high-income (27.1%) and low-income families (16.1%). Higher socioeconomic status has been associated with better health knowledge and adherence to supplementation programs (Adanu et al., 2016), likely due to increased access to educational resources and healthcare information. Living arrangements were similarly influential. Over half of the participants (51.1%) lived with both parents, while 38.9% lived with relatives and 10% with a single parent. Studies have shown that adolescents residing in supportive family environments benefit from social and logistical support that facilitates adherence to health programs (Akosuah et al., 2020). Parental education, particularly maternal and paternal levels, also played a critical role in shaping adolescent health literacy. In this study, 19.6% of mothers had a tertiary education, while the majority had secondary or primary education. Paternal education was similarly influential, with 45.7% of fathers having a tertiary education. Higher parental education is consistently associated with improved knowledge and positive attitudes towards health interventions, including IFA supplementation (Adanu et al., 2012). Accessibility of Iron-Folic Acid Supplementation Programs Program accessibility is essential for effective supplementation, particularly in school-based settings. A substantial proportion of adolescents reported awareness of IFA programs, with a significant association between program awareness and the frequency of receiving supplements (p < 0.001). Awareness is a prerequisite for adherence, as students who understand the benefits of supplementation are more likely to engage in the program (Ogundele et al., 2022; Nakitto, 2021). Despite high awareness (98.6%), only 76.8% of participants reported ever receiving IFA supplements at school. This discrepancy highlights a critical gap between knowledge and actual program participation, often attributed to supply-side challenges such as the unavailability of supplements or distribution inefficiencies. Similar patterns have been observed in other school-based nutrition interventions, where awareness does not always translate into uptake (Cliffer et al., 2023). Frequency of supplement receipt varied, with 34.1% reporting monthly intake, 37.9% never receiving supplements, 5.7% receiving them rarely, and 36.4% receiving them weekly. Consistent intake is essential for the prevention of anaemia, as irregular consumption reduces the potential health benefits of supplementation (Mollay et al., 2022). These findings underscore the importance of ensuring both the availability and regular distribution of IFA supplements in school programs. Adherence to Iron-Folic Acid Supplementation The study examined adherence in relation to grade level and living arrangements. No significant differences were observed between adherence among students in higher versus lower grades (t = 0.780, p = 0.436), consistent with prior research indicating that grade level may not strongly influence adherence behaviours among adolescents (Smith et al., 2022). Similarly, living arrangement was not a significant determinant under equal variance assumptions, although a marginal effect was observed under unequal variance assumptions (t = 2.013, df = 232, p = 0.045). These results suggest that while social support from family may contribute to adherence, it is not the sole determinant (Olmsted et al., 2022). The relationship between frequency of supplement intake and adherence was significant (χ² = 209.873, p < .001), consistent with studies indicating that repeated exposure to supplementation is positively associated with adherence (Islam et al., 2021). Participants who were aware of IFA programs were more likely to adhere (OR = 1.780, p = .045), reinforcing the role of knowledge in promoting health behaviours (Abdisa et al., 2023). However, other factors, such as household size and proximity to health facilities, were not significantly associated with adherence, suggesting that awareness and structured program delivery may be more critical than physical accessibility in this urban school setting. Barriers to Adherence Barriers to adherence were multifactorial. Forgetfulness was the most common reason cited, followed by fear of side effects, lack of knowledge, and unavailability of supplements. These findings are consistent with previous research showing that logistical challenges, misconceptions, and cognitive barriers hinder adherence to micronutrient supplementation programs (Tam et al., 2020; Mishra et al., 2023). Supply-side issues, such as non-palatability and irregular distribution, and demand-side factors such as lack of awareness, contribute to suboptimal adherence (Charchar et al., 2024; Salam et al., 2016). Cross-tabulation of reasons for non-adherence with knowledge of IFA benefits indicated that higher knowledge levels were associated with reduced reports of forgetfulness (χ² = 265.587, p < .001), highlighting the critical role of health education in improving adherence behaviours. Moreover, only a subset of respondents who had heard about the program adhered to the recommended monthly intake, indicating that knowledge alone is insufficient and must be paired with behavioural reinforcement strategies (Tsegai et al., 2023). Contrary to expectations, distance to the nearest health facility did not significantly influence adherence. While other studies, particularly in rural areas, have reported proximity as a barrier (Hunegnaw et al., 2022), the urban context of this study likely reduced such logistical challenges (Ejara et al.,2023). Knowledge and Attitudes Knowledge and attitudes towards IFA supplementation are critical determinants of adherence. The study found that knowledge levels varied by age, grade level, family socioeconomic status, and religion. Girls in higher grades or from higher socioeconomic backgrounds generally had greater access to IFA information. Logistic regression analysis revealed that while knowledge of IFA benefits was not a direct predictor of ever taking supplements, the perceived importance of adherence significantly influenced supplementation behaviour (Bhutta et al., 2013; Cohn, 2014). This finding highlights the distinction between awareness and behaviour: even when knowledge is adequate, positive attitudes and motivation to act are necessary for consistent adherence. Therefore, interventions should not only disseminate information but also foster positive perceptions of supplementation, highlighting the health benefits and addressing concerns such as side effects (Sendeku et al., 2020; Abdisa et al., 2023). Conclusion The study found that knowledge levels about IFA may vary based on factors such as age, grade level, family socioeconomic status, and religion. However, knowledge of IFA benefits was not a significant predictor of ever taking supplements, which aligns with findings from other health interventions that simply knowing about a health practice may not lead to consistent behaviour. On the other hand, the study found a significant association between perceived importance of adherence and ever having taken supplements, highlighting the importance of fostering positive attitudes towards adherence within the program. Distance to the nearest health facility was not found to be a significant barrier to IFA supplementation adherence, consistent with a previous study in Ethiopia, although other studies have found it to be a significant barrier in rural areas. Overall, the study suggests that knowledge of IFA benefits alone may not be sufficient to ensure adherence to supplementation programs. Instead, fostering positive attitudes towards adherence, addressing barriers such as forgetfulness and side effects, and integrating supplements into girls' routines may be more effective in improving adherence among adolescent girls. Recommendations Based on the study findings, several recommendations are proposed to improve adherence to IFA supplementation among adolescent girls, structured for key stakeholders and future research. Recommendations for the Ghana Health Service (GHS) Implement a coherent IFA supplementation program: GHS should design a standardised program for adolescent girls that integrates education, sensitisation, and strategies to address adherence barriers. Capacity building for healthcare workers: Health professionals should be trained to provide accurate information on IFA supplementation, manage side effects, and address misconceptions effectively. Ensure supplement availability and accessibility: The GHS should guarantee that IFA supplements are consistently available in schools, and distribution mechanisms should be strengthened to avoid stockouts. Promote behavioural strategies for adherence: Innovative approaches such as mobile phone reminders, integration with school schedules, and peer support networks should be employed to encourage consistent supplement intake. Monitoring and evaluation: GHS should establish a routine system for tracking adherence rates and program outcomes. Data collected should inform program refinement, policy adjustments, and continuous improvement. Recommendations for the Regional Health Directorate Improve access in rural areas: Mobile health clinics, community-based distribution, or satellite supplementation points should be implemented to reduce barriers posed by distance to health facilities. Strengthen monitoring and evaluation: Regular program audits and surveys should be conducted to assess coverage, uptake, and adherence, ensuring that the program reaches its intended population. Capacity building at the regional level: Healthcare personnel should receive specialised training on IFA program delivery, communication strategies, and addressing adolescent concerns. Collaboration with schools: Partnerships with school administrators and teachers are essential to ensure smooth distribution of supplements and to integrate intake into school routines effectively. Information sharing and scaling up: Successful strategies and interventions implemented in the region should be communicated with the national GHS to inform best practices and facilitate nationwide improvements. Recommendations for Future Research Evaluate adherence-enhancing strategies: Future studies should examine the effectiveness of behavioural interventions, such as reminders, incentives, peer support, or integration into routine school activities, on improving IFA adherence. Integration with other health programs: Research should explore the potential benefits of combining IFA supplementation with other adolescent health interventions, such as sexual and reproductive health education, vaccination campaigns, or deworming programs. Contextual factors influencing knowledge and attitudes: Further studies are needed to understand how sociocultural, familial, and economic factors influence knowledge, attitudes, and adherence to IFA supplementation, particularly in rural or hard-to-reach populations. Longitudinal adherence studies: Future research should assess long-term adherence patterns, identifying predictors of sustained supplementation behaviours over time and their impact on anaemia prevalence and overall nutritional