Understanding Knowledge, Attitudes, and Practices Around Multiple Micronutrient Supplementation in Rwanda

Understanding Knowledge, Attitudes, and Practices Around Multiple Micronutrient Supplementation in Rwanda | 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 Understanding Knowledge, Attitudes, and Practices Around Multiple Micronutrient Supplementation in Rwanda Eric Matsiko, Annet Birungi, Eliphaz Tuyisenge, Patrick Izabayo Rudatinya, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6932308/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: In Rwanda, micronutrient deficiencies among pregnant women remain a public health concern. To address this, Rwanda introduced Multiple Micronutrient Supplementation (MMS) in antenatal care (ANC) services in an integrated manner. Understanding knowledge, attitudes, and practices (KAP) related to MMS is crucial for effective implementation. Therefore, the current study aimed to assess knowledge, attitudes, and practices related to MMS among pregnant and lactating women, and to identify factors influencing adherence and uptake. Methods: A mixed-methods study was conducted in December 2024 in the Rwandan districts of Gasabo, Rutsiro, and Burera, where the MMS program was implemented. Quantitative data were collected from 484 women (pregnant and lactating) through structured questionnaires, while qualitative data were gathered via 18 focus group discussions (FGDs) with women and husbands, exit interviews with 12 pregnant women, and key informant interviews with healthcare providers and district officials. Data were analyzed using SPSS and Atlas.ti. Results: Despite high reported use (94%) and adherence (92%) to MMS among pregnant women, knowledge levels remained largely moderate, with 58.5% scoring in the moderate range and only 15% achieving high knowledge scores. In terms of attitudes, 56.6% demonstrated a high attitude toward MMS, while only 2% showed low attitudes. Notably, most respondents expressed a willingness to recommend MMS to others (96%), had minimal concerns about its use (83%), and intended to continue supplementation (77.7%). Trust in healthcare providers was high, with 95.5% expressing confidence in the advice received and 93.6% reporting satisfaction with the information provided. However, misconceptions—such as fears of delivery complications due to large babies and confusion between MMS and other medications, fear of side effects—remain key barriers. Conversely, male partner support, awareness of MMS benefits, and encouragement from health providers were identified as significant facilitators. Conclusions: Despite high MMS use and adherence among women, knowledge levels remain largely moderate, whereas attitudes toward MMS are generally positive. Misconceptions about MMS and the fear of side effects are the challenges. Partner support, knowing the benefits of MMS and encouragement from healthcare providers are key facilitators. Strengthening early health education and involving partners could enhance MMS uptake and impact. Multiple Micronutrient Supplementation (MMS) antenatal care (ANC) knowledge attitudes and practices (KAP) supplement adherence Rwanda Background Micronutrient deficiencies during pregnancy remain a significant public health concern, particularly in low- and middle-income countries. Pregnant women are especially vulnerable to deficiencies in essential micronutrients such as iron, folate, iodine, zinc, vitamins A and D, as well as riboflavin and vitamins B6 and B12 ( 1 ). Inadequate intake of these nutrients during pregnancy can adversely affect both maternal health and pregnancy outcomes ( 2 – 4 ). The increased metabolic demands associated with pregnancy, coupled with poor dietary quality, often result in unmet nutritional needs, leading to heightened risks of complications such as preterm birth, small-for-gestational-age (SGA) infants, neural tube defects (NTDs), and various maternal health conditions ( 5 – 8 ). In Rwanda, micronutrient malnutrition is prevalent among pregnant women. Data from the Rwanda Demographic and Health Survey (DHS) Supplemental Report on Micronutrients ( 9 ) underscore the magnitude of this issue. Anemia affects 17.6% of pregnant women, and 15% are iron deficient. Additionally, 28% of pregnant women experience vitamin A insufficiency, while vitamin B12 deficiency affects 43.5%, and the risk of deficiency is present in 72% of women. In response to the high burden of anemia, Rwanda has implemented an iron-folic acid (IFA) supplementation program; however, uptake remains low, with only 16% of pregnant women reporting the intake of iron tablets for at least 90 days during their most recent pregnancy( 9 ). Moreover, the IFA program addresses primarily iron deficiency anemia, leaving other micronutrient deficiencies unaddressed. In response, Rwanda began integrating Multiple Micronutrient Supplementation (MMS) into antenatal care (ANC) services in 2024 Given the multifaceted impact of micronutrient deficiencies during pregnancy, MMS has emerged as a promising public health intervention. MMS not only offers comparable benefits to iron-folate supplementation in reducing anemia but also addresses other micronutrient deficiencies and supports fetal growth, neonatal health, and infant development ( 7 , 10 , 11 ). MMS represents a safe and effective strategy to bridge nutritional gaps and fulfill the elevated micronutrient demands of pregnancy, particularly in settings where dietary diversity is limited ( 8 ). Cost-effective analyses further support the adoption of MMS, indicating that it offers substantial economic benefits relative to traditional IFA supplementation ( 12 ). Evidence suggests that MMS reduces maternal anemia, preterm birth, SGA births, and the incidence of NTDs in newborns ( 7 , 8 , 11 ). By ensuring sufficient intake of key nutrients—including iron, folic acid, docosahexaenoic acid (DHA), and vitamin D—MMS not only promotes maternal well-being and metabolic health but also optimizes placental function( 13 ). For the fetus, MMS plays a critical role in promoting brain development, improving neurocognitive function, and mitigating the risk of neurodevelopmental disorders( 14 ). It is particularly advantageous in high-risk pregnancies, where it has been associated with better outcomes in conditions such as pre-eclampsia and intrauterine growth restriction (IUGR) ( 11 ). The World Health Organization (WHO) now recommends the use of MMS as part of comprehensive nutritional interventions to improve maternal micronutrient status and pregnancy outcomes ( 5 ). The updated WHO guidelines create a valuable opportunity for countries to incorporate MMS into national health strategies, thereby enhancing the provision of quality nutrition services through antenatal care (ANC) platforms. In line with this WHO recommendation and recognizing the potential benefits of MMS, Rwanda initiated the integration of MMS into ANC services. This effort commenced with a pilot program launched in seven districts in 2024, with plans for expansion to other districts in 2025. As part of the scale-up preparations, UNICEF Rwanda, in collaboration with the Rwanda Biomedical Center and the Ministry of Health, commissioned an assessment to evaluate knowledge, attitudes, and practices (KAP) related to MMS because studies have shown that women with strong awareness of the benefits of supplements during pregnancy are more likely to initiate and continue MMS use ( 15 – 17 ). The current study aimed to assess knowledge, attitudes, and practices related to MMS among pregnant and lactating women, and to identify factors influencing adherence and uptake. Understanding these factors is essential for designing effective strategies to promote the successful adoption of MMS at the national level and ensure that pregnant women benefit fully from enhanced nutrition interventions during pregnancy Methods Design and setting This study employed a mixed methods design, combining both quantitative and qualitative approaches. The qualitative component included key informant interviews (KIIs) and focus group discussions (FGDs). We targeted pregnant women attending ANC visits who were registered for MMS, as well as lactating mothers with infants aged three months or younger who had used MMS. We also included husbands, community health workers, health center staff responsible for ANC (nurses and midwives), and district-level staff responsible for health (district health directors) as participants. We conducted data collection in December 2024 in the districts of Gasabo, Rutsiro, and Burera, where the MMS program was being implemented. Sampling and sample size We randomly selected a representative sample of twelve health centers from a total of 52 health centers across the three districts, allocating four health centers to each district. From a comprehensive, alphabetically arranged list of all health centers in each district, we used the random function in Excel for selection. At each selected health center, we arbitrarily chose four villages—two located near the health center headquarters and two situated farther away. We applied random sampling to select participants from a comprehensive list of pregnant women attending ANC and enrolled in the MMS program, as well as lactating mothers who had used MMS in the selected villages. We obtained the complete lists from the respective health centers. We targeted a minimum sample size of 483 pregnant women and lactating mothers, calculated using Yamane Taro’s formula, with a 95% confidence level, 80% power, and a 5% margin of error. We based the calculation on a total population of 28,889 pregnant women enrolled in the MMS program across the three districts as of October 2024. We proportionally allocated the sample across the three districts according to the number of pregnant women receiving MMS in each district. For the qualitative component, we conducted 18 focus group discussions (FGDs): seven with women, five with husbands, and six with community health workers. Additionally, we conducted 12 exit interviews with women immediately after their ANC visits to gather real-time feedback on the MMS service. We also conducted key informant interviews with three health center staff in charge of ANC (nurses or midwives) and two district-level Directors of Health. Data collection procedures Enumerators administered a quantitative questionnaire, developed specifically for this study and programmed into the Kobo Collect application for data collection. They submitted completed questionnaires daily through the application, and the data analyst reviewed them for completeness and accuracy. Moderators and note-takers facilitated the FGDs and audio-recorded them with participants’ consent. Guides, developed in English and translated into Kinyarwanda, structured the FGDs. Similarly, experienced facilitators conducted the KIIs using a translated interview guide and audio-recorded the sessions upon receiving consent. Additionally, we conducted 12 exit interviews with pregnant women immediately after their ANC visits to capture real-time feedback on the MMS service. Data analysis We conducted all quantitative analyses using SPSS and analyzed qualitative data using Atlas.ti. Knowledge and attitude were each assessed using 12 questions (see Table 2 for knowledge and Table 3 for attitude), with one point awarded for each correct response and zero for incorrect answers. Based on total scores, responses were categorized as follows: low ( 1 – 4 ), moderate ( 5 – 8 ), and high ( 9 – 12 ). This same scoring and categorization approach was applied to both knowledge and attitude. We used percentages and medians to present the data, as appropriate. For the qualitative analysis, we applied thematic analysis, which involved verbatim transcription, coding, and theme generation. We included illustrative quotes to support and triangulate findings. Table 2 Knowledge of pregnant and lactating women about MMS Characteristics Count N = 484 % Knowing some micronutrients that are important for pregnancy Yes 246 51.0 No 238 49.0 Knowing different types of micronutrient supplements (MMS, IFA, MNPs) Yes 261 54.0 No 223 46.0 Knowing that MMS are tablets containing a combination of vitamins and minerals Yes 182 37.6 No 302 62.4 Knowing some examples of vitamins and minerals included in MMS Yes 225 46.5 No 259 53.5 Knowing when MMS can be taken (before pregnancy, during pregnancy and lactation) Yes 463 95.7 No 21 4.3 Knowing the benefits of taking MMS during pregnancy Yes 274 56.6 No 210 43.4 Knowing when a pregnant mother should start taking MMS in the first trimester Yes 428 88.4 No 56 11.6 Knowing that MMS must be taken daily Yes 452 93.4 No 32 6.6 Knowing if MMS can be taken when a mother/woman is not pregnant Yes 30 6.2 No 454 93.8 Knowing that 180 MMS should be taken through pregnancy Yes 161 33.3 No 323 66.7 Knowing that not taking MMS may have negative effects Yes 383 79.0 No 101 21.0 Knowing the side effects associated with taking MMS Yes 215 44.4 No 269 55.6 Knowledge Score Median (Minimum, Maximum) 7 ( 1 – 12 ) Women with low knowledge 72 15.0 Women with moderate knowledge 283 58.5 Women with high knowledge 129 26.5 Sources of information on micronutrient supplements Health care providers 283 85.0 Community health workers 147 44.0 Mass media 56 16.8 Friends and relatives 28 8.4 Table 3 Attitudes of pregnant and lactating women towards MMS Characteristics Count (N = 484) % Thinking that micronutrients are essential/important during pregnancy Yes 465 96.0 No 19 4.0 Thinking that taking MMS during pregnancy is important Yes 451 93.2 No 33 6.8 Thinking that taking MMS during lactation is important Yes 190 39.3 No 294 60.7 Having concerns about taking MMS during pregnancy Yes 82 17.0 No 402 83.0 Thinking that taking MMS can hurt a baby Yes 22 4.8 No 432 95.2 Believing that taking MMS can hurt women’s lives Yes 32 7.0 No 431 93.0 Believing that taking MMS can help reduce the risk of anemia during pregnancy Yes 408 83.4 No 76 15.7 Been regularly advised by a health professional to take MMS Yes 286 67.8 No 138 32.5 Trusting the advice given by healthcare providers regarding MMS Yes 405 95.5 No 19 4.5 Being satisfied with the information provided by healthcare providers about MMS Yes 397 93.6 No 27 6.7 Feeling that they can recommend MMS to other women Yes 465 96.0 No 19 4.0 Feeling that they can stop MMS at any time Yes 108 22.3 No 376 77.7 Attitude Score