From testing to treatment: a mixed-methods study assessing organisational readiness for intravenous iron for pregnant women with anaemia in Bangladesh

From testing to treatment: a mixed-methods study assessing organisational readiness for intravenous iron for pregnant women with anaemia in Bangladesh | 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 From testing to treatment: a mixed-methods study assessing organisational readiness for intravenous iron for pregnant women with anaemia in Bangladesh Ebony Verbunt, ABM Rasheduzzaman, Bidhan Krishna Sarker, AM Quaiyum Rahman, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8013520/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Anaemia affects over one-third of pregnant women in Bangladesh, leading to serious consequences such as maternal death and stillbirth. Yet, only about half of pregnant women are tested for anaemia, and few receive intravenous iron – a fast and effective treatment option. It remains unclear whether health facilities have the resources, and whether health workers are willing and able, to deliver these services. Embedded within a demonstration project, our study aimed to evaluate the organisational readiness of Bangladesh’s primary health care system to provide point-of-care anaemia testing and intravenous iron treatment for pregnant women. We employed a multi-phase, mixed-methods, parallel convergent design. Formative research included a baseline health facility readiness assessment (n=20). In the parallel process evaluation, health workers completed the Organisational Readiness for Implementing Change (ORIC) questionnaire (n=35), and a sample participated in qualitative interviews (n=21). Quantitative data were analysed descriptively, while qualitative data were analysed using inductive thematic analysis. We integrated findings across data sources to provide a comprehensive evaluation. We found high organisational readiness for implementing anaemia testing and intravenous iron treatment, with health workers demonstrating strong commitment and confidence in providing these services to pregnant women. However, sustaining both interventions beyond the demonstration project would require addressing resource constraints, including limited equipment and shortage of nurses and doctors. Ultimately, government support for implementation and resource provision will be essential to ensure the continued delivery of anaemia testing and intravenous iron treatment in Bangladesh’s primary health care system. Findings from our study may help inform government decision-making. organisational readiness implementation research pregnant women antenatal care anaemia testing intravenous iron treatment Figures Figure 1 Introduction Anaemia in pregnancy is a major public health problem, affecting 29.2 million women in 2023 (World Health Organization, 2025c). Women in low- and middle-income countries are disproportionately impacted, particularly those living in Africa (10.9 million women affected) and South-East Asia (8.9 million women affected) (World Health Organization, 2025a). Anaemia during pregnancy increases women’s risks of maternal death, postpartum haemorrhage, stillbirth, low birth weight, puerperal sepsis, and both antenatal and postnatal depression (Azami et al., 2019; Dama et al., 2018; Daru et al., 2018; Jung et al., 2019; Melkie & Dagnew, 2021; WOMAN-2 trial collaborators, 2023; Young et al., 2019). Symptoms of anaemia include fatigue, dizziness, and weakness – all of which can affect a woman’s physical and emotional wellbeing, as well as her ability to engage in paid work or home care (Ogunbode & Ogunbode, 2021; Yilmaz et al., 2019). Iron-deficiency is the most common cause of anaemia in pregnant women, due to the increased blood volume required to support the growing fetus and placenta (McMahon, 2010; Safiri et al., 2021; World Health Organization, 2015a). To prevent anaemia, the World Health Organisation (WHO) recommends that pregnant women take a daily oral supplement of iron (30 to 60 mg) and folic acid (0.4 mg) (World Health Organization, 2016). Folic acid should be started pre-conception, and iron as early as possible after conception, with both continued throughout a woman’s pregnancy (World Health Organization, 2016). WHO also recommend that pregnant women be tested for anaemia using a full blood count (World Health Organization, 2016), with clinical and public health guidelines recommending testing at the woman’s first antenatal care visit and again at 28 weeks gestation (American College of Obstetricians and Gynecologists' Committee on Practice Bulletins - Obstetrics, 2021; Pavord et al., 2019). In settings where laboratory facilities and qualified personnel are unavailable, WHO recommend point-of-care haemoglobinometers over colour scales for testing (World Health Organization, 2016). For women diagnosed with anaemia during pregnancy, WHO advises increasing the daily iron dose to 120 mg (World Health Organization, 2016). Once anaemia is corrected, the standard daily dose should be resumed to prevent recurrence. Although not currently included in WHO recommendations, intravenous iron is an alternative treatment option for anaemia in pregnant women. In many high-income countries, intravenous iron is recommended during the second or third trimester for women with moderate to severe anaemia who do not respond to, or cannot tolerate, oral iron and folic acid supplements (ACOG Practice Bulletin, 2021; Nowak et al., 2019; Pavord et al., 2019). Modern formulations, such as ferric carboxymaltose, can rapidly replenish iron stores and haemoglobin levels with a single 15-minute dose (Auerbach & Deloughery, 2016; Pasricha, Moya, Ataíde, et al., 2025; Rogozińska et al., 2021). Importantly, these formulations are safe, with a very low risk of anaphylaxis and no marked difference in adverse events compared to oral iron (Afolabi et al., 2024; Dave et al., 2022; Pasricha, Moya, Ataide, et