status. Cost-effectiveness and program sustainability: Evaluations of the financial and operational feasibility of school-based supplementation programs will inform scalable and sustainable strategies for national implementation. Abbreviations IFA Iron and Folic Acid IFAS Iron and Folic Acid Supplementation IDA Iron Deficiency Anaemia JHS Junior High School WHO World Health Organization MoH Ministry of Health UNICEF United Nations International Children’s Emergency Fund SPSS Statistical Package for the Social Sciences AOR Adjusted Odds Ratio CI Confidence Interval Declarations Ethics approval and consent to participate Ethical clearance was obtained from the Ghana Health Service Ethics Review Committee (GHS-ERC: 050/05/24). The study was conducted in accordance with the Declaration of Helsinki. Informed consent was obtained from all participants or their guardians. Availability of Data and Materials The associated data will be available upon request from the corresponding author Funding The Study was funded solely by the Authors Competing Interest The authors declare no competing interests. Authors’ Contribution FT is the principal Author. SA drafted the Manuscript. FT conceived and designed the study, collected and interpreted the data, and drafted the manuscript. SA critically reviewed the study design, contributed to the interpretation of data, and drafted the Manuscript. DA provided methodological guidance, supported data analysis, and reviewed draft versions. JYE supervised the work and offered valuable insights into content validation and manuscript revision. All authors read, reviewed, and approved the final manuscript. Acknowledgements The Authors would like to acknowledge the generous contribution of time and expertise by those who participated in this study. References Abdisa DK, Jaleta DD, Tsegaye D, Jarso MH, Jaleta GD, Tolesa GF, Kitila KM. (2023). Effect of community based nutritional education on knowledge, attitude and compliance to IFA supplementation among pregnant women in rural areas of southwest Ethiopia: a quasi experimental study. Effect of community based nutritional education on knowledge, attitude and compliance to IFA supplementation among pregnant women in rural areas of southwest Ethiopia: a quasi experimental study . Abduh M, Alawiyah T, Apriansyah G, Sirodj RA, Afgani MW. (2023). Survey Design: Cross Sectional dalam Penelitian Kualitatif. Adanu RM, Awoonor-Williams JK, Phillips JF, Laar A. (2016). Factors associated with knowledge and use of iron folic acid supplements among adolescent girls in senior high schools in Ghana. BMC Public Health, 1–11. Aguilar-Palomo ME, Martínez-Andrade RM, Sánchez-Pérez LM. (2019). Knowledge and attitudes towards iron supplementation in pregnant women. Revista de enfermería, 10–6. Agyemang C, Amo-Adjei J, Poku NK. (2012). Religion and use of modern contraceptives among women in Ghana. Afr Popul Stud, 7262–76. Akosuah R, Amankwah EK, Agyei-Baffour P. (2020). Living arrangement and sexual and reproductive health outcomes among adolescent girls in Ghana. J Biosoc Sci, 123–37. Angadi N, Balu PS. Effectiveness of weekly iron and folic acid supplementation programme to control anemia among rural adolescent school girls of Davangere, Karnataka. Natl J Community Med. 2019;10(8):479–82. Antwi EO, Whyte BK, Alhassan SE, Ayirezang AF, Arhin RE, Ayembilla AJ, Osei TA. Determination of prevalence and cause of anaemia among adolescent pregnant girls in Ussher Hospital, James Town, Ghana. BMC Pregnancy Childbirth. 2025;25(1):983. Balarajan Y, Ramakrishnan U, Özaltin E, Shankar AH, Subramanian SV. Anaemia in low-income and middle-income countries. lancet. 2011;378(9809):2123–35. Beard JL. Iron requirements in adolescent females. J Nutr. 2000;130(2):S440–2. Bhutta ZA, Das JK, Rizvi A, Gaffey MF, Walker N, Horton S, Black RE. (2013). Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? Lancet . Charchar F, PR P, Korostovtseva CMSMCDNFZM. L, Z. M. (2024). Lifestyle management of hypertension: International Society of Hypertension position paper endorsed by the World Hypertension League and European Society of Hypertension. J Hypertens, 23–49. Cliffer IR, Wang D, Wang ASD, Sie A, Fawz W. (2023). School-based supplementation with iron-folic acid or multiple micronutrient tablets to address anemia among adolescents in Burkina Faso: a cluster-randomized trial. Am J Clin Nutr, 977–88. Cohn S, editor. From health behaviours to health practices: critical perspectives. Wiley; 2014. Desta M, Kassie B, Chanie H, Mulugeta H, Yirga T, Temesgen H, Merkeb Y. Adherence of iron and folic acid supplementation and determinants among pregnant women in Ethiopia: a systematic review and meta-analysis. Reprod Health. 2019;16:182. 10.1186/s12978-019-0848-9 . Dubik SD, Amegah KE, Alhassan A, Mornah LN, Fiagbe L. (2019). Compliance with Weekly Iron and Folic Acid Supplementation and Its Associated Factors among Adolescent Girls in Tamale Metropolis of Ghana. Journal of nutrition and metabolism, 2019 . 10.1155/2019/8242896 Ejara D, Ferede AS, Bekele F, Ahmed T. (2023). Predictors of compliance with Iron Folic Acid Supplementation among pregnant women in North Shoa Zone, Ethiopia. Geneva S, World Health Organization. &. (2011). Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Vitamin and Mineral Nutrition Information System. Document Reference WHO . Gosdin L, Sharma AJ, Tripp K, Amoaful EF, Mahama AB, Selenje L, Addo OY. A school-based weekly iron and folic acid supplementation program effectively reduces anemia in a prospective cohort of Ghanaian adolescent girls. J Nutr. 2021;151(6):1646–55. 10.1093/jn/nxab024 . GSS. 2010 population and housing census: Summary report of final results. Accra: Ghana Statistical Service; 2013. Hunegnaw WA, Ferede AG, Azene TW. Compliance level and factors associated with iron–folic acid supplementation among pregnant women in Dangila, Northern Ethiopia: A cross-sectional study. SAGE Open Medicine; 2022. Lyoba WB, Mwakatoga JD, Festo C, Mrema J, Elisaria E. (2020). Adherence to Iron-Folic Acid Supplementation and Associated Factors among Pregnant Women in Kasulu Communities in North-Western Tanzania. Int J Reproductive Med. Mhango M. (2022). Determinants of non-compliance to iron and folic acid supplementation among adolescent girls in schools of Salima district. Mishra JP, Ramakrishnan J, Ramasubramani P, Banu Z, Sahoo SK. (2023). Adherence and barriers of prophylactic iron and folic acid supplementation in children: a community-based mixed method study. Int J Community Med Public Health, 2138–43. Mollay C, Kimanya M, Kassim N, Stoltzfus R. (2022). Main complementary food ingredients contributing to aflatoxin exposure to infants and young children in Kongwa, Tanzania. Food Control . Nakitto R. (2021). Knowledge, Attitudes and Practices regarding iron and Folic acid Supplementation among pregnant women attending Antenatal care clinics in Kira Municipality health centers (Doctoral dissertation, Makerere University). Nokes C, van den Bosch C, Bundy DA. (1998). The effects of iron deficiency and anemia on mental and motor performance, educational achievement, and behavior in children. A report of the INACG. Washington, DC: International Life Sciences Institute . Ogundele OA, Ogundele T, Fehintola FO, Fagbemi AT, Beloved OO, Osunmakinwa OO. (2022). Determinants of incomplete vaccination among children 12–23 months in Nigeria: an analysis of a national sample. Tzu Chi Med J, 448–55. Olmsted AE, Markham CM, Shegog R, Ugueto AM, Johnson EL, Peskin MF, Newlin EW. (2022). Feasibility and acceptability of technology-supported sexual health education among adolescents receiving inpatient psychiatric care. ournal Child Family Stud, 2050–64. Salam RA, Hooda M, Lassi MJ, Middleton ZS, P., Bhutta ZA. (2016). Interventions to Improve Adolescent Nutrition: A Systematic Review and Meta-Analysis. J Adolesc Health, 29–39. Sendeku FW, Azeze GG, Fenta SL. Adherence to iron-folic acid supplementation among pregnant women in Ethiopia: a systematic review and meta-analysis. BMC Pregnancy and Childbirth; 2020. Silitonga HT, Salim LA, Nurmala I, Wartiningsih M. Compliance of Iron Supplementation and Determinants among Adolescent Girls: A Systematic Review. Iran J Public Health. 2023;52(1):37–48. Smith TE, Holmes SR, Romero ME, Sheridan SM. (2022). Evaluating the effects of family–school engagement interventions on parent–teacher relationships: A meta-analysis. School mental health, 278–93. Tam E, Keats EC, Rind F, Das JK, Bhutta ZA. (2020). Micronutrient Supplementation and Fortification Interventions on Health and Development Outcomes among Children Under-Five in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis. Nutrients, 289. Tsegai MB, Berhe AH, Tesfaezgi SB, Weldemariam DG, Petros KT, Weldetinsae HB, Tesfamariam EH. (2023). Knowledge, Attitude, and Practice Regarding Supplemental Iron and Folic Acid Amongst Women Delivering in Edaga-Hamus Community Hospital: A Cross-Sectional Study in Asmara, Eritrea. Int J Womens Health, 1593–609. UNICEF & MoH. Iron & Folic Acid (IFA) Supplementation for Adolescent Girls and Women. UNICEF & the Ministry of Health; 2017. Victora C, L, A., C F. (2010). Maternal and child undernutrition: consequences for adult health and human capital. Lancet, 340–57. World Health Organization. Global Accelerated Action for the Health of Adolescents (AA-HA!): guidance to support country implementation. World Health Organization; 2023. Yidana A, Azongo TB, Mohammed A. Iron and Folic Acid Supplementation Compliance among Adolescent Girls in Karaga District, Ghana. SAP. 2020;10(5):133–42. 