Median (Minimum, Maximum) 9 ( 1 , 11 ) Women with low attitude 10 2.0 Women with moderate attitudes 200 41.4 Women with high attitude 274 56.6 Results Participants Profile The characteristics of women are summarized in Table 1 . A total of 484 women participated in the assessment, comprising 376 pregnant women and 108 lactating mothers with infants aged younger than three months. The majority (66.7%) of women were in their second or third trimester, while 11% were in the first trimester. Lactating women accounted for 22.3% of the sample. Approximately two-thirds (67%) of the women were under the age of 30, and a substantial proportion (88%) reported living with their partners. Regarding educational attainment, nearly half (49.6%) had completed some level of primary education, while 41.4% had attained secondary education or higher. Despite varying education levels, the majority of women (85%) were literate. In terms of religious affiliation, Protestantism was the most commonly reported (56.2%). Notably, 28.3% of participants reported that reaching the nearest health center required more than one hour of travel. Table 1 Participants' profile Characteristics Count n = 484 % Categories of participants 1st trimester 53 11.0 2nd trimester 160 33.0 3rd trimester 163 33.7 Lactating mothers 108 22.3 Age ≤ 30 224 67.0 ≥ 30 160 33.0 Median, 27 (18–49) Marital status Living with a partner 426 88.0 Living with no partner 58 12.0 Education None 44 9.0 Any Primary 240 49.6 Any secondary and higher 126 41.4 Ability to read and write Reading and writing 412 85.1 Only reading 30 6.2 None of them 42 8.7 Occupation Agriculture 125 25.8 Business 75 15.5 Casual labor 184 38.0 Salaried 11 2.3 Household work 103 21.3 Religion Catholic 154 31.8 Protestant 272 56.2 Seventh Day Adventist 55 11.4 Muslim 3 0.6 Walking time to the nearest health center < 30 minutes 205 42.4 30–60 minutes 142 29.3 ≥ 60 minutes 137 28.3 Table 1 : Participants' profile Knowledge towards MMS Slightly more than a quarter (26.5%) of women demonstrated high knowledge, while over half (58.5%) had moderate knowledge, and a smaller proportion (15%) exhibited low knowledge levels (Table 2 ). Awareness of the role of micronutrients during pregnancy was relatively limited. Only 51% of women recognized their significance, and merely 37% correctly identified MMS as tablets containing a combination of vitamins and minerals. Similarly, only 46.5% could name some micronutrients found in MMS. Nonetheless, 56.6% of the women knew the benefits of MMS, such as the prevention of anemia and support for fetal development. Qualitative data from FGDs and interviews reinforced these findings. Women expressed a general awareness of the benefits of MMS, often associating them with healthier pregnancies and improved birth outcomes. One woman remarked: “These supplements help you give birth to a healthy baby with adequate growth and height .” Another stated: “MMS prevents stunting, increases blood levels, and improves the mother’s health .” However, in some cases, knowledge was often general and lacked detail. As one participant noted: “ It’s to ensure the baby is healthy and to prevent anything that might harm the baby or the mother.” While many women acknowledged the benefits of MMS, gaps in understanding remained. Some could not differentiate MMS from other supplements or questioned their composition. Misconceptions—such as believing MMS contained deworming components—were found. One woman asked: “Do these tablets replace the old ones? Do they include deworming medicine?” Table 2 : Knowledge of pregnant and lactating women about MMS Awareness of MMS use protocols was higher than knowledge of its composition. Most women (88.4%) were aware that supplementation should commence in the first trimester, and 93.4% understood that MMS is taken daily. However, only 33.3% were cognizant of the total number of tablets (180) recommended during pregnancy. Additionally, 21% did not realize that failing to take MMS could lead to adverse outcomes, such as anemia. About forty-four percent (44.4%) were aware of possible side effects, including stomach discomfort and headache. In FGDs, some women shared strategies they learned for alleviating side effects, such as taking MMS after meals. Knowledge gap among family members, particularly husbands or partners, was noticed. Some partners reported only partial or second-hand knowledge, often obtained through their wives. One noted: “The midwives did not fully explain their benefits to us. I only found out later at home.” Others were hearing about MMS for the first time during FGDs. These knowledge deficits may limit male support for adherence to supplementation. As one CHW observed: “If husbands or mothers-in-law don’t understand the importance of MMS, they discourage women from using it .” The necessity for enhanced and inclusive education efforts was widely acknowledged. Both women and their partners expressed interest in receiving clearer information. One suggested: “They should explain the tablets in more detail to husbands, so we understand their importance better.” Another proposed utilizing community meetings or radio broadcasts as accessible communication channels. Healthcare providers were the primary source of information, with 85% of women citing health centers and 44% mentioning CHWs. At health centers, group education sessions were commonly employed during ANC visits to communicate key messages. While these sessions allowed providers to reach many women simultaneously, they did not always facilitate personalized counselling or address individual misconceptions. Despite this, systemic challenges such as staff shortages and overcrowding limited the quality of counselling. One nurse explained: “We see so many patients in one day that it’s hard to give each one enough time to explain MMS benefits fully .” Women confirmed that the information provided was sometimes incomplete. One said: “I was told to take one tablet daily, but there was no detailed explanation.” This limited counseling could also be attributed to insufficient training on MMS, as acknowledged by healthcare providers, particularly nurses and midwives responsible for antenatal care (ANC) and MMS distribution. CHWs also faced constraints. Some admitted to never having seen MMS tablets or receiving detailed training. One CHW noted: “We need to know more about these supplements—what they look like, when to take them, and how to explain them to women.” Attitudes toward MMS The current study revealed generally positive attitudes among women regarding the use of MMS during pregnancy (Table 3 ). Large proportions of women demonstrated high (56.6%) or moderate (41.4%) attitudes toward MMS use, while only a small fraction (2%) exhibited low attitudes. Specifically, most women (96%) acknowledged the importance of micronutrients during pregnancy, and 93.2% believed that taking MMS was important. A substantial proportion (83.4%) specifically associated MMS use with a reduced risk of anemia. Slightly more than two-thirds (67.8%) of women reported being regularly advised by a healthcare provider to take MMS. Trust in healthcare providers was notably high: 95.5% of women expressed confidence in the advice they received, and 93.6% were satisfied with the information provided. Furthermore, 96% indicated they would recommend MMS to other women, 77.7% reported they would not stop taking the supplements, and 83% expressed no concerns about using MMS during pregnancy. These attitudes were reflected in the qualitative data. Women frequently emphasized their reliance on healthcare providers for reassurance. One woman noted, “I trusted the midwife because she said the tablets were safe for both me and the baby.” Another stated, “We trust the advice midwives give us because what they say never causes harm.” Table 3 : Attitudes of pregnant and lactating women towards MMS Cultural barriers to MMS use were minimal, with 91% of women reporting no such influence. However, qualitative data revealed misconceptions that may negatively shape attitudes and behaviors. Some women believed that MMS could lead to delivery complications, fearing that the supplements might cause the baby to grow too large. A nurse observed, “Many women fear MMS will make the baby too big, making delivery more difficult.” Others expressed concern about the packaging, which resembled antiretroviral medication and triggered stigma. “Some women think MMS is for HIV, just because of the way it’s packaged,” a nurse explained. Side effects were a commonly cited barrier. Nausea, vomiting, and the unpleasant taste or size of the tablets discouraged some women, especially first-time mothers. One woman stated, “Whenever I take the tablet, I vomit or burp with a sour taste.” Another added, “The smell made me want to stop, but I endured because I knew it helped increase blood levels. ” Healthcare providers acknowledged this issue, with one nurse explaining, “The smell and size of the tablets make some women feel sick, and they stop taking them.” Concerns extended to partners as well. While some expressed support, others voiced skepticism. “I worry that something might happen because I don’t fully trust the tablets yet,” a partner stated. Another added, “They should be tested thoroughly before being given to pregnant women everywhere.” A woman noted, “My mother-in-law said I didn’t need the tablets because I was already eating well.” These perceptions might discourage adherence. Stigma also emerged as a barrier, particularly for women experiencing unplanned pregnancies or those who feared being judged by their communities. As one nurse noted, “Some women avoid ANC because they don’t want people to know they’re pregnant.” The association of MMS with disease treatment further contributed to the stigma, with one woman commenting, “Some think the tablets are for curing diseases.” Scepticism about MMS effectiveness was noticed. Some women questioned whether supplements could replace the nutrients found in natural foods. One remarked, “I don’t understand why these tablets are better than beans or meat.” Others preferred alternative remedies: “If it’s about increasing blood, I’ll just buy pineapple or beetroot juice.” Nonetheless, there was some recognition of MMS as a complement to a healthy diet. “I thought eating well was enough, but I later realized these tablets provide what food sometimes can’t,” one woman shared. Current practices Most women (94%) reported currently taking MMS, with 66.4% initiating use during the first trimester of pregnancy. Among those taking MMS, adherence was high, with 92% reporting consistent use as advised by healthcare providers. Women’s practices regarding the timing of MMS intake varied: 45.5% preferred taking tablets in the evening, 35.2% in the morning, and 15.5% at any time during the day. Motivators for adherence included knowledge of MMS benefits (77.4%) and encouragement from healthcare providers (45.5%). Support from partners played a significant role, cited by 87.8% of women as a reason for continued use. Partners reminded their spouses, provided emotional support, and helped reinforce routines. As one woman noted, “My husband reminded me every morning to take the tablets. ” Similarly, a partner said, “If she forgets, I remind her and encourage her to stick to the schedule ”. Family involvement extended beyond partners. About 28% of women reported forgetting to take MMS at times, but support from other household members, — including children, — helped by providing reminders. One woman explained, “Even the children would remind me: ‘Mama, did you take the tablet? ’” Some women reported that household responsibilities and work demands took precedence over their health, making it difficult for them to maintain consistent MMS use. One woman reflected, “I get busy with work and forget to take the tablets or attend the health center.” Another added, “My household duties keep me busy all day, so it’s hard to focus on these things.” These insights underscore the importance of family support in enabling women to prioritize their health. Table 4 : Practices and Adherence to MMS Table 4 Practices and adherence to MMS Characteristics Count N = 484 % Women currently taking MMS Yes 455 94.0 No 29 6.0 When taking MMS started 1st trimester 302 66.4 2nd trimester 140 30.8 3rd trimester 15 2.8 Taking MMS as advised by a health care provider Yes 419 92.0 No 36 8.0 Time of day when MMS is taken Morning 157 35.2 Noon 17 3.8 Evening 203 45.5 Anytime 69 15.5 Barriers that make it challenging to take MMS regularly Forgetting to take them 136 28.0 Side effects 34 7.0 Hard to access 9 2.0 None 304 63.0 Husband’s support in taking MMS Strongly support 276 64.8 Support 98 23.0 No support 52 12.2 Cultural beliefs or traditions that influence the decision to take or not take MMS Yes 44 9.0 No 440 91.0 Side effects experienced from taking MMS Stomach discomfort 474 97.4 Headaches 21 4.5 Constipation 3 0.6 MMS effect on appetite Increased 122 25.2 Decreased 44 9.0 No effect 318 65.8 Perception of MMS taste Good 32 6.7 Bad 173 35.7 No taste 279 57.6 Perception of MMS smell Good 53 11.0 Bad 304 62.8 No smell 127 26.2 Regarding the sensory experience of MMS, 65.8% of women reported no effect on appetite, and 57.6% did not find the taste problematic. However, 35.7% found the taste unpleasant, and 62.8% described the smell as bad. Women also reported experiencing side effects, with 97.5% identifying stomach discomfort as the primary concern. Nausea and vomiting were frequently mentioned in FGDs, often attributed to the tablet’s smell and bitterness. As one woman stated, “ The tablets smell bad and make me throw up immediately after taking them.” Despite these challenges, women often demonstrated resilience. Some adjusted intake routines, such as taking MMS with porridge or before bedtime, reduce nausea. One woman shared, “The bitterness and nausea were unbearable, but I still took them because they helped.” Another barrier to effective MMS use was the late initiation of ANC. Some women delayed their first visit until the second or third trimester, often due to misconceptions about the purpose of ANC. A CHW noted, “Many women think ANC is just for checking blood pressure.” Another explained, “Some wait until they feel the baby move before coming for ANC, thinking it’s unnecessary before then.” Discussion This study revealed a moderate level of knowledge about maternal MMS among pregnant and lactating women, with a gap in understanding its composition, benefits and appropriate use. These findings are consistent with evidence from other low- and middle-income countries (LMICs), where limited knowledge about MMS remains a common barrier( 16 , 18 ). Nevertheless, previous studies have shown that nutritional knowledge is a key driver of supplement use and healthy dietary practices during pregnancy( 19 – 21 ). In this study, limited knowledge was reflected in misconceptions about the contents of MMS, with some women unable to identify the specific micronutrients or believing that the supplements included deworming or antiretroviral medications based on their packaging. Similar misconceptions have been documented elsewhere, where stigma and confusion surrounding MMS have negatively impacted uptake and adherence ( 15 , 16 , 22 ). These knowledge limitations may be attributed, in part, to infrequent and insufficient counselling, which is a key barrier at health centers, as fewer than two-thirds of women reported receiving consistent guidance from healthcare providers. This represents a missed opportunity to reinforce behavior change during ANC visits. These findings corroborate previous research showing that poor-quality counselling can negatively affect the uptake and utilization of supplementation programs( 17 ). Regular and personalized counselling is essential for enhancing understanding, building trust, and improving adherence to supplementation regimens( 22 ). The present study identified that inadequate counselling was often a consequence of staff shortages and high patient volumes—challenges similarly documented in other settings( 23 , 24 ). In addition, healthcare providers and CHWs themselves acknowledged gaps in training and exposure to MMS, which hindered their ability to educate and counsel women effectively. This finding aligns with evidence from other countries where insufficient provider training has compromised the delivery of nutrition interventions( 25 – 28 ). These systemic challenges mirror findings in similar settings and point to the urgent need for enhanced investment in training, supportive supervision, and workload management( 20 , 29 ). Building a well-equipped and adequately supported health workforce is central to improving the delivery and impact of maternal supplementation programs. Limited awareness of the appropriate timing for initiating MMS may contribute to its delayed uptake among pregnant women. In this study, approximately one-third of women reported beginning MMS in the second or third trimester, rather than during the recommended first trimester. This delay is closely linked to the low rate of first ANC visits occurring within the first trimester, recorded at 52% in the 2023/2024 fiscal year ( 30 ), and previously at 59% according to the 2020 Rwanda Demographic and Health Survey( 9 ). Notably, the challenge of timely ANC initiation is not unique to Rwanda; similar trends have been observed in other low- and middle-income countries ( 31 , 32 ). Delayed initiation of MMS diminishes the opportunity to realize its full benefits, which include reducing the risk of maternal anemia, low birth weight, preterm birth, and small-for-gestational-age outcomes (Smith et al., 2017) ( 8 ). Furthermore, women who reported using MMS also identified barriers that may hinder optimal adherence. Commonly reported challenges included experiencing side effects such as stomach discomfort, nausea, and the unpleasant taste or smell of the tablets. These findings align with evidence from other LMICs, where similar side effects have been identified as key deterrents to sustained supplement uptake ( 18 , 23 ). Some women adapted by taking MMS with meals or before bedtime to reduce discomfort, reflecting adaptive strategies that can be encouraged through tailored counselling (Hyder et al., 2019). Additionally, competing household responsibilities constrained some women’s ability to adhere to MMS consistently. These findings underline the importance of designing context-specific behavioral interventions that account for women’s daily realities( 33 ). The study also underscored the role of household dynamics, particularly male support, in promoting adherence. A substantial number of women cited their husbands’ reminders and encouragement as motivators for continued use of MMS. This is consistent with evidence suggesting that male involvement enhances maternal health outcomes, particularly when men are included in health education efforts and empowered to support their partners ( 16 , 23 , 34 ). However, the limited awareness among men about MMS and their general exclusion from counselling sessions were seen as barriers. Addressing this gap through inclusive health education—via community meetings, mass media, or targeted sessions at ANC clinics—may foster a more enabling environment for MMS adherence ( 35 ). The strengths of this study include its mixed-methods design, which provided comprehensive and triangulated insights into knowledge, attitudes, and practices related to MMS among diverse stakeholders, such as women, partners, CHWs, and healthcare providers. Conducted during the early phase of MMS implementation in Rwanda, the study offers timely, policy-relevant evidence to inform the national scale-up. However, this study has to three limitations. First, the geographic scope was restricted to only 3 districts—Gasabo, Rutsiro, and Burera —out of 7 pilot districts where the MMS program was implemented. These districts may not be fully representative of the diverse cultural, socioeconomic, and healthcare contexts across Rwanda’s 30 districts. As a result, the generalizability of the findings to the broader Rwandan population may be limited. Second, the study relied on self-reported data from participants regarding their knowledge, attitudes, and practices. This approach is subject to potential recall bias. Moreover, social desirability bias may have influenced respondents to provide answers they perceived as favorable or acceptable. Third, the study was conducted towards the end of the first year of MMS implementation—a period during which awareness and understanding might have still been evolving. As such, the findings may not have captured long-term knowledge, attitudes, or behavioral outcomes. Conclusions This study shows high levels of MMS uptake and adherence among pregnant and lactating women in Rwanda’s pilot districts, supported by generally positive attitudes and partner involvement. However, moderate knowledge levels, delayed start, and misconceptions—both among women and their families—act as barriers to optimal implementation. Inconsistent counselling and limited provider training further restrict the delivery of adequate counseling. Addressing these gaps requires a multifaceted approach. Enhancing antenatal counselling through capacity building for healthcare providers and CHWs is vital to ensure consistent, personalized guidance. Community-level education—particularly involving male partners—can strengthen support systems. Additionally, promoting timely ANC attendance and correcting misinformation about MMS content and purpose will be crucial to improving early uptake. As Rwanda prepares to expand MMS nationwide, these findings provide timely insights to guide implementation. An inclusive, system-strengthening approach that combines evidence-based education, support for the health workforce, and family engagement will be vital to maximize the nutritional and health benefits of MMS for pregnant women and their infants. Abbreviations ANC Antenatal Care CHW Community Health Worker KII Key Informant Interview MMS Multiple Micronutrient Supplementation RDHS Rwanda Demographic and Health Survey UNICEF United Nations Children's Fund WHO World Health Organization FGD Focus Group Discussion. HIV:Human Immunodeficiency Virus. Declarations Ethics approval and consent to participate: We obtained ethical approval from the Rwanda National Ethics Committee (RNEC 638/2024) and secured written informed consent from all participants. Before participation, we explained the study's purpose, voluntary nature, potential risks and benefits, and confidentiality measures Consent for publication : Not applicable Competing interests: The authors declare that they have no competing interests. Funding: This study was funded by UNICEF Rwanda. The statements in this publication are the views of the author(s) and do not necessarily reflect the policies or the views of UNICEF. Author Contribution E. M, S. D., A.B and E.T. conceptualized the study. E.M., P.N. and P.I.R. collected and analyzed data and analysis: EM.. and H.G.A. wrote the main manuscript text. S. D., A.B, J. D. D. H. and E.T. reviewed and edited the manuscript. All authors read and approved the final manuscript Acknowledgements: Not applicable Data Availability The datasets used and/or analyzed during the current study are readily available from the corresponding author on request References Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, De Onis M, et al. Maternal and child undernutrition and overweight in low-income and middle-income countries. lancet. 2013;382(9890):427–51. Santander Ballestín S, Giménez Campos MI, Ballestin Ballestin J, Luesma Bartolomé MJ. Is supplementation with micronutrients still necessary during pregnancy? A review. Nutrients. 2021;13(9):3134. Milman N, Paszkowski T, Cetin I, Castelo-Branco C. Supplementation during pregnancy: beliefs and science. Gynecol Endocrinol. 2016;32(7):509–16. Kebede AS, Muche AA, Alene AG. Factors associated with adverse pregnancy outcome in Debre Tabor town, Northwest Ethiopia: a case control study. BMC Res Notes. 2018;11:1–6. WHO. WHO antenatal care recommendations for a positive pregnancy experience: Nutritional interventions update: Multiple micronutrient supplements during pregnancy. Geneva: World Health Organization; 2020. Tsiklauri R, Jijeishvili L, Kherkheulidze M, Kvanchakhadze R, Kazakhashvili N. Neural tube defects and micronutrient deficiency prevalence in Georgia. Georgian Med News. 2020(298):61–6. Smith ER, Shankar AH, Wu LS, Aboud S, Adu-Afarwuah S, Ali H, et al. Modifiers of the effect of maternal multiple micronutrient supplementation on stillbirth, birth outcomes, and infant mortality: a meta-analysis of individual patient data from 17 randomised trials in low-income and middle-income countries. Lancet Global Health. 2017;5(11):e1090–100. Keats EC, Haider BA, Tam E, Bhutta ZA. Multiple-micronutrient supplementation for women during pregnancy. Cochrane Database Syst Reviews. 2019(3). National Institute of Statistics of Rwanda (NISR). MoHMR, & ICF. Rwanda Demographic and Health Survey 2020: Micronutrient Supplementation Report. Kigali, Rwanda, and Rockville. Maryland, USA: NISR and ICF; 2022. Oh C, Keats EC, Bhutta ZA. Vitamin and mineral supplementation during pregnancy on maternal, birth, child health and development outcomes in low- and middle-income countries: a systematic review and meta-analysis. Nutrients. 2020;12(2):491. 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Silubonde TM, Draper CE, Baumgartner J, Ware LJ, Smuts CM, Norris SA. Barriers and facilitators of micronutrient supplementation among non-pregnant women of reproductive age in Johannesburg, South Africa. PLOS Global Public Health. 2022;2(11):e0001310. Labonté JM, Hoang MA, Panicker A, Kroeun H, Sokchea M, Sambo S, et al. Exploring factors affecting adherence to multiple micronutrient supplementation during pregnancy in Cambodia: A qualitative analysis. Matern Child Nutr. 2025;21(1):e13745. Atmadani RN, Akrom A, Ananda D, Saputri LY, Puspitasari AA, Urbayatun S. Supports and Barriers Regarding The Iron-Folic Acid Supplementation Adherence Level in Anemic Pregnant Women: Indonesians’ Perspective. Media Kesehatan Masyarakat Indonesia. 2024;20(2):46–56. Popa AD, Niţă O, Graur LI, Popescu RM, Botnariu GE, Mihalache L, et al. Nutritional knowledge as a determinant of vitamin and mineral supplementation during pregnancy. BMC Public Health. 2013;13:1–10. Olloqui-Mundet MJ, Cavia MM, Alonso-Torre SR, Carrillo C. Dietary habits and nutritional knowledge of pregnant women: the importance of nutrition education. Foods. 2024;13(19):3189. Garcia-Casal MN, Estevez D, De‐Regil LM. Multiple micronutrient supplements in pregnancy: Implementation considerations for integration as part of quality services in routine antenatal care. Objectives, results, and conclusions of the meeting. Matern Child Nutr. 2018;14:e12704. Martin SL, Wawire V, Ombunda H, Li T, Sklar K, Tzehaie H, et al. Integrating calcium supplementation into facility-based antenatal care services in western Kenya: a qualitative process evaluation to identify implementation barriers and facilitators. Curr Developments Nutr. 2018;2(11):nzy068. Jafari A, Hosseini Z, Tehrani H, Alami A. Evaluation of the barriers and facilitators of iron supplementation program among adolescent females. Clin Nutr ESPEN. 2023;56:36–42. Alehegn MA, Fanta TK, Ayalew AF. Exploring maternal nutrition counseling provided by health professionals during antenatal care follow-up: a qualitative study in Addis Ababa, Ethiopia-2019. BMC Nutr. 2021;7:1–16. Kraemer K, Beesabathuni K, Askari S, Khondker R, Khan TU, Rahman M, et al. editors. Knowledge, attitudes and practices of pregnant women and healthcare providers in Bangladesh regarding multivitamin supplements during pregnancy. Healthcare: MDPI; 2023. Mowe M, Bosaeus I, Rasmussen HH, Kondrup J, Unosson M, Rothenberg E, et al. Insufficient nutritional knowledge among health care workers? Clin Nutr. 2008;27(2):196–202. Ibikunle HA, Okafor IP, Adejimi AA. Pre-natal nutrition education: Health care providers’ knowledge and quality of services in primary health care centres in Lagos, Nigeria. PLoS ONE. 2021;16(11):e0259237. Vrkatić A, Grujičić M, Jovičić-Bata J, Novaković B, editors. Nutritional knowledge, confidence, attitudes towards nutritional care and nutrition counselling practice among general practitioners. Healthcare: MDPI; 2022. WHO, Guideline. Intermittent iron and folic acid supplementation in non-anaemic pregnant women. Guideline: Intermittent iron and folic acid supplementation in non-anaemic pregnant women2011. p. 31-. RBC. Annual report 2023-024. Maternal, Child and Community Health Division. 