10.5923/j.phr.20201005.01 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 31 Mar, 2026 Reviews received at journal 26 Mar, 2026 Reviewers agreed at journal 22 Mar, 2026 Reviewers agreed at journal 22 Mar, 2026 Reviewers agreed at journal 22 Mar, 2026 Reviews received at journal 21 Mar, 2026 Reviewers agreed at journal 21 Mar, 2026 Reviewers agreed at journal 20 Mar, 2026 Reviewers agreed at journal 20 Mar, 2026 Reviews received at journal 05 Mar, 2026 Reviewers agreed at journal 16 Feb, 2026 Reviewers invited by journal 13 Feb, 2026 Editor invited by journal 12 Feb, 2026 Editor assigned by journal 11 Feb, 2026 Submission checks completed at journal 11 Feb, 2026 First submitted to journal 10 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8842850","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":592523029,"identity":"6b7f7f30-88b8-4932-bf60-a8e04ee2c7d5","order_by":0,"name":"Francisca Tsidih","email":"","orcid":"","institution":"University of Ghana","correspondingAuthor":false,"prefix":"","firstName":"Francisca","middleName":"","lastName":"Tsidih","suffix":""},{"id":592523030,"identity":"17dfea21-e374-4505-847c-3e1389fef6d7","order_by":1,"name":"Samuel Antwi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5klEQVRIiWNgGAWjYBADHjb2/ocPQAw+4jQkAFXynGE2AOslVguDnIQPmwSITVCLfPvpxM+FPw7LsEnwHqv8mmMnw8bA/PDRDTxaDM7kbpaekXCYh026L+227LZkoMPYjI1z8GlhyN0gzZNwm4dN5oDZbcltzEAtQO34tMj3v938G6xFIsGsWHJbPWEtDDdyt0FskcgxY/y47TBhLQY33m6z5kn7z8PGcyxZmnHbcR42ZgJ+ke/P3XybxybNXr69+eDHn9uq7fnZmx8+xuswZMDMAyaJVQ4CjD9IUT0KRsEoGAUjBgAAF1RB/X3X5pAAAAAASUVORK5CYII=","orcid":"","institution":"University of Ghana","correspondingAuthor":true,"prefix":"","firstName":"Samuel","middleName":"","lastName":"Antwi","suffix":""},{"id":592523032,"identity":"f1fbfbaf-2c44-4f46-b8d0-fd39f6f2d9ec","order_by":2,"name":"Daniel Aboagye","email":"","orcid":"","institution":"Ghana Health Service","correspondingAuthor":false,"prefix":"","firstName":"Daniel","middleName":"","lastName":"Aboagye","suffix":""},{"id":592523033,"identity":"1497fab3-1065-402f-a906-5c5eed5919d7","order_by":3,"name":"Juliana Yartey Enos","email":"","orcid":"","institution":"University of Ghana","correspondingAuthor":false,"prefix":"","firstName":"Juliana","middleName":"Yartey","lastName":"Enos","suffix":""}],"badges":[],"createdAt":"2026-02-10 15:53:37","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8842850/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8842850/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103049518,"identity":"651df31d-7fb3-42cb-933a-2221df924e46","added_by":"auto","created_at":"2026-02-20 07:42:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1718431,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8842850/v1/64a62cfc-61af-487f-a38b-1c6043ceb74a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eThe Determinants Associated With Adherence to Iron-folic Acidsupplementation Among Adolescent Girls in Jhs: A Cross-sectional Study at Mawuli Junior High School, Volta Region\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eAccording to the World Health Organisation (WHO, 2023; Geneva \u0026amp; WHO, 2011), as cited by Gosdin et al. (\u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e), the main cause of mortality and morbidity among teenage girls aged 10 to 19 worldwide is iron deficiency anaemia. If the issue is not resolved, the burden of adolescent anaemia will carry over into the next generation (Silitonga et al., \u003cspan class=\"CitationRef\"\u003e2023\u003c/span\u003e; Ejara et al., \u003cspan class=\"CitationRef\"\u003e2023\u003c/span\u003e). The need for improved nutrition, particularly iron intake, increases during adolescence (Dubik et al., \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e; Angadi \u0026amp; Balu, \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e; Cohn, \u003cspan class=\"CitationRef\"\u003e2014\u003c/span\u003e). Anaemia caused by iron and folic acid deficiency accounts for 1.45% of all years of life lost to disability globally (Desta et al., \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e). Short-term consequences include reduced immunity, decreased metabolism, low aerobic capacity, increased susceptibility to disease, lethargy, exhaustion, and poor concentration (Balarajan et al., \u003cspan class=\"CitationRef\"\u003e2011\u003c/span\u003e; Beard, \u003cspan class=\"CitationRef\"\u003e2000\u003c/span\u003e; Nokes et al., \u003cspan class=\"CitationRef\"\u003e1998\u003c/span\u003e; Gosdin et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e). Iron deficiency causes over half of all anaemia cases, affecting over two billion people worldwide, with 30\u0026ndash;50% residing in developing countries (Lyoba et al., \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eAdolescence is a critical developmental stage that forms the foundation for productivity and well-being later in life (Yidana et al., \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e). It is also considered an optimal period for anaemia prevention strategies, laying the nutritional groundwork for future reproductive health (Dubik et al., \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e; UNICEF \u0026amp; MoH, 2017). Iron deficiency anaemia (IDA) remains a major cause of disability-adjusted life years among adolescent girls globally and heightens risks during adolescent pregnancy (Antwi et al., \u003cspan class=\"CitationRef\"\u003e2025\u003c/span\u003e; WHO, 2011; WHO, 2023). In nations where anaemia prevalence exceeds 20%, the WHO recommends periodic iron supplementation for all adolescents (Silitonga et al., \u003cspan class=\"CitationRef\"\u003e2023\u003c/span\u003e), supported by evidence that iron and folic acid supplementation (IFAS) is a cost-effective strategy (Mhango, \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eDespite these global recommendations, many adolescent girls, especially those in low- and middle-income settings, continue to face difficulties adhering to IFAS regimens. This situation poses a challenge to achieving meaningful anaemia reduction. Schools represent an ideal platform for reaching large numbers of adolescents, yet adherence to supplementation within school settings remains inconsistent. These ongoing gaps highlight the need to better understand the specific determinants that influence adherence in Ghanaian junior high schools, particularly in the Volta Region, where contextual factors, behavioural barriers, and supply-side constraints may shape supplementation practices. Generating such evidence is essential for strengthening school-based interventions and improving the nutritional well-being of adolescent girls.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e\u003cem\u003eStudy Design, Population and Setting\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA cross-sectional design was employed, a methodological approach widely utilised in epidemiology and public health research to examine the prevalence of health-related outcomes and investigate associations between variables at a single point in time (Abduh et al., \u003cspan class=\"CitationRef\"\u003e2023\u003c/span\u003e). This design was appropriate for assessing adherence to iron\u0026ndash;folic acid supplementation (IFAS) among adolescent girls in Junior High Schools (JHSs) in the Volta Region because it enabled the collection of data at a single time point, providing a snapshot of adherence behaviours and their associated determinants. Through this approach, the study captured information on demographic characteristics, knowledge, attitudes, accessibility of supplementation programs, and potential barriers to adherence, thereby facilitating a comprehensive understanding of factors influencing IFAS uptake among adolescent girls.\u003c/p\u003e\n\u003cp\u003eThe study was conducted at Mawuli E.P. Junior High School, located in the Ho Municipality of the Volta Region of Ghana. The school, established by the Evangelical Presbyterian Church, has a total student population of 1,034, of whom 548 are girls across Forms 1 to 3. The school is situated within an educational enclave that includes Mawuko E.P. Senior High School and the Evangelical Presbyterian Church Cathedral, and it serves students from diverse socioeconomic backgrounds. Mawuli JHS was selected as the study site because it is representative of a typical public junior high school in Ghana and has a substantial number of adolescent girls, making it a suitable setting for investigating adherence to IFAS.\u003c/p\u003e\n\u003cp\u003eThe study population consisted of adolescent girls aged 13 to 18 years enrolled in Forms 2 and 3 who had been receiving iron\u0026ndash;folic acid supplements continuously for more than one year. This population group was selected because adolescent girls experience increased iron requirements due to rapid growth and menstruation, placing them at higher risk of iron deficiency and anaemia. Focusing on this group allowed the study to explore adherence patterns within a population particularly vulnerable to micronutrient deficiencies and essential to improved nutritional and health outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSampling and Sample Size\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe sampling frame for this study, obtained from the school\u0026rsquo;s records, consisted of the total population of 1,034 students. The sample size was determined using the Cochran formula to ensure statistical reliability. The formula, applied with a 95% confidence level (Z-score of 1.96), a 5% margin of error (e\u0026thinsp;=\u0026thinsp;0.05), and an estimated proportion (p) of 0.5 (to maximise variability and ensure a conservative sample size), is presented below:\u003c/p\u003e\n\u003cdiv id=\"Equa\" class=\"Equation\"\u003e\n\u003cdiv id=\"FileID_Equa\" class=\"mathdisplay\"\u003e$$\\:\\text{n}=\\frac{N*{Z}^{2}*p*(1-p)}{\\left(N-1\\right)*{e}^{2}+{Z}^{2}*p*(1-p)}$$\u003c/div\u003e\n\u003c/div\u003e\n\u003cp\u003ewhere n is required sample, N is total population size, Z is Z-score corresponding to the desired confidence level (for a 95% confidence level, 𝑍 is approximately 1.96), p is estimated proportion of the population with the attribute of interest (assumed to be 0.5 for maximum variability) and e is margin of error (set at 0.05 for a 5% margin of error).\u003c/p\u003e\n\u003cdiv id=\"Equb\" class=\"Equation\"\u003e\n\u003cdiv id=\"FileID_Equb\" class=\"mathdisplay\"\u003e$$\\:\\text{s}\\text{o}\\text{l}\\text{v}\\text{e}\\left(n=\\frac{1034{\\left(1.96\\right)}^{2}\\left(0.5\\right)\\left(1-0.5\\right)}{\\left(1034\\right){\\left(0.05\\right)}^{2}+{\\left(1.96\\right)}^{2}\\left(0.5\\right)\\left(1-0.5\\right)},n\\right)$$\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Equc\" class=\"Equation\"\u003e\n\u003cdiv id=\"FileID_Equc\" class=\"mathdisplay\"\u003e$$\\:\\text{n}=\\frac{4965268}{17727}$$\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Equd\" class=\"Equation\"\u003e\n\u003cdiv id=\"FileID_Equd\" class=\"mathdisplay\"\u003e$$\\:\\text{n}=280.09635$$\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Eque\" class=\"Equation\"\u003e\n\u003cdiv id=\"FileID_Eque\" class=\"mathdisplay\"\u003e$$\\:\\text{n}=280$$\u003c/div\u003e\n\u003c/div\u003e\n\u003cp\u003eThe sampling frame was obtained from the school\u0026rsquo;s updated enrolment records, and participants were selected using a random number generator to ensure each eligible student had an equal chance of being included.\u003c/p\u003e\n\u003cp\u003eThe study population consisted of adolescent girls aged 13 to 18 years who were currently enrolled students at Mawuli Junior High School and were willing and able to provide informed consent and complete the questionnaire. Only those present during the designated data collection period and able to understand the study procedures were included. Girls below 13 or above 18 years, those unable to provide informed consent, those with cognitive or language limitations, and those absent during the data collection period were excluded from the study. This sampling approach ensured that the selected participants accurately represented the target population and enhanced the validity of the study findings.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData Collection and Instruments\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eData were collected using structured questionnaires designed to gather quantitative data on demographic characteristics, accessibility of IFA programs, adherence, knowledge, attitudes, and perceived barriers. Trained research assistants administered the questionnaires after explaining the study and ensuring informed consent. Completed questionnaires were checked for accuracy, completeness, and consistency. A pilot test was conducted using 28 respondents (10% of the sample) to refine the questionnaire and ensure clarity, linguistic appropriateness, and reliability.