2025. Tawfiq E, Fazli MR, Wasiq AW, Stanikzai MH, Mansouri A, Saeedzai SA. Sociodemographic predictors of initiating Antenatal Care visits by pregnant women during first trimester of pregnancy: findings from the Afghanistan Health Survey 2018. Int J Women's Health. 2023:475–85. Abdo R, Demelash M, Seid AM, Mussema A. First trimester antenatal care contact in Africa: a systematic review and meta-analysis of prevalence and contributing factors. BMC Pregnancy Childbirth. 2023;23(1):742. Tumilowicz A, Neufeld LM, Pelto GH. Using ethnography in implementation research to improve nutrition interventions in populations. Matern Child Nutr. 2015;11:55–72. Ditekemena J, Koole O, Engmann C, Matendo R, Tshefu A, Ryder R, et al. Determinants of male involvement in maternal and child health services in sub-Saharan Africa: a review. Reproductive health. 2012;9:1–8. Comrie-Thomson L, Tokhi M, Ampt F, Portela A, Chersich M, Khanna R, et al. Challenging gender inequity through male involvement in maternal and newborn health: critical assessment of an emerging evidence base. Cult Health Sex. 2015;17(sup2):177–89. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted 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-6932308","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":495481459,"identity":"a36aa444-3a6f-4f25-b1e4-1c277155e5c4","order_by":0,"name":"Eric Matsiko","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIie3PPWrDMBTA8ScEziLHa4OhucILmQItuopNVvsGGVwML4viOZl6i8wxgkw5QEFTb+C0UEIxpZa3DrWdLRD9B32AfkgCcLluMpa1kycADpVdjIYRtISVW0v4sKsQQADXwq77SBDql4+3VS3HQh/00/d+OubAqnPyP5kUcR4mR4zJp0inhZkRBz7Z7TtedGLEEw8jLxCoU2WabfMdv4PIlvygbMlCGdlLUDQkJWTkK9RwMXEveTixPEyLeUziGJWbzCyJs7zzL4EavX8mX49yqpa6utTm+XWdl9W5g/yNUTtmQ8/b6msOu1wu1730Cw7bTDR+ft4xAAAAAElFTkSuQmCC","orcid":"","institution":"University of Rwanda, City of Kigali","correspondingAuthor":true,"prefix":"","firstName":"Eric","middleName":"","lastName":"Matsiko","suffix":""},{"id":495481460,"identity":"edafa5e2-c463-449b-82b6-1c9f5feb680f","order_by":1,"name":"Annet Birungi","email":"","orcid":"","institution":"Unicef Rwanda, City of Kigali","correspondingAuthor":false,"prefix":"","firstName":"Annet","middleName":"","lastName":"Birungi","suffix":""},{"id":495481461,"identity":"c451d1a4-0e28-4392-962e-4d21bf459c36","order_by":2,"name":"Eliphaz Tuyisenge","email":"","orcid":"","institution":"Unicef Rwanda, City of Kigali","correspondingAuthor":false,"prefix":"","firstName":"Eliphaz","middleName":"","lastName":"Tuyisenge","suffix":""},{"id":495481462,"identity":"c41ee8e4-cedc-46bd-b724-47e6e5f9ec4d","order_by":3,"name":"Patrick Izabayo Rudatinya","email":"","orcid":"","institution":"University of Rwanda, City of Kigali","correspondingAuthor":false,"prefix":"","firstName":"Patrick","middleName":"Izabayo","lastName":"Rudatinya","suffix":""},{"id":495481463,"identity":"b296e5dd-7788-4b2c-8af5-0e2d5c6b507f","order_by":4,"name":"Phionah Nziza","email":"","orcid":"","institution":"University of Rwanda, City of Kigali","correspondingAuthor":false,"prefix":"","firstName":"Phionah","middleName":"","lastName":"Nziza","suffix":""},{"id":495481464,"identity":"4a3f390b-8e44-46ef-bd88-fcd0ac653538","order_by":5,"name":"Jean Dieu Habimana","email":"","orcid":"","institution":"University of Rwanda, City of Kigali","correspondingAuthor":false,"prefix":"","firstName":"Jean","middleName":"Dieu","lastName":"Habimana","suffix":""},{"id":495481465,"identity":"d930ef04-3e09-4b5d-afba-474c342fa5e6","order_by":6,"name":"Harriet Gyamfuah Adu-Amoah","email":"","orcid":"","institution":"University of Rwanda, City of Kigali","correspondingAuthor":false,"prefix":"","firstName":"Harriet","middleName":"Gyamfuah","lastName":"Adu-Amoah","suffix":""},{"id":495481466,"identity":"cc7046fb-0c61-40f1-bc53-d234352b7276","order_by":7,"name":"Samson Desie","email":"","orcid":"","institution":"Unicef Rwanda, City of Kigali","correspondingAuthor":false,"prefix":"","firstName":"Samson","middleName":"","lastName":"Desie","suffix":""}],"badges":[],"createdAt":"2025-06-19 14:53:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6932308/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6932308/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108601116,"identity":"7ec9ddcd-2cd7-4425-bc81-2fdf59030e4b","added_by":"auto","created_at":"2026-05-06 11:28:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":539056,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6932308/v1/20fd8e8d-a54e-49cf-b81e-93e33e970b87.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Understanding Knowledge, Attitudes, and Practices Around Multiple Micronutrient Supplementation in Rwanda","fulltext":[{"header":"Background","content":"\u003cp\u003eMicronutrient deficiencies during pregnancy remain a significant public health concern, particularly in low- and middle-income countries. Pregnant women are especially vulnerable to deficiencies in essential micronutrients such as iron, folate, iodine, zinc, vitamins A and D, as well as riboflavin and vitamins B6 and B12 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Inadequate intake of these nutrients during pregnancy can adversely affect both maternal health and pregnancy outcomes (\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). The increased metabolic demands associated with pregnancy, coupled with poor dietary quality, often result in unmet nutritional needs, leading to heightened risks of complications such as preterm birth, small-for-gestational-age (SGA) infants, neural tube defects (NTDs), and various maternal health conditions (\u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn Rwanda, micronutrient malnutrition is prevalent among pregnant women. Data from the Rwanda Demographic and Health Survey (DHS) Supplemental Report on Micronutrients (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) underscore the magnitude of this issue. Anemia affects 17.6% of pregnant women, and 15% are iron deficient. Additionally, 28% of pregnant women experience vitamin A insufficiency, while vitamin B12 deficiency affects 43.5%, and the risk of deficiency is present in 72% of women. In response to the high burden of anemia, Rwanda has implemented an iron-folic acid (IFA) supplementation program; however, uptake remains low, with only 16% of pregnant women reporting the intake of iron tablets for at least 90 days during their most recent pregnancy(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Moreover, the IFA program addresses primarily iron deficiency anemia, leaving other micronutrient deficiencies unaddressed. In response, Rwanda began integrating Multiple Micronutrient Supplementation (MMS) into antenatal care (ANC) services in 2024\u003c/p\u003e\u003cp\u003eGiven the multifaceted impact of micronutrient deficiencies during pregnancy, MMS has emerged as a promising public health intervention. MMS not only offers comparable benefits to iron-folate supplementation in reducing anemia but also addresses other micronutrient deficiencies and supports fetal growth, neonatal health, and infant development (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). MMS represents a safe and effective strategy to bridge nutritional gaps and fulfill the elevated micronutrient demands of pregnancy, particularly in settings where dietary diversity is limited (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eCost-effective analyses further support the adoption of MMS, indicating that it offers substantial economic benefits relative to traditional IFA supplementation (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Evidence suggests that MMS reduces maternal anemia, preterm birth, SGA births, and the incidence of NTDs in newborns (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). By ensuring sufficient intake of key nutrients\u0026mdash;including iron, folic acid, docosahexaenoic acid (DHA), and vitamin D\u0026mdash;MMS not only promotes maternal well-being and metabolic health but also optimizes placental function(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). For the fetus, MMS plays a critical role in promoting brain development, improving neurocognitive function, and mitigating the risk of neurodevelopmental disorders(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). It is particularly advantageous in high-risk pregnancies, where it has been associated with better outcomes in conditions such as pre-eclampsia and intrauterine growth restriction (IUGR) (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe World Health Organization (WHO) now recommends the use of MMS as part of comprehensive nutritional interventions to improve maternal micronutrient status and pregnancy outcomes (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). The updated WHO guidelines create a valuable opportunity for countries to incorporate MMS into national health strategies, thereby enhancing the provision of quality nutrition services through antenatal care (ANC) platforms. In line with this WHO recommendation and recognizing the potential benefits of MMS, Rwanda initiated the integration of MMS into ANC services. This effort commenced with a pilot program launched in seven districts in 2024, with plans for expansion to other districts in 2025. As part of the scale-up preparations, UNICEF Rwanda, in collaboration with the Rwanda Biomedical Center and the Ministry of Health, commissioned an assessment to evaluate knowledge, attitudes, and practices (KAP) related to MMS because studies have shown that women with strong awareness of the benefits of supplements during pregnancy are more likely to initiate and continue MMS use (\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe current study aimed to assess knowledge, attitudes, and practices related to MMS among pregnant and lactating women, and to identify factors influencing adherence and uptake. Understanding these factors is essential for designing effective strategies to promote the successful adoption of MMS at the national level and ensure that pregnant women benefit fully from enhanced nutrition interventions during pregnancy\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eDesign and setting\u003c/h2\u003e\u003cp\u003eThis study employed a mixed methods design, combining both quantitative and qualitative approaches. The qualitative component included key informant interviews (KIIs) and focus group discussions (FGDs). We targeted pregnant women attending ANC visits who were registered for MMS, as well as lactating mothers with infants aged three months or younger who had used MMS. We also included husbands, community health workers, health center staff responsible for ANC (nurses and midwives), and district-level staff responsible for health (district health directors) as participants. We conducted data collection in December 2024 in the districts of Gasabo, Rutsiro, and Burera, where the MMS program was being implemented.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSampling and sample size\u003c/h3\u003e\n\u003cp\u003eWe randomly selected a representative sample of twelve health centers from a total of 52 health centers across the three districts, allocating four health centers to each district. From a comprehensive, alphabetically arranged list of all health centers in each district, we used the random function in Excel for selection. At each selected health center, we arbitrarily chose four villages\u0026mdash;two located near the health center headquarters and two situated farther away. We applied random sampling to select participants from a comprehensive list of pregnant women attending ANC and enrolled in the MMS program, as well as lactating mothers who had used MMS in the selected villages. We obtained the complete lists from the respective health centers.\u003c/p\u003e\u003cp\u003eWe targeted a minimum sample size of 483 pregnant women and lactating mothers, calculated using Yamane Taro\u0026rsquo;s formula, with a 95% confidence level, 80% power, and a 5% margin of error. We based the calculation on a total population of 28,889 pregnant women enrolled in the MMS program across the three districts as of October 2024. We proportionally allocated the sample across the three districts according to the number of pregnant women receiving MMS in each district.\u003c/p\u003e\u003cp\u003eFor the qualitative component, we conducted 18 focus group discussions (FGDs): seven with women, five with husbands, and six with community health workers. Additionally, we conducted 12 exit interviews with women immediately after their ANC visits to gather real-time feedback on the MMS service. We also conducted key informant interviews with three health center staff in charge of ANC (nurses or midwives) and two district-level Directors of Health.\u003c/p\u003e\n\u003ch3\u003eData collection procedures\u003c/h3\u003e\n\u003cp\u003eEnumerators administered a quantitative questionnaire, developed specifically for this study and programmed into the Kobo Collect application for data collection. They submitted completed questionnaires daily through the application, and the data analyst reviewed them for completeness and accuracy. Moderators and note-takers facilitated the FGDs and audio-recorded them with participants\u0026rsquo; consent. Guides, developed in English and translated into Kinyarwanda, structured the FGDs. Similarly, experienced facilitators conducted the KIIs using a translated interview guide and audio-recorded the sessions upon receiving consent. Additionally, we conducted 12 exit interviews with pregnant women immediately after their ANC visits to capture real-time feedback on the MMS service.\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eWe conducted all quantitative analyses using SPSS and analyzed qualitative data using Atlas.ti. Knowledge and attitude were each assessed using 12 questions (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e for knowledge and Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e for attitude), with one point awarded for each correct response and zero for incorrect answers. Based on total scores, responses were categorized as follows: low (\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), moderate (\u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), and high (\u003cspan additionalcitationids=\"CR10 CR11\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). This same scoring and categorization approach was applied to both knowledge and attitude. We used percentages and medians to present the data, as appropriate. For the qualitative analysis, we applied thematic analysis, which involved verbatim transcription, coding, and theme generation. We included illustrative quotes to support and triangulate findings.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eKnowledge of pregnant and lactating women about MMS\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003eCount\u003c/p\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;484\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eKnowing some micronutrients that are important for pregnancy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003e246\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e51.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003e238\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e49.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eKnowing different types of micronutrient supplements (MMS, IFA, MNPs)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003e261\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e54.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003e223\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e46.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eKnowing that MMS are tablets containing a combination of vitamins and minerals\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003e182\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e37.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003e302\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e62.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eKnowing some examples of vitamins and minerals included in MMS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003e225\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e46.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003e259\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e53.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eKnowing when MMS can be taken (before pregnancy, during pregnancy and lactation)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003e463\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e95.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eKnowing the benefits of taking MMS during pregnancy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003e274\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e56.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003e210\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e43.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eKnowing when a pregnant mother should start taking MMS in the first trimester\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003e428\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e88.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003e56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e11.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eKnowing that MMS must be taken daily\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003e452\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e93.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eKnowing if MMS can be taken when a mother/woman is not pregnant\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003e454\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e93.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eKnowing that 180 MMS should be taken through pregnancy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003e161\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e33.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003e323\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e66.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eKnowing that not taking MMS may have negative effects\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003e383\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e79.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003e101\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e21.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eKnowing the side effects associated with taking MMS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003e215\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e44.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003e269\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e55.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKnowledge Score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedian (Minimum, Maximum)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7 (\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5 CR6 CR7 CR8 CR9 CR10 CR11\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWomen with low knowledge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003e72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e15.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWomen with moderate knowledge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003e283\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e58.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWomen with high knowledge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u003cp\u003e129\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e26.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eSources of information on micronutrient supplements\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eHealth care providers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e283\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e\u003cp\u003e85.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eCommunity health workers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e147\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e\u003cp\u003e44.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eMass media\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e\u003cp\u003e16.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eFriends and relatives\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e\u003cp\u003e8.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAttitudes of pregnant and lactating women towards MMS\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCount\u003c/p\u003e\u003cp\u003e(N\u0026thinsp;=\u0026thinsp;484)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eThinking that micronutrients are essential/important during pregnancy\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e465\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e96.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eThinking that taking MMS during pregnancy is important\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e451\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e93.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eThinking that taking MMS during lactation is important\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e190\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e39.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e294\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e60.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eHaving concerns about taking MMS during pregnancy\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e402\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e83.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eThinking that taking MMS can hurt a baby\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e432\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e95.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eBelieving that taking MMS can hurt women\u0026rsquo;s lives\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e431\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e93.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eBelieving that taking MMS can help reduce the risk of anemia during pregnancy\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e408\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e83.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eBeen regularly advised by a health professional to take MMS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e286\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e67.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e138\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e32.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eTrusting the advice given by healthcare providers regarding MMS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e405\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e95.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eBeing satisfied with the information provided by healthcare providers about MMS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e397\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e93.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eFeeling that they can recommend MMS to other women\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e465\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e96.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFeeling that they can stop MMS at any time\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e108\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e376\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e77.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eAttitude Score\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedian (Minimum, Maximum)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWomen with low attitude\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWomen with moderate attitudes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e200\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e41.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWomen with high attitude\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e274\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e56.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eParticipants Profile\u003c/h2\u003e\u003cp\u003eThe characteristics of women are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e1\u003c/span\u003e. A total of 484 women participated in the assessment, comprising 376 pregnant women and 108 lactating mothers with infants aged younger than three months. The majority (66.7%) of women were in their second or third trimester, while 11% were in the first trimester. Lactating women accounted for 22.3% of the sample. Approximately two-thirds (67%) of the women were under the age of 30, and a substantial proportion (88%) reported living with their partners. Regarding educational attainment, nearly half (49.6%) had completed some level of primary education, while 41.4% had attained secondary education or higher. Despite varying education levels, the majority of women (85%) were literate. In terms of religious affiliation, Protestantism was the most commonly reported (56.2%). Notably, 28.3% of participants reported that reaching the nearest health center required more than one hour of travel.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eParticipants' profile\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCount\u003c/p\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;484\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eCategories of participants\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1st trimester\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2nd trimester\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e160\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e33.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3rd trimester\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e163\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e33.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLactating mothers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e108\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e224\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e67.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e160\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e33.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedian,\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27 (18\u0026ndash;49)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eMarital status\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLiving with a partner\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e426\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e88.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLiving with no partner\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eEducation\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAny Primary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e240\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e49.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAny secondary and higher\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e126\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e41.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eAbility to read and write\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReading and writing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e412\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e85.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOnly reading\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNone of them\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eOccupation\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAgriculture\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e125\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBusiness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCasual labor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e184\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e38.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSalaried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHousehold work\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e103\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eReligion\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCatholic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e154\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e31.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProtestant\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e272\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e56.