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData Management and Analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eData management procedures ensured accuracy, consistency, and completeness before analysis. Completed questionnaires were manually checked for errors and missing responses. The data were then coded and entered into Microsoft Excel, utilising built-in verification checks to minimise entry errors. The cleaned dataset was then exported to SPSS for statistical analysis.\u003c/p\u003e\n\u003cp\u003eDescriptive statistics, including frequencies, percentages, means, and standard deviations, were used to summarise participant characteristics and key study variables. Inferential statistical tests such as chi-square tests, t-tests, and logistic regression were conducted to examine associations between independent variables (demographic characteristics, knowledge, attitudes, accessibility, and barriers) and the dependent variable (adherence to IFAS). Odds ratios with 95% confidence intervals were generated for regression models. A significance level of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was used to determine statistical significance. Findings were presented using tables and figures to enhance clarity and facilitate interpretation.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEthical Considerations and Confidentiality\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eEthical clearance for the study was granted by the Ghana Health Service Ethics Review Committee (GHS-ERC: 050/05/24). Additional authorisation was obtained from the Ho Municipal Health Directorate and the administration of Mawuli JHS. Informed consent was obtained from all participants or their guardians. The study was conducted in accordance with the ethical principles of the \u003cstrong\u003eDeclaration of Helsinki\u003c/strong\u003e. Participation was voluntary, and respondents were assured of the right to withdraw at any time without consequences. Confidentiality was ensured by using anonymous identifiers instead of names. All data were securely stored, and participants\u0026rsquo; privacy was protected throughout the study. Support or referral mechanisms were provided for participants who experienced discomfort or required additional assistance.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cstrong\u003eSociodemographic Characteristics of Study Participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe majority of participants were aged 14\u0026ndash;16 years (76.4%), with the largest proportions in JHS 2 and JHS 3. Most participants were Christian (70%) and from middle-class families (56.8%). Over half (51.1%) lived with both parents. Regarding parental education, most mothers had completed SHS (42.5%), and most fathers had a tertiary education (45.7%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable1: Demographic Information of Participants (N = 280)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"606\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 226px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency (N)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e13.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e27.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e27.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e21.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e9.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade Level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eJHS 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e19.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eJHS 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e112\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eJHS 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e113\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e40.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eReligion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eChristian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e196\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eMuslim\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eTraditional\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFamily Socioeconomic Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e27.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eMiddle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e159\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e56.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e16.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLiving Arrangement\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eBoth parents\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e143\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e51.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eOne parent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eRelatives\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e109\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e38.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMother\u0026rsquo;s Education\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eNo education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e4.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003ePrimary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e15.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eJHS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eSHS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e119\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e42.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eTertiary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e19.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eVocational/Training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFather\u0026rsquo;s Education\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eNo education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e6.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003ePrimary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e21.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eJHS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e7.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eSHS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e16.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eTertiary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e128\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e45.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 226px;\"\u003e\n \u003cp\u003eVocational/Training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAwareness of the IFA Program and Frequency of Receipt in Schools\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 2 presents the distribution of respondents based on their awareness of the Iron and Folic Acid (IFA) program and the frequency with which they received IFA supplements in school. Among the 280 respondents, 216 (77.1%) reported having heard of IFA programs in their schools, while 64 (22.9%) had not. Regarding receipt of IFA supplements, 216 (77.1%) reported receiving them in school, whereas 64 (22.9%) did not.\u003c/p\u003e\n\u003cp\u003eA chi-square test was conducted to assess the association between awareness of IFA programs and receipt of IFA supplements in school. The results indicated a statistically significant association (\u0026chi;\u0026sup2; = 137.108, df = 1, p \u0026lt; 0.001), suggesting that students who were aware of IFA programs were more likely to receive supplements (Table 2.1)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2: Awareness of the IFA program in schools and the frequency received in school.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eReceived IFA in School?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHeard of IFA Programs in School?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e212\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e216\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChi-Square Test Results\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 32px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTest\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eValue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e\u003cstrong\u003edf\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAsymptotic Significance (2-sided)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 32px;\"\u003e\n \u003cp\u003ePearson Chi-Square\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e137.108\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 32px;\"\u003e\n \u003cp\u003eContinuity Correction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e132.567\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 32px;\"\u003e\n \u003cp\u003eLikelihood Ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e119.027\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 32px;\"\u003e\n \u003cp\u003eFisher\u0026apos;s Exact Test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 41px;\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNotes\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; N of Valid Cases: 280\u003c/p\u003e\n \u003cp\u003e\u0026bull; 0 cells (0.0%) have expected count less than 5. The minimum expected count is 10.06.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Computed only for a 2x2 table\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eSource: Field Data\u003c/em\u003e\u003c/p\u003e\n\u003cp id=\"_Toc182496073\"\u003eTable 2.1: Association between Awareness of IFA Programs and Receipt of IFA Supplements in School\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003eReceived IFA in School?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003eHeard of IFA Programs in School?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e212\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e64\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e216\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003eChi-Square Test Results\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTest\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eValue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003edf\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAsymptotic Significance (2-sided)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003ePearson Chi-Square\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e137.108\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003eContinuity Correction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e132.567\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003eLikelihood Ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e119.027\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003eFisher\u0026apos;s Exact Test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 619px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNotes\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; N of Valid Cases: 280\u003c/p\u003e\n \u003cp\u003e\u0026bull; 0 cells (0.0%) have expected count less than 5. The minimum expected count is 10.06.\u003c/p\u003e\n \u003cp\u003e\u0026bull; Computed only for a 2x2 table\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eSource: Field Data\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAdherence to IFA Supplementation by Grade Level and Living Arrangement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eT-test analyses were conducted to examine differences in adherence to IFA supplementation by grade level and living arrangement. For grade level, students in grade \u0026ge;3 had a mean adherence score of 1.99 (SD = 0.090), while those in grades \u0026lt;3 had a mean of 1.98 (SD = 0.138). There was no statistically significant difference in adherence between the groups (t = 0.780, df = 278, p = 0.436), indicating similar adherence across grade levels (Table 4).\u003c/p\u003e\n\u003cp\u003eWhen adherence was analyzed by living arrangement, students living in grade \u0026ge;4 hostels had a mean adherence score of 2.00 (SD = 0.000), compared to 1.98 (SD = 0.130) for those in grade \u0026lt;4 hostels. The difference was not statistically significant under equal variance assumptions (t = 0.903, df = 278, p = 0.367); however, using unequal variance assumptions, a small but significant difference was observed (t = 2.013, df = 232, p = 0.045), suggesting that living arrangement may have a marginal effect on adherence (Table 4.1).\u003c/p\u003e\n\u003cp id=\"_Toc182496074\"\u003eTable 3: T-test analysis for adherence to IFA supplementation\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"97%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\" valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup Statistics and Independent Samples Test for IFA Supplement Usage by Grade Level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade Level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStd. Deviation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStd. Error Mean\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e\u0026gt;= 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e124\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e1.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e0.090\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e\u0026lt; 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e156\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e1.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e0.138\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e0.011\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\" valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIndependent Samples Test\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003eTest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003eValue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003edf\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003eSig. (2-tailed)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003eMean Difference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003eStd. Error Difference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e95% Confidence Interval of the Difference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003eLevene\u0026apos;s Test for Equality of Variances\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e2.462\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e0.118\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003et-test for Equality of Means (Equal variances assumed)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e0.780\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e278\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e0.436\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e0.011\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e-0.017 to 0.039\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003et-test for Equality of Means (Equal variances not assumed)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e0.817\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e268.360\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e0.415\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e0.011\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e0.014\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e-0.016 to 0.038\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp id=\"_Toc182496075\"\u003eTable 3.1: T-test Analysis for adherence to IFA and living arrangement.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\" valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup Statistics and Independent Samples Test for IFA Supplement Usage by Grade Level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade Level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStd. Deviation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStd. Error Mean\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026gt;= 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e2.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026lt; 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e233\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e1.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e0.130\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e0.009\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\" valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIndependent Samples Test\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003eTest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003eValue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003edf\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003eSig. (2-tailed)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003eMean Difference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003eStd. Error Difference\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e95% Confidence Interval of the Difference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003eLevene\u0026apos;s Test for Equality of Variances\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e3.377\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e0.067\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003et-test for Equality of Means (Equal variances assumed)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e0.903\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e278\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e0.367\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e0.017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e0.019\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e-0.020 to 0.055\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003et-test for Equality of Means (Equal variances not assumed)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e2.013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e232.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e0.045\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e0.017\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e0.009\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e0.000 to 0.034\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eSource: Field Data\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePerceived Barriers to IFA Adherence\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDescriptive statistics were used to identify perceived barriers to IFA adherence (Table 6). The mean score for reasons for not taking IFA regularly was 4.54 (SD = 2.897), while 39% of respondents reported experiencing side effects, with an average severity score of 5.99 (SD = 3.354).\u003c/p\u003e\n\u003cp\u003eCross-tabulation analysis revealed a significant relationship between knowledge of IFA benefits and reasons for non-adherence (\u0026chi;\u0026sup2; = 265.587, df = 21, p \u0026lt; 0.001). Forgetfulness was the most commonly reported barrier among students with \u0026ldquo;a lot\u0026rdquo; of knowledge (40 respondents), while fear of side effects was more common among those with limited knowledge (Table 6.1).\u003c/p\u003e\n\u003cp id=\"_Toc182496081\"\u003eTable 4: Descriptive analysis in identifying perceived barriers to IFA adherence.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"101%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDescriptive Statistics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003eMinimum\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003eMaximum\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003eStd. Deviation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003eReasons for not taking IFA regularly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e280\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e4.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e2.897\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003eExperienced side effects?\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e280\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e1.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e.503\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003eSide effects experienced\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e280\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e5.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e3.354\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 29px;\"\u003e\n \u003cp\u003eValid N (listwise)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e280\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eSource: Field Data\u003c/em\u003e\u003c/p\u003e\n\u003cp id=\"_Toc182496082\"\u003eTable 4.1: Cross-tabulation with Adherence\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCrosstabulation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eReasons for Not Taking IFA Regularly\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eKnowledge of IFA Benefits\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 46px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eA lot\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003eSome\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003eForgetfulness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003eFear of side effects\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003eLack of knowledge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003eNot available\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003eNot applicable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e93\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e117\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003eTests\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003eValue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003edf\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003eAsymptotic Significance (2-sided)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003ePearson Chi-Square\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003e265.587\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003eLikelihood Ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003e194.406\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 40px;\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNotes\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026bull; N of Valid Cases: 280\u003c/p\u003e\n \u003cp\u003e\u0026bull; 15 cells (46.9%) have expected count less than 5. The minimum expected count is 0.20.