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSeventh Day Adventist\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMuslim\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eWalking time to the nearest health center\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;30 minutes\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e205\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e30\u0026ndash;60 minutes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e142\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e29.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;60 minutes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e137\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e1\u003c/span\u003e: \u003cb\u003eParticipants' profile\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eKnowledge towards MMS\u003c/h3\u003e\n\u003cp\u003eSlightly more than a quarter (26.5%) of women demonstrated high knowledge, while over half (58.5%) had moderate knowledge, and a smaller proportion (15%) exhibited low knowledge levels (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAwareness of the role of micronutrients during pregnancy was relatively limited. Only 51% of women recognized their significance, and merely 37% correctly identified MMS as tablets containing a combination of vitamins and minerals. Similarly, only 46.5% could name some micronutrients found in MMS. Nonetheless, 56.6% of the women knew the benefits of MMS, such as the prevention of anemia and support for fetal development.\u003c/p\u003e\u003cp\u003eQualitative data from FGDs and interviews reinforced these findings. Women expressed a general awareness of the benefits of MMS, often associating them with healthier pregnancies and improved birth outcomes. One woman remarked: \u003cem\u003e\u0026ldquo;These supplements help you give birth to a healthy baby with adequate growth and height\u003c/em\u003e.\u0026rdquo; Another stated: \u003cem\u003e\u0026ldquo;MMS prevents stunting, increases blood levels, and improves the mother\u0026rsquo;s health\u003c/em\u003e.\u0026rdquo; However, in some cases, knowledge was often general and lacked detail. As one participant noted: \u0026ldquo;\u003cem\u003eIt\u0026rsquo;s to ensure the baby is healthy and to prevent anything that might harm the baby or the mother.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003eWhile many women acknowledged the benefits of MMS, gaps in understanding remained. Some could not differentiate MMS from other supplements or questioned their composition. Misconceptions\u0026mdash;such as believing MMS contained deworming components\u0026mdash;were found. One woman asked: \u003cem\u003e\u0026ldquo;Do these tablets replace the old ones? Do they include deworming medicine?\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e: \u003cem\u003eKnowledge of pregnant and lactating women about MMS\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAwareness of MMS use protocols was higher than knowledge of its composition. Most women (88.4%) were aware that supplementation should commence in the first trimester, and 93.4% understood that MMS is taken daily. However, only 33.3% were cognizant of the total number of tablets (180) recommended during pregnancy. Additionally, 21% did not realize that failing to take MMS could lead to adverse outcomes, such as anemia. About forty-four percent (44.4%) were aware of possible side effects, including stomach discomfort and headache. In FGDs, some women shared strategies they learned for alleviating side effects, such as taking MMS after meals.\u003c/p\u003e\u003cp\u003eKnowledge gap among family members, particularly husbands or partners, was noticed. Some partners reported only partial or second-hand knowledge, often obtained through their wives. One noted: \u003cem\u003e\u0026ldquo;The midwives did not fully explain their benefits to us. I only found out later at home.\u0026rdquo;\u003c/em\u003e Others were hearing about MMS for the first time during FGDs. These knowledge deficits may limit male support for adherence to supplementation. As one CHW observed: \u003cem\u003e\u0026ldquo;If husbands or mothers-in-law don\u0026rsquo;t understand the importance of MMS, they discourage women from using it\u003c/em\u003e.\u0026rdquo;\u003c/p\u003e\u003cp\u003eThe necessity for enhanced and inclusive education efforts was widely acknowledged. Both women and their partners expressed interest in receiving clearer information. One suggested: \u003cem\u003e\u0026ldquo;They should explain the tablets in more detail to husbands, so we understand their importance better.\u0026rdquo;\u003c/em\u003e Another proposed utilizing community meetings or radio broadcasts as accessible communication channels.\u003c/p\u003e\u003cp\u003eHealthcare providers were the primary source of information, with 85% of women citing health centers and 44% mentioning CHWs. At health centers, group education sessions were commonly employed during ANC visits to communicate key messages. While these sessions allowed providers to reach many women simultaneously, they did not always facilitate personalized counselling or address individual misconceptions. Despite this, systemic challenges such as staff shortages and overcrowding limited the quality of counselling. One nurse explained: \u003cem\u003e\u0026ldquo;We see so many patients in one day that it\u0026rsquo;s hard to give each one enough time to explain MMS benefits fully\u003c/em\u003e.\u0026rdquo; Women confirmed that the information provided was sometimes incomplete. One said: \u003cem\u003e\u0026ldquo;I was told to take one tablet daily, but there was no detailed explanation.\u0026rdquo;\u003c/em\u003e This limited counseling could also be attributed to insufficient training on MMS, as acknowledged by healthcare providers, particularly nurses and midwives responsible for antenatal care (ANC) and MMS distribution. CHWs also faced constraints. Some admitted to never having seen MMS tablets or receiving detailed training. One CHW noted: \u003cem\u003e\u0026ldquo;We need to know more about these supplements\u0026mdash;what they look like, when to take them, and how to explain them to women.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003ch3\u003eAttitudes toward MMS\u003c/h3\u003e\n\u003cp\u003eThe current study revealed generally positive attitudes among women regarding the use of MMS during pregnancy (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Large proportions of women demonstrated high (56.6%) or moderate (41.4%) attitudes toward MMS use, while only a small fraction (2%) exhibited low attitudes.\u003c/p\u003e\u003cp\u003eSpecifically, most women (96%) acknowledged the importance of micronutrients during pregnancy, and 93.2% believed that taking MMS was important. A substantial proportion (83.4%) specifically associated MMS use with a reduced risk of anemia. Slightly more than two-thirds (67.8%) of women reported being regularly advised by a healthcare provider to take MMS. Trust in healthcare providers was notably high: 95.5% of women expressed confidence in the advice they received, and 93.6% were satisfied with the information provided. Furthermore, 96% indicated they would recommend MMS to other women, 77.7% reported they would not stop taking the supplements, and 83% expressed no concerns about using MMS during pregnancy. These attitudes were reflected in the qualitative data. Women frequently emphasized their reliance on healthcare providers for reassurance. One woman noted, \u003cem\u003e\u0026ldquo;I trusted the midwife because she said the tablets were safe for both me and the baby.\u0026rdquo;\u003c/em\u003e Another stated, \u003cem\u003e\u0026ldquo;We trust the advice midwives give us because what they say never causes harm.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e: \u003cem\u003eAttitudes of pregnant and lactating women towards MMS\u003c/em\u003e\u003c/p\u003e\u003cp\u003eCultural barriers to MMS use were minimal, with 91% of women reporting no such influence. However, qualitative data revealed misconceptions that may negatively shape attitudes and behaviors. Some women believed that MMS could lead to delivery complications, fearing that the supplements might cause the baby to grow too large. A nurse observed, \u0026ldquo;Many women fear MMS will make the baby too big, making delivery more difficult.\u0026rdquo; Others expressed concern about the packaging, which resembled antiretroviral medication and triggered stigma. \u003cem\u003e\u0026ldquo;Some women think MMS is for HIV, just because of the way it\u0026rsquo;s packaged,\u0026rdquo;\u003c/em\u003e a nurse explained.\u003c/p\u003e\u003cp\u003eSide effects were a commonly cited barrier. Nausea, vomiting, and the unpleasant taste or size of the tablets discouraged some women, especially first-time mothers. One woman stated, \u003cem\u003e\u0026ldquo;Whenever I take the tablet, I vomit or burp with a sour taste.\u0026rdquo;\u003c/em\u003e Another added, \u003cem\u003e\u0026ldquo;The smell made me want to stop, but I endured because I knew it helped increase blood levels.\u003c/em\u003e\u0026rdquo; Healthcare providers acknowledged this issue, with one nurse explaining, \u003cem\u003e\u0026ldquo;The smell and size of the tablets make some women feel sick, and they stop taking them.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003eConcerns extended to partners as well. While some expressed support, others voiced skepticism. \u003cem\u003e\u0026ldquo;I worry that something might happen because I don\u0026rsquo;t fully trust the tablets yet,\u0026rdquo;\u003c/em\u003e a partner stated. Another added, \u003cem\u003e\u0026ldquo;They should be tested thoroughly before being given to pregnant women everywhere.\u0026rdquo;\u003c/em\u003e A woman noted, \u003cem\u003e\u0026ldquo;My mother-in-law said I didn\u0026rsquo;t need the tablets because I was already eating well.\u0026rdquo;\u003c/em\u003e These perceptions might discourage adherence.\u003c/p\u003e\u003cp\u003eStigma also emerged as a barrier, particularly for women experiencing unplanned pregnancies or those who feared being judged by their communities. As one nurse noted, \u003cem\u003e\u0026ldquo;Some women avoid ANC because they don\u0026rsquo;t want people to know they\u0026rsquo;re pregnant.\u0026rdquo;\u003c/em\u003e The association of MMS with disease treatment further contributed to the stigma, with one woman commenting, \u003cem\u003e\u0026ldquo;Some think the tablets are for curing diseases.\u0026rdquo;\u003c/em\u003e Scepticism about MMS effectiveness was noticed. Some women questioned whether supplements could replace the nutrients found in natural foods. One remarked, \u003cem\u003e\u0026ldquo;I don\u0026rsquo;t understand why these tablets are better than beans or meat.\u0026rdquo;\u003c/em\u003e Others preferred alternative remedies: \u003cem\u003e\u0026ldquo;If it\u0026rsquo;s about increasing blood, I\u0026rsquo;ll just buy pineapple or beetroot juice.\u0026rdquo;\u003c/em\u003e Nonetheless, there was some recognition of MMS as a complement to a healthy diet. \u003cem\u003e\u0026ldquo;I thought eating well was enough, but I later realized these tablets provide what food sometimes can\u0026rsquo;t,\u0026rdquo;\u003c/em\u003e one woman shared.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eCurrent practices\u003c/h2\u003e\u003cp\u003eMost women (94%) reported currently taking MMS, with 66.4% initiating use during the first trimester of pregnancy. Among those taking MMS, adherence was high, with 92% reporting consistent use as advised by healthcare providers. Women\u0026rsquo;s practices regarding the timing of MMS intake varied: 45.5% preferred taking tablets in the evening, 35.2% in the morning, and 15.5% at any time during the day. Motivators for adherence included knowledge of MMS benefits (77.4%) and encouragement from healthcare providers (45.5%). Support from partners played a significant role, cited by 87.8% of women as a reason for continued use. Partners reminded their spouses, provided emotional support, and helped reinforce routines. As one woman noted, \u003cem\u003e\u0026ldquo;My husband reminded me every morning to take the tablets.\u003c/em\u003e\u0026rdquo; Similarly, a partner said, \u003cem\u003e\u0026ldquo;If she forgets, I remind her and encourage her to stick to the schedule\u003c/em\u003e\u0026rdquo;. Family involvement extended beyond partners. About 28% of women reported forgetting to take MMS at times, but support from other household members, \u0026mdash; including children, \u0026mdash; helped by providing reminders. One woman explained, \u003cem\u003e\u0026ldquo;Even the children would remind me: \u0026lsquo;Mama, did you take the tablet?\u003c/em\u003e\u0026rsquo;\u0026rdquo;\u003c/p\u003e\u003cp\u003eSome women reported that household responsibilities and work demands took precedence over their health, making it difficult for them to maintain consistent MMS use. One woman reflected, \u003cem\u003e\u0026ldquo;I get busy with work and forget to take the tablets or attend the health center.\u0026rdquo;\u003c/em\u003e Another added, \u003cem\u003e\u0026ldquo;My household duties keep me busy all day, so it\u0026rsquo;s hard to focus on these things.\u0026rdquo;\u003c/em\u003e These insights underscore the importance of family support in enabling women to prioritize their health.\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e: Practices and Adherence to MMS\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePractices and adherence to MMS\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCount\u003c/p\u003e\u003cp\u003eN\u0026thinsp;=\u0026thinsp;484\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eWomen currently taking MMS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e455\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e94.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eWhen taking MMS started\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1st trimester\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e302\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e66.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2nd trimester\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e140\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3rd trimester\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eTaking MMS as advised by a health care provider\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e419\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e92.