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eLogistic Regression of Independence of respondent knowledge and attitudes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLogistic regression was performed to evaluate the independence of respondents\u0026rsquo; knowledge and attitudes toward IFA adherence (Table 7). The model correctly classified 98.6% of cases. Knowledge of IFA benefits (Wald = 12.212, p = 0.007) and the perceived importance of IFA adherence for adolescent girls (Wald = 8.697, p = 0.034) were significant predictors of adherence. Specifically, higher knowledge of IFA benefits and recognition of its importance were associated with increased likelihood of adherence.\u003c/p\u003e\n\u003cp\u003eTable 5: Logistic Regression of Independence of respondent knowledge and attitudes\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\" style=\"width: 601px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCase Processing Summary\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\" style=\"width: 601px;\"\u003e\n \u003cp\u003eIncluded in Analysis: 280 cases (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\" style=\"width: 601px;\"\u003e\n \u003cp\u003eMissing Cases: 0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\" style=\"width: 601px;\"\u003e\n \u003cp\u003eTotal: 280 cases (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\" style=\"width: 601px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDependent Variable Encoding\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\" style=\"width: 601px;\"\u003e\n \u003cp\u003eNo: 0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\" style=\"width: 601px;\"\u003e\n \u003cp\u003eYes: 1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\" style=\"width: 601px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eClassification Table\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eObserved\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 164px;\"\u003e\n \u003cp\u003ePredicted\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 249px;\"\u003e\n \u003cp\u003ePercentage Correct\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 164px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 249px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 164px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 249px;\"\u003e\n \u003cp\u003e276\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall Percentage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 164px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e98.6%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 249px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\" style=\"width: 601px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables in the Equation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003eB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003eS.E.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003eWald\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003edf\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003eSig.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003eExp(B)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 107px;\"\u003e\n \u003cp\u003eConstant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e4.234\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e.504\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e70.686\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e69.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\" style=\"width: 601px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables not in the Equation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003eScore\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003edf\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003eSig.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003eKnowledge of IFA benefits\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e12.212\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e.007\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003eKnowledge of IFA benefits (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e2.018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e.155\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003eKnowledge of IFA benefits (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e2.913\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e.088\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003eKnowledge of IFA benefits (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e8.784\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003eImportance of IFA adherence for adolescent girls\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e8.697\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e.034\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003eImportance of IFA adherence for adolescent girls (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e1.439\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e.230\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003eImportance of IFA adherence for adolescent girls (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e.947\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e.330\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003eImportance of IFA adherence for adolescent girls (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e8.544\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 270px;\"\u003e\n \u003cp\u003eOverall Statistics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e32.603\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eSource: Field Data\u003c/em\u003e\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eIntroduction\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis chapter discusses the findings of the study in relation to the research objectives and questions, focusing on determinants associated with adherence to iron-folic acid (IFA) supplementation among adolescent girls. The discussion integrates participant characteristics, program accessibility, adherence patterns, barriers, and knowledge and attitudes towards IFA supplementation. By situating the findings within the broader literature, this section provides an understanding of the factors influencing IFA supplementation adherence and identifies potential strategies to improve program effectiveness in Ghanaian schools.\u003c/p\u003e\n\u003cp\u003eThe study sample was representative of adolescent girls in Junior High Schools (JHS) in the selected districts, capturing diverse religious, socioeconomic, and living arrangement backgrounds. Additionally, the inclusion of participants with varying levels of parental education allowed for a nuanced understanding of how family background influences health knowledge and behaviours, which are essential determinants of adherence to supplementation programs (Victora et al., 2010; Cohn, 2014).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eParticipant Characteristics\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe demographic characteristics of the study participants provided important insights into the population under investigation and the generalizability of the study findings. Participants ranged in age from 13 to 18 years, with the majority between 14 and 15 years (27.1% and 27.9%, respectively). This age distribution aligns with the typical adolescent population in JHS and is consistent with previous research highlighting that older adolescent girls tend to exhibit better knowledge and attitudes towards IFA supplementation compared to younger peers (Aguilar-Palomo et al., 2019; Ejara et al., 2023).\u003c/p\u003e\n\u003cp\u003eRegarding grade level, most participants were in JHS 2 (40%) and JHS 3 (40.4%), while fewer were in JHS 1 (19.6%). This distribution ensures the study captured the perspectives of girls across different academic stages. Grade level has been identified as a significant factor in health knowledge acquisition and attitudes toward supplementation, with higher grades often correlating with better awareness and adherence (Adanu et al., 2016).\u003c/p\u003e\n\u003cp\u003eReligious affiliation was predominantly Christian (70%), followed by Muslim (19%), Traditional (10%), and other religions (1.1%), reflecting the national religious composition of Ghana (GSS, 2013). Religion is an important determinant of health behaviors, as it can influence attitudes towards interventions, including supplementation programs. Previous studies have demonstrated that religious affiliation is significantly associated with health-seeking behaviours, such as the use of modern contraceptives among women (Agyemang et al., 2012), suggesting similar effects could apply to adolescent health interventions like IFA supplementation.\u003c/p\u003e\n\u003cp\u003eFamily socioeconomic status also emerged as a notable determinant. In this study, most participants were from middle-income families (56.8%), followed by high-income (27.1%) and low-income families (16.1%). Higher socioeconomic status has been associated with better health knowledge and adherence to supplementation programs (Adanu et al., 2016), likely due to increased access to educational resources and healthcare information.\u003c/p\u003e\n\u003cp\u003eLiving arrangements were similarly influential. Over half of the participants (51.1%) lived with both parents, while 38.9% lived with relatives and 10% with a single parent. Studies have shown that adolescents residing in supportive family environments benefit from social and logistical support that facilitates adherence to health programs (Akosuah et al., 2020).\u003c/p\u003e\n\u003cp\u003eParental education, particularly maternal and paternal levels, also played a critical role in shaping adolescent health literacy. In this study, 19.6% of mothers had a tertiary education, while the majority had secondary or primary education. Paternal education was similarly influential, with 45.7% of fathers having a tertiary education. Higher parental education is consistently associated with improved knowledge and positive attitudes towards health interventions, including IFA supplementation (Adanu et al., 2012).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAccessibility of Iron-Folic Acid Supplementation Programs\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eProgram accessibility is essential for effective supplementation, particularly in school-based settings. A substantial proportion of adolescents reported awareness of IFA programs, with a significant association between program awareness and the frequency of receiving supplements (p \u0026lt; 0.001). Awareness is a prerequisite for adherence, as students who understand the benefits of supplementation are more likely to engage in the program (Ogundele et al., 2022; Nakitto, 2021).\u003c/p\u003e\n\u003cp\u003eDespite high awareness (98.6%), only 76.8% of participants reported ever receiving IFA supplements at school. This discrepancy highlights a critical gap between knowledge and actual program participation, often attributed to supply-side challenges such as the unavailability of supplements or distribution inefficiencies. Similar patterns have been observed in other school-based nutrition interventions, where awareness does not always translate into uptake (Cliffer et al., 2023).\u003c/p\u003e\n\u003cp\u003eFrequency of supplement receipt varied, with 34.1% reporting monthly intake, 37.9% never receiving supplements, 5.7% receiving them rarely, and 36.4% receiving them weekly. Consistent intake is essential for the prevention of anaemia, as irregular consumption reduces the potential health benefits of supplementation (Mollay et al., 2022). These findings underscore the importance of ensuring both the availability and regular distribution of IFA supplements in school programs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAdherence to Iron-Folic Acid Supplementation\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study examined adherence in relation to grade level and living arrangements. No significant differences were observed between adherence among students in higher versus lower grades (t = 0.780, p = 0.436), consistent with prior research indicating that grade level may not strongly influence adherence behaviours among adolescents (Smith et al., 2022). Similarly, living arrangement was not a significant determinant under equal variance assumptions, although a marginal effect was observed under unequal variance assumptions (t = 2.013, df = 232, p = 0.045). These results suggest that while social support from family may contribute to adherence, it is not the sole determinant (Olmsted et al., 2022).\u003c/p\u003e\n\u003cp\u003eThe relationship between frequency of supplement intake and adherence was significant (χ² = 209.873, p \u0026lt; .001), consistent with studies indicating that repeated exposure to supplementation is positively associated with adherence (Islam et al., 2021). Participants who were aware of IFA programs were more likely to adhere (OR = 1.780, p = .045), reinforcing the role of knowledge in promoting health behaviours (Abdisa et al., 2023). However, other factors, such as household size and proximity to health facilities, were not significantly associated with adherence, suggesting that awareness and structured program delivery may be more critical than physical accessibility in this urban school setting.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eBarriers to Adherence\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBarriers to adherence were multifactorial. Forgetfulness was the most common reason cited, followed by fear of side effects, lack of knowledge, and unavailability of supplements. These findings are consistent with previous research showing that logistical challenges, misconceptions, and cognitive barriers hinder adherence to micronutrient supplementation programs (Tam et al., 2020; Mishra et al., 2023). Supply-side issues, such as non-palatability and irregular distribution, and demand-side factors such as lack of awareness, contribute to suboptimal adherence (Charchar et al., 2024; Salam et al., 2016).\u003c/p\u003e\n\u003cp\u003eCross-tabulation of reasons for non-adherence with knowledge of IFA benefits indicated that higher knowledge levels were associated with reduced reports of forgetfulness (χ² = 265.587, p \u0026lt; .001), highlighting the critical role of health education in improving adherence behaviours. Moreover, only a subset of respondents who had heard about the program adhered to the recommended monthly intake, indicating that knowledge alone is insufficient and must be paired with behavioural reinforcement strategies (Tsegai et al., 2023).\u003c/p\u003e\n\u003cp\u003eContrary to expectations, distance to the nearest health facility did not significantly influence adherence. While other studies, particularly in rural areas, have reported proximity as a barrier (Hunegnaw et al., 2022), the urban context of this study likely reduced such logistical challenges (Ejara et al.,2023).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eKnowledge and Attitudes\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKnowledge and attitudes towards IFA supplementation are critical determinants of adherence. The study found that knowledge levels varied by age, grade level, family socioeconomic status, and religion. Girls in higher grades or from higher socioeconomic backgrounds generally had greater access to IFA information. Logistic regression analysis revealed that while knowledge of IFA benefits was not a direct predictor of ever taking supplements, the perceived importance of adherence significantly influenced supplementation behaviour (Bhutta et al., 2013; Cohn, 2014).\u003c/p\u003e\n\u003cp\u003eThis finding highlights the distinction between awareness and behaviour: even when knowledge is adequate, positive attitudes and motivation to act are necessary for consistent adherence. Therefore, interventions should not only disseminate information but also foster positive perceptions of supplementation, highlighting the health benefits and addressing concerns such as side effects (Sendeku et al., 2020; Abdisa et al., 2023).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe study found that knowledge levels about IFA may vary based on factors such as age, grade level, family socioeconomic status, and religion. However, knowledge of IFA benefits was not a significant predictor of ever taking supplements, which aligns with findings from other health interventions that simply knowing about a health practice may not lead to consistent behaviour. On the other hand, the study found a significant association between perceived importance of adherence and ever having taken supplements, highlighting the importance of fostering positive attitudes towards adherence within the program. Distance to the nearest health facility was not found to be a significant barrier to IFA supplementation adherence, consistent with a previous study in Ethiopia, although other studies have found it to be a significant barrier in rural areas. Overall, the study suggests that knowledge of IFA benefits alone may not be sufficient to ensure adherence to supplementation programs. Instead, fostering positive attitudes towards adherence, addressing barriers such as forgetfulness and side effects, and integrating supplements into girls' routines may be more effective in improving adherence among adolescent girls.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecommendations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBased on the study findings, several recommendations are proposed to improve adherence to IFA supplementation among adolescent girls, structured for key stakeholders and future research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eRecommendations for the Ghana Health Service (GHS)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eImplement a coherent IFA supplementation program:\u003c/strong\u003e GHS should design a standardised program for adolescent girls that integrates education, sensitisation, and strategies to address adherence barriers.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eCapacity building for healthcare workers:\u003c/strong\u003e Health professionals should be trained to provide accurate information on IFA supplementation, manage side effects, and address misconceptions effectively.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eEnsure supplement availability and accessibility:\u003c/strong\u003e The GHS should guarantee that IFA supplements are consistently available in schools, and distribution mechanisms should be strengthened to avoid stockouts.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003ePromote behavioural strategies for adherence:\u003c/strong\u003e Innovative approaches such as mobile phone reminders, integration with school schedules, and peer support networks should be employed to encourage consistent supplement intake.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eMonitoring and evaluation:\u003c/strong\u003e GHS should establish a routine system for tracking adherence rates and program outcomes. Data collected should inform program refinement, policy adjustments, and continuous improvement.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eRecommendations for the Regional Health Directorate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eImprove access in rural areas:\u003c/strong\u003e Mobile health clinics, community-based distribution, or satellite supplementation points should be implemented to reduce barriers posed by distance to health facilities.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eStrengthen monitoring and evaluation:\u003c/strong\u003e Regular program audits and surveys should be conducted to assess coverage, uptake, and adherence, ensuring that the program reaches its intended population.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eCapacity building at the regional level:\u003c/strong\u003e Healthcare personnel should receive specialised training on IFA program delivery, communication strategies, and addressing adolescent concerns.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eCollaboration with schools:\u003c/strong\u003e Partnerships with school administrators and teachers are essential to ensure smooth distribution of supplements and to integrate intake into school routines effectively.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eInformation sharing and scaling up:\u003c/strong\u003e Successful strategies and interventions implemented in the region should be communicated with the national GHS to inform best practices and facilitate nationwide improvements.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eRecommendations for Future Research\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eEvaluate adherence-enhancing strategies:\u003c/strong\u003e Future studies should examine the effectiveness of behavioural interventions, such as reminders, incentives, peer support, or integration into routine school activities, on improving IFA adherence.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eIntegration with other health programs:\u003c/strong\u003e Research should explore the potential benefits of combining IFA supplementation with other adolescent health interventions, such as sexual and reproductive health education, vaccination campaigns, or deworming programs.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eContextual factors influencing knowledge and attitudes:\u003c/strong\u003e Further studies are needed to understand how sociocultural, familial, and economic factors influence knowledge, attitudes, and adherence to IFA supplementation, particularly in rural or hard-to-reach populations.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eLongitudinal adherence studies:\u003c/strong\u003e Future research should assess long-term adherence patterns, identifying predictors of sustained supplementation behaviours over time and their impact on anaemia prevalence and overall nutritional status.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eCost-effectiveness and program sustainability:\u003c/strong\u003e Evaluations of the financial and operational feasibility of school-based supplementation programs will inform scalable and sustainable strategies for national implementation.