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eTime of day when MMS is taken\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMorning\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e157\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNoon\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEvening\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e203\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e45.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnytime\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eBarriers that make it challenging to take MMS regularly\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eForgetting to take them\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e136\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSide effects\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHard to access\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e304\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e63.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eHusband\u0026rsquo;s support in taking MMS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStrongly support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e276\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e64.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSupport\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eCultural beliefs or traditions that influence the decision to take or not take MMS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e440\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e91.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eSide effects experienced from taking MMS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStomach discomfort\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e474\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e97.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHeadaches\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eConstipation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eMMS effect on appetite\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIncreased\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e122\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDecreased\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo effect\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e318\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e65.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003ePerception of MMS taste\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGood\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBad\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e173\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo taste\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e279\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e57.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003ePerception of MMS smell\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGood\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBad\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e304\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e62.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo smell\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e127\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eRegarding the sensory experience of MMS, 65.8% of women reported no effect on appetite, and 57.6% did not find the taste problematic. However, 35.7% found the taste unpleasant, and 62.8% described the smell as bad. Women also reported experiencing side effects, with 97.5% identifying stomach discomfort as the primary concern. Nausea and vomiting were frequently mentioned in FGDs, often attributed to the tablet\u0026rsquo;s smell and bitterness. As one woman stated, \u0026ldquo;\u003cem\u003eThe tablets smell bad and make me throw up immediately after taking them.\u0026rdquo;\u003c/em\u003e Despite these challenges, women often demonstrated resilience. Some adjusted intake routines, such as taking MMS with porridge or before bedtime, reduce nausea. One woman shared, \u003cem\u003e\u0026ldquo;The bitterness and nausea were unbearable, but I still took them because they helped.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAnother barrier to effective MMS use was the late initiation of ANC. Some women delayed their first visit until the second or third trimester, often due to misconceptions about the purpose of ANC. A CHW noted, \u003cem\u003e\u0026ldquo;Many women think ANC is just for checking blood pressure.\u0026rdquo;\u003c/em\u003e Another explained, \u003cem\u003e\u0026ldquo;Some wait until they feel the baby move before coming for ANC, thinking it\u0026rsquo;s unnecessary before then.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study revealed a moderate level of knowledge about maternal MMS among pregnant and lactating women, with a gap in understanding its composition, benefits and appropriate use. These findings are consistent with evidence from other low- and middle-income countries (LMICs), where limited knowledge about MMS remains a common barrier(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Nevertheless, previous studies have shown that nutritional knowledge is a key driver of supplement use and healthy dietary practices during pregnancy(\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). In this study, limited knowledge was reflected in misconceptions about the contents of MMS, with some women unable to identify the specific micronutrients or believing that the supplements included deworming or antiretroviral medications based on their packaging. Similar misconceptions have been documented elsewhere, where stigma and confusion surrounding MMS have negatively impacted uptake and adherence (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThese knowledge limitations may be attributed, in part, to infrequent and insufficient counselling, which is a key barrier at health centers, as fewer than two-thirds of women reported receiving consistent guidance from healthcare providers. This represents a missed opportunity to reinforce behavior change during ANC visits. These findings corroborate previous research showing that poor-quality counselling can negatively affect the uptake and utilization of supplementation programs(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Regular and personalized counselling is essential for enhancing understanding, building trust, and improving adherence to supplementation regimens(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). The present study identified that inadequate counselling was often a consequence of staff shortages and high patient volumes\u0026mdash;challenges similarly documented in other settings(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). In addition, healthcare providers and CHWs themselves acknowledged gaps in training and exposure to MMS, which hindered their ability to educate and counsel women effectively. This finding aligns with evidence from other countries where insufficient provider training has compromised the delivery of nutrition interventions(\u003cspan additionalcitationids=\"CR26 CR27\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). These systemic challenges mirror findings in similar settings and point to the urgent need for enhanced investment in training, supportive supervision, and workload management(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Building a well-equipped and adequately supported health workforce is central to improving the delivery and impact of maternal supplementation programs.\u003c/p\u003e\u003cp\u003eLimited awareness of the appropriate timing for initiating MMS may contribute to its delayed uptake among pregnant women. In this study, approximately one-third of women reported beginning MMS in the second or third trimester, rather than during the recommended first trimester. This delay is closely linked to the low rate of first ANC visits occurring within the first trimester, recorded at 52% in the 2023/2024 fiscal year (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), and previously at 59% according to the 2020 Rwanda Demographic and Health Survey(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Notably, the challenge of timely ANC initiation is not unique to Rwanda; similar trends have been observed in other low- and middle-income countries (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Delayed initiation of MMS diminishes the opportunity to realize its full benefits, which include reducing the risk of maternal anemia, low birth weight, preterm birth, and small-for-gestational-age outcomes (Smith et al., 2017) (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eFurthermore, women who reported using MMS also identified barriers that may hinder optimal adherence. Commonly reported challenges included experiencing side effects such as stomach discomfort, nausea, and the unpleasant taste or smell of the tablets. These findings align with evidence from other LMICs, where similar side effects have been identified as key deterrents to sustained supplement uptake (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Some women adapted by taking MMS with meals or before bedtime to reduce discomfort, reflecting adaptive strategies that can be encouraged through tailored counselling (Hyder et al., 2019). Additionally, competing household responsibilities constrained some women\u0026rsquo;s ability to adhere to MMS consistently. These findings underline the importance of designing context-specific behavioral interventions that account for women\u0026rsquo;s daily realities(\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe study also underscored the role of household dynamics, particularly male support, in promoting adherence. A substantial number of women cited their husbands\u0026rsquo; reminders and encouragement as motivators for continued use of MMS. This is consistent with evidence suggesting that male involvement enhances maternal health outcomes, particularly when men are included in health education efforts and empowered to support their partners (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). However, the limited awareness among men about MMS and their general exclusion from counselling sessions were seen as barriers. Addressing this gap through inclusive health education\u0026mdash;via community meetings, mass media, or targeted sessions at ANC clinics\u0026mdash;may foster a more enabling environment for MMS adherence (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe strengths of this study include its mixed-methods design, which provided comprehensive and triangulated insights into knowledge, attitudes, and practices related to MMS among diverse stakeholders, such as women, partners, CHWs, and healthcare providers. Conducted during the early phase of MMS implementation in Rwanda, the study offers timely, policy-relevant evidence to inform the national scale-up. However, this study has to three limitations. First, the geographic scope was restricted to only 3 districts\u0026mdash;Gasabo, Rutsiro, and Burera \u0026mdash;out of 7 pilot districts where the MMS program was implemented. These districts may not be fully representative of the diverse cultural, socioeconomic, and healthcare contexts across Rwanda\u0026rsquo;s 30 districts. As a result, the generalizability of the findings to the broader Rwandan population may be limited. Second, the study relied on self-reported data from participants regarding their knowledge, attitudes, and practices. This approach is subject to potential recall bias. Moreover, social desirability bias may have influenced respondents to provide answers they perceived as favorable or acceptable. Third, the study was conducted towards the end of the first year of MMS implementation\u0026mdash;a period during which awareness and understanding might have still been evolving. As such, the findings may not have captured long-term knowledge, attitudes, or behavioral outcomes.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study shows high levels of MMS uptake and adherence among pregnant and lactating women in Rwanda\u0026rsquo;s pilot districts, supported by generally positive attitudes and partner involvement. However, moderate knowledge levels, delayed start, and misconceptions\u0026mdash;both among women and their families\u0026mdash;act as barriers to optimal implementation. Inconsistent counselling and limited provider training further restrict the delivery of adequate counseling.\u003c/p\u003e\u003cp\u003eAddressing these gaps requires a multifaceted approach. Enhancing antenatal counselling through capacity building for healthcare providers and CHWs is vital to ensure consistent, personalized guidance. Community-level education\u0026mdash;particularly involving male partners\u0026mdash;can strengthen support systems. Additionally, promoting timely ANC attendance and correcting misinformation about MMS content and purpose will be crucial to improving early uptake.\u003c/p\u003e\u003cp\u003eAs Rwanda prepares to expand MMS nationwide, these findings provide timely insights to guide implementation. An inclusive, system-strengthening approach that combines evidence-based education, support for the health workforce, and family engagement will be vital to maximize the nutritional and health benefits of MMS for pregnant women and their infants.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eANC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAntenatal Care\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCHW\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCommunity Health Worker\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eKII\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eKey Informant Interview\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMMS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMultiple Micronutrient Supplementation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eRDHS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eRwanda Demographic and Health Survey\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eUNICEF\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eUnited Nations Children's Fund\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eWHO\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\"\u003eFGD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eFocus Group Discussion. HIV:Human Immunodeficiency Virus.\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\u003cp\u003e We obtained ethical approval from the Rwanda National Ethics Committee (RNEC 638/2024) and secured written informed consent from all participants. Before participation, we explained the study's purpose, voluntary nature, potential risks and benefits, and confidentiality measures\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cb\u003eConsent for publication\u003c/b\u003e:\u003c/strong\u003e\u003cp\u003eNot applicable\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e\u003cp\u003eThis study was funded by UNICEF Rwanda. The statements in this publication are the views of the author(s) and do not necessarily reflect the policies or the views of UNICEF.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eE. M, S. D., A.B and E.T. conceptualized the study. E.M., P.N. and P.I.R. collected and analyzed data and analysis: EM.. and H.G.A. wrote the main manuscript text. S. D., A.B, J. D. D. H. and E.T. reviewed and edited the manuscript. All authors read and approved the final manuscript\u003c/p\u003e\u003ch2\u003eAcknowledgements:\u003c/h2\u003e\u003cp\u003eNot applicable\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and/or analyzed during the current study are readily available from the corresponding author on request\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBlack RE, Victora CG, Walker SP, Bhutta ZA, Christian P, De Onis M, et al. Maternal and child undernutrition and overweight in low-income and middle-income countries. lancet. 2013;382(9890):427\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSantander Ballest\u0026iacute;n S, Gim\u0026eacute;nez Campos MI, Ballestin Ballestin J, Luesma Bartolom\u0026eacute; MJ. Is supplementation with micronutrients still necessary during pregnancy? A review. Nutrients. 2021;13(9):3134.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMilman N, Paszkowski T, Cetin I, Castelo-Branco C. Supplementation during pregnancy: beliefs and science. Gynecol Endocrinol. 2016;32(7):509\u0026ndash;16.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKebede AS, Muche AA, Alene AG. Factors associated with adverse pregnancy outcome in Debre Tabor town, Northwest Ethiopia: a case control study. BMC Res Notes. 2018;11:1\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWHO. WHO antenatal care recommendations for a positive pregnancy experience: Nutritional interventions update: Multiple micronutrient supplements during pregnancy. Geneva: World Health Organization; 2020.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTsiklauri R, Jijeishvili L, Kherkheulidze M, Kvanchakhadze R, Kazakhashvili N. Neural tube defects and micronutrient deficiency prevalence in Georgia. Georgian Med News. 2020(298):61\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSmith ER, Shankar AH, Wu LS, Aboud S, Adu-Afarwuah S, Ali H, et al. Modifiers of the effect of maternal multiple micronutrient supplementation on stillbirth, birth outcomes, and infant mortality: a meta-analysis of individual patient data from 17 randomised trials in low-income and middle-income countries. Lancet Global Health. 2017;5(11):e1090\u0026ndash;100.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKeats EC, Haider BA, Tam E, Bhutta ZA. Multiple-micronutrient supplementation for women during pregnancy. Cochrane Database Syst Reviews. 2019(3).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNational Institute of Statistics of Rwanda (NISR). MoHMR, \u0026amp; ICF. Rwanda Demographic and Health Survey 2020: Micronutrient Supplementation Report. Kigali, Rwanda, and Rockville. Maryland, USA: NISR and ICF; 2022.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOh C, Keats EC, Bhutta ZA. Vitamin and mineral supplementation during pregnancy on maternal, birth, child health and development outcomes in low- and middle-income countries: a systematic review and meta-analysis. Nutrients. 2020;12(2):491.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHaider BA, Bhutta ZA. Multiple-micronutrient supplementation for women during pregnancy. Cochrane Database Syst Reviews. 2017(4).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBourassa MW, Osendarp SJ, Adu-Afarwuah S, Ahmed S, Ajello C, Bergeron G, et al. Review of the evidence regarding the use of antenatal multiple micronutrient supplementation in low- and middle‐income countries. Ann N Y Acad Sci. 2019;1444(1):6\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBhutta ZA, Das JK, Rizvi A, Gaffey MF, Walker N, Horton S, et al. Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? lancet. 2013;382(9890):452\u0026ndash;77.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePrado EL, Dewey KG. Nutrition and brain development in early life. Nutr Rev. 2014;72(4):267\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNechitilo M, Nguyen P, Webb-Girard A, Gonzalez-Casanova I, Martorell R, DiGirolamo A, et al. A qualitative study of factors influencing initiation and adherence to micronutrient supplementation among women of reproductive age in Vietnam. FoodNutr Bull. 2016;37(4):461\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSilubonde TM, Draper CE, Baumgartner J, Ware LJ, Smuts CM, Norris SA. Barriers and facilitators of micronutrient supplementation among non-pregnant women of reproductive age in Johannesburg, South Africa. PLOS Global Public Health. 2022;2(11):e0001310.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLabont\u0026eacute; JM, Hoang MA, Panicker A, Kroeun H, Sokchea M, Sambo S, et al. Exploring factors affecting adherence to multiple micronutrient supplementation during pregnancy in Cambodia: A qualitative analysis. Matern Child Nutr. 2025;21(1):e13745.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAtmadani RN, Akrom A, Ananda D, Saputri LY, Puspitasari AA, Urbayatun S. Supports and Barriers Regarding The Iron-Folic Acid Supplementation Adherence Level in Anemic Pregnant Women: Indonesians\u0026rsquo; Perspective. Media Kesehatan Masyarakat Indonesia. 2024;20(2):46\u0026ndash;56.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePopa AD, Niţă O, Graur LI, Popescu RM, Botnariu GE, Mihalache L, et al. Nutritional knowledge as a determinant of vitamin and mineral supplementation during pregnancy. BMC Public Health. 2013;13:1\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOlloqui-Mundet MJ, Cavia MM, Alonso-Torre SR, Carrillo C. Dietary habits and nutritional knowledge of pregnant women: the importance of nutrition education. Foods. 2024;13(19):3189.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGarcia-Casal MN, Estevez D, De‐Regil LM. Multiple micronutrient supplements in pregnancy: Implementation considerations for integration as part of quality services in routine antenatal care. Objectives, results, and conclusions of the meeting. Matern Child Nutr. 2018;14:e12704.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMartin SL, Wawire V, Ombunda H, Li T, Sklar K, Tzehaie H, et al. Integrating calcium supplementation into facility-based antenatal care services in western Kenya: a qualitative process evaluation to identify implementation barriers and facilitators. Curr Developments Nutr. 2018;2(11):nzy068.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJafari A, Hosseini Z, Tehrani H, Alami A. Evaluation of the barriers and facilitators of iron supplementation program among adolescent females. Clin Nutr ESPEN. 2023;56:36\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlehegn MA, Fanta TK, Ayalew AF. Exploring maternal nutrition counseling provided by health professionals during antenatal care follow-up: a qualitative study in Addis Ababa, Ethiopia-2019. BMC Nutr. 2021;7:1\u0026ndash;16.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKraemer K, Beesabathuni K, Askari S, Khondker R, Khan TU, Rahman M, et al. editors. Knowledge, attitudes and practices of pregnant women and healthcare providers in Bangladesh regarding multivitamin supplements during pregnancy. Healthcare: MDPI; 2023.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMowe M, Bosaeus I, Rasmussen HH, Kondrup J, Unosson M, Rothenberg E, et al. Insufficient nutritional knowledge among health care workers? Clin Nutr. 2008;27(2):196\u0026ndash;202.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eIbikunle HA, Okafor IP, Adejimi AA. Pre-natal nutrition education: Health care providers\u0026rsquo; knowledge and quality of services in primary health care centres in Lagos, Nigeria. PLoS ONE. 2021;16(11):e0259237.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVrkatić A, Grujičić M, Jovičić-Bata J, Novaković B, editors. Nutritional knowledge, confidence, attitudes towards nutritional care and nutrition counselling practice among general practitioners. Healthcare: MDPI; 2022.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWHO, Guideline. Intermittent iron and folic acid supplementation in non-anaemic pregnant women. Guideline: Intermittent iron and folic acid supplementation in non-anaemic pregnant women2011. p. 31-.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRBC. Annual report 2023-024. Maternal, Child and Community Health Division. 2025.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTawfiq E, Fazli MR, Wasiq AW, Stanikzai MH, Mansouri A, Saeedzai SA. Sociodemographic predictors of initiating Antenatal Care visits by pregnant women during first trimester of pregnancy: findings from the Afghanistan Health Survey 2018. Int J Women's Health. 2023:475\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAbdo R, Demelash M, Seid AM, Mussema A. First trimester antenatal care contact in Africa: a systematic review and meta-analysis of prevalence and contributing factors. BMC Pregnancy Childbirth. 2023;23(1):742.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTumilowicz A, Neufeld LM, Pelto GH. Using ethnography in implementation research to improve nutrition interventions in populations. Matern Child Nutr. 2015;11:55\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDitekemena J, Koole O, Engmann C, Matendo R, Tshefu A, Ryder R, et al. Determinants of male involvement in maternal and child health services in sub-Saharan Africa: a review. Reproductive health. 2012;9:1\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eComrie-Thomson L, Tokhi M, Ampt F, Portela A, Chersich M, Khanna R, et al. Challenging gender inequity through male involvement in maternal and newborn health: critical assessment of an emerging evidence base. Cult Health Sex. 2015;17(sup2):177\u0026ndash;89.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"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":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Multiple Micronutrient Supplementation (MMS), antenatal care (ANC), knowledge, attitudes, and practices (KAP), supplement adherence, Rwanda","lastPublishedDoi":"10.21203/rs.3.rs-6932308/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6932308/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e\u003cp\u003eIn Rwanda, micronutrient deficiencies among pregnant women remain a public health concern. To address this, Rwanda introduced Multiple Micronutrient Supplementation (MMS) in antenatal care (ANC) services in an integrated manner. Understanding knowledge, attitudes, and practices (KAP) related to MMS is crucial for effective implementation. Therefore, the current study aimed to assess knowledge, attitudes, and practices related to MMS among pregnant and lactating women, and to identify factors influencing adherence and uptake.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e\u003cp\u003eA mixed-methods study was conducted in December 2024 in the Rwandan districts of Gasabo, Rutsiro, and Burera, where the MMS program was implemented. Quantitative data were collected from 484 women (pregnant and lactating) through structured questionnaires, while qualitative data were gathered via 18 focus group discussions (FGDs) with women and husbands, exit interviews with 12 pregnant women, and key informant interviews with healthcare providers and district officials. Data were analyzed using SPSS and Atlas.ti.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003eDespite high reported use (94%) and adherence (92%) to MMS among pregnant women, knowledge levels remained largely moderate, with 58.5% scoring in the moderate range and only 15% achieving high knowledge scores. In terms of attitudes, 56.6% demonstrated a high attitude toward MMS, while only 2% showed low attitudes. Notably, most respondents expressed a willingness to recommend MMS to others (96%), had minimal concerns about its use (83%), and intended to continue supplementation (77.7%). Trust in healthcare providers was high, with 95.5% expressing confidence in the advice received and 93.6% reporting satisfaction with the information provided. However, misconceptions\u0026mdash;such as fears of delivery complications due to large babies and confusion between MMS and other medications, fear of side effects\u0026mdash;remain key barriers. Conversely, male partner support, awareness of MMS benefits, and encouragement from health providers were identified as significant facilitators.\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e\u003cp\u003eDespite high MMS use and adherence among women, knowledge levels remain largely moderate, whereas attitudes toward MMS are generally positive. Misconceptions about MMS and the fear of side effects are the challenges. Partner support, knowing the benefits of MMS and encouragement from healthcare providers are key facilitators. Strengthening early health education and involving partners could enhance MMS uptake and impact.\u003c/p\u003e","manuscriptTitle":"Understanding Knowledge, Attitudes, and Practices Around Multiple Micronutrient Supplementation in Rwanda","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-05 18:54:47","doi":"10.21203/rs.3.rs-6932308/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"54228f03-cd5b-447e-95c0-277fdf71ffc4","owner":[],"postedDate":"August 5th, 2025","published":true,"recentEditorialEvents":[{"type":"decision","content":"Withdrawn","date":"2026-05-06T11:21:04+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-06T11:27:42+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-05 18:54:47","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6932308","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6932308","identity":"rs-6932308","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}