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eIFA\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIron and Folic Acid\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eIFAS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIron and Folic Acid Supplementation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eIDA\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIron Deficiency Anaemia\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eJHS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eJunior High School\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eWHO\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eMoH\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMinistry of Health\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eUNICEF\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUnited Nations International Children\u0026rsquo;s Emergency Fund\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eSPSS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStatistical Package for the Social Sciences\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eAOR\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAdjusted Odds Ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCI\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eConfidence Interval\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e Ethical clearance was obtained from the Ghana Health Service Ethics Review Committee (GHS-ERC: 050/05/24). The study was conducted in accordance with the Declaration of Helsinki. Informed consent was obtained from all participants or their guardians.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe associated data will be available upon request from the corresponding author\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Study was funded solely by the Authors\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFT is the principal Author. SA drafted the Manuscript. FT conceived and designed the study, collected and interpreted the data, and drafted the manuscript. SA critically reviewed the study design, contributed to the interpretation of data, and drafted the Manuscript. DA provided methodological guidance, supported data analysis, and reviewed draft versions. JYE supervised the work and offered valuable insights into content validation and manuscript revision. All authors read, reviewed, and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Authors would like to acknowledge the generous contribution of time and expertise by those who participated in this study. \u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAbdisa DK, Jaleta DD, Tsegaye D, Jarso MH, Jaleta GD, Tolesa GF, Kitila KM. (2023). 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Natl J Community Med. 2019;10(8):479\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAntwi EO, Whyte BK, Alhassan SE, Ayirezang AF, Arhin RE, Ayembilla AJ, Osei TA. Determination of prevalence and cause of anaemia among adolescent pregnant girls in Ussher Hospital, James Town, Ghana. BMC Pregnancy Childbirth. 2025;25(1):983.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBalarajan Y, Ramakrishnan U, \u0026Ouml;zaltin E, Shankar AH, Subramanian SV. Anaemia in low-income and middle-income countries. lancet. 2011;378(9809):2123\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBeard JL. Iron requirements in adolescent females. J Nutr. 2000;130(2):S440\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBhutta ZA, Das JK, Rizvi A, Gaffey MF, Walker N, Horton S, Black RE. (2013). 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Wiley; 2014.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDesta M, Kassie B, Chanie H, Mulugeta H, Yirga T, Temesgen H, Merkeb Y. Adherence of iron and folic acid supplementation and determinants among pregnant women in Ethiopia: a systematic review and meta-analysis. Reprod Health. 2019;16:182. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12978-019-0848-9\u003c/span\u003e\u003cspan address=\"10.1186/s12978-019-0848-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDubik SD, Amegah KE, Alhassan A, Mornah LN, Fiagbe L. (2019). 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Micronutrient Supplementation and Fortification Interventions on Health and Development Outcomes among Children Under-Five in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis. Nutrients, 289.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTsegai MB, Berhe AH, Tesfaezgi SB, Weldemariam DG, Petros KT, Weldetinsae HB, Tesfamariam EH. (2023). Knowledge, Attitude, and Practice Regarding Supplemental Iron and Folic Acid Amongst Women Delivering in Edaga-Hamus Community Hospital: A Cross-Sectional Study in Asmara, Eritrea. Int J Womens Health, 1593\u0026ndash;609.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUNICEF \u0026amp; MoH. Iron \u0026amp; Folic Acid (IFA) Supplementation for Adolescent Girls and Women. UNICEF \u0026amp; the Ministry of Health; 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVictora C, L, A., C F. (2010). Maternal and child undernutrition: consequences for adult health and human capital. Lancet, 340\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Global Accelerated Action for the Health of Adolescents (AA-HA!): guidance to support country implementation. World Health Organization; 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYidana A, Azongo TB, Mohammed A. Iron and Folic Acid Supplementation Compliance among Adolescent Girls in Karaga District, Ghana. SAP. 2020;10(5):133\u0026ndash;42. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5923/j.phr.20201005.01\u003c/span\u003e\u003cspan address=\"10.5923/j.phr.20201005.01\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Iron-Folic Acid Supplementation, Adolescent Girls, Adherence, Determinants, Junior High School, Nutrition, School-Based Program, Volta Region, Ghana","lastPublishedDoi":"10.21203/rs.3.rs-8842850/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8842850/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eIron and folic acid (IFA) supplementation is essential for improving the nutritional status of adolescent girls and preventing related health issues. However, adherence to IFA supplementation remains a significant challenge in many Ghanaian school settings.\u003c/p\u003e\u003cp\u003e\u003cb\u003eObjective\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis study aimed to provide insights into adherence to IFA supplementation among adolescent girls and identify strategies to improve their nutritional status.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethod\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe study was conducted at Mawuli Junior High School in the Volta Region of Ghana, selected as a representative public junior high school with a large population of adolescent girls. The study involved girls aged 13 to 18 years in Forms 2 and 3. A sample of 350 participants was selected using simple random sampling. Data were collected through structured questionnaires and analysed using descriptive and inferential statistics.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eAwareness of IFA programs in school was strongly associated with receiving and taking supplements (AOR\u0026thinsp;=\u0026thinsp;8.54, 95% CI: 3.12\u0026ndash;23.36, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Grade level and distance to the nearest health facility did not significantly influence adherence (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). A strong association was found between frequency of intake and adherence (AOR\u0026thinsp;=\u0026thinsp;5.99, 95% CI: 2.45\u0026ndash;14.65, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Logistic regression showed that hearing of IFA programs in school significantly predicted adherence (AOR\u0026thinsp;=\u0026thinsp;8.78, 95% CI: 2.91\u0026ndash;26.45, p\u0026thinsp;=\u0026thinsp;0.003). Although knowledge of IFA benefits was not a significant predictor of supplement intake overall (p\u0026thinsp;=\u0026thinsp;0.155), the perceived importance of adherence increased the likelihood of initiation (AOR\u0026thinsp;=\u0026thinsp;8.54, 95% CI: 2.33\u0026ndash;21.65, p\u0026thinsp;=\u0026thinsp;0.003). Forgetfulness emerged as the most common barrier to regular intake, followed by fear of side effects, lack of knowledge, and unavailability of supplements.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eStrategies to improve adherence should focus on enhancing knowledge and attitudes toward IFA supplementation, addressing practical barriers such as forgetfulness and side effects, and integrating supplementation into adolescents\u0026rsquo; daily routines. The study provides valuable insights into factors influencing adherence and offers direction for strengthening school-based IFA programs.\u003c/p\u003e","manuscriptTitle":"The Determinants Associated With Adherence to Iron-folic Acidsupplementation Among Adolescent Girls in Jhs: A Cross-sectional Study at Mawuli Junior High School, Volta Region","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-18 17:31:00","doi":"10.21203/rs.3.rs-8842850/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-31T08:10:22+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-26T14:25:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"49052479492986113916597089166182930676","date":"2026-03-22T13:17:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"145729405119339284889720732606653745949","date":"2026-03-22T06:54:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"110597010787218636869710319000936509703","date":"2026-03-22T04:59:01+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-21T21:47:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"3406838068955389266517764002448163553","date":"2026-03-21T20:57:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"25776847605268433980124852273411129423","date":"2026-03-20T17:54:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"203643710547949640919494919804802624799","date":"2026-03-20T08:36:38+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-05T15:09:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"240183727653822187059018600021580905893","date":"2026-02-16T13:19:29+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-13T07:58:23+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-12T10:05:04+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-11T22:54:58+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-11T22:54:29+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2026-02-10T14:51:58+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d29043ab-80da-43f4-a622-5dbc27c568e9","owner":[],"postedDate":"February 18th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-11T10:23:42+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-18 17:31:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8842850","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8842850","identity":"rs-8842850","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}