al., 2025). Despite clear recommendations for managing anaemia during pregnancy, implementation remains inconsistent in many settings. Anaemia management in pregnant women in Bangladesh In Bangladesh, anaemia affects over one-third of pregnant women (World Health Organization, 2025b). Oral iron and folic acid supplements are provided for free as part of routine antenatal care at government health facilities (Directorate General of Health Services, 2017). However, only approximately 20% of women complete the recommended regimen during pregnancy (Sanin et al., 2023). This is likely due to several factors, including inadequate counselling by health workers about the benefits of supplements, gastrointestinal side-effects such as vomiting and constipation, misconceptions that they increase fetal growth and consequently difficult childbirth, and challenges in remembering to take them (Alam et al., 2015; Siekmans et al., 2018; Verbunt, Corona, et al., 2025) Despite the high burden of anaemia in Bangladesh and its importance for timely and appropriate treatment, only about half of pregnant women are tested during routine antenatal care (Verbunt, Hasan, et al., 2025). Most pregnant women (95.8%) are tested using a full blood count, which although the WHO recommended method, is more resource-intensive than collecting capillary blood using point-of-care haemoglobinometers (Verbunt, Hasan, et al., 2025; World Health Organization, 2016). Portable devices such as the HemoCue could increase anaemia testing rates due to their suitability for use in government primary health facilities, which are widely available in rural areas (Sanchis-Gomar et al., 2013; Verbunt, Hasan, et al., 2025; World Health Organization, 2011; World Health Organization. Regional Office for the Western Pacific, 2015). Most pregnant women (73.3%) diagnosed with anaemia are treated with oral iron and folic acid supplements only (Verbunt, Hasan, et al., 2025). However, many women in Bangladesh initiate antenatal care in the second trimester, delaying the diagnosis and treatment of anaemia – an important concern, as supplements may require up to six months to fully replenish iron stores (Brittenham, 2018; Sarker et al., 2020; Stoffel et al., 2020). Intravenous iron is not formally available as a treatment option within the government health care system. As a result, only a small proportion of pregnant women (5.9%) receive intravenous iron only for the treatment of anaemia (Verbunt, Hasan, et al., 2025). The EDIVA Programme Demonstration Project Alongside investments to ensure that all pregnant women in Bangladesh are tested for anaemia, and the promising use of intravenous iron to improve its treatment, the EDIVA programme: ‘ E fficacy and D emonstration of I ntra V enous iron for A naemia in pregnancy’ was launched in 2021. The programme is led by the research institute [organisation name removed for peer-review] in Bangladesh, in collaboration with [organisation name removed for peer-review] and the [organisation name removed for peer-review] in Australia. It consists of a maternal anaemia prevalence survey (Ahmed et al., 2024), randomised controlled trial (Australian New Zealand Clinical Trials Registry, 2021), and demonstration project (Prang et al., 2025). This paper focuses on the EDIVA demonstration project, with results from other programme components reported elsewhere (Hasan et al., 2024). The EDIVA demonstration project aims to assess the feasibility and acceptability of implementing an intravenous iron intervention within the Bangladesh primary health care system (Prang et al., 2025). It was conducted in Bandar upazila (sub-district) in Narayanganj district, which is part of the urban sprawl surrounding the capital city of Dhaka. The study area was chosen due to existing relationships with the community and local health authorities, established during a previous randomised controlled trial conducted in Narayanganj district (Hasan et al., 2017; Pasricha et al., 2021). Bandar upazila is comprised of five unions – Dhamgar, Madanpur, Musapur, Bandar, and Kalagachhia. Formative research was conducted in preparation for implementation of the demonstration project (October 2021-December 2023), and the demonstration project ran from March 2024 to May 2025 (14 months). Anaemia testing for pregnant women was performed using a HemoCue® Hb 301 device, and ferric carboxymaltose was the intravenous iron formulation used. Health workers who provided usual care received relevant training, and all necessary equipment and materials were provided by the EDIVA programme (Prang et al., 2025). To compare the feasibility and acceptability of different anaemia testing pathways, Bandar upazila was divided into two areas: the North (Dhamgar, Madanpur, and Musapur unions), where home-based testing was conducted by Family Welfare Assistants (n = 15), and the South (Bandar and Kalagachhia unions), where health facility-based testing was conducted by Community Health Care Providers (n = 6) and Family Welfare Visitors (n = 4). All women diagnosed with anaemia (Hb <10 g/dL) and who fit other components of the inclusion criteria were referred to the Upazila Health Complex for intravenous iron administered by nurses (n = 9) or doctors (n = 3) (Prang et al., 2025). A parallel process evaluation was conducted approximately halfway through the EDIVA demonstration project, at around seven months in, to allow sufficient time for health workers to integrate either anaemia testing or intravenous iron treatment into their routine responsibilities. Implementation research seeks to reduce the time it takes for evidence-based interventions to be translated into real-world settings (Eccles & Mittman, 2006). This is achieved through multi-method inquiry that explores the context in which the intervention is to be implemented, ultimately enhancing outcomes including acceptability, feasibility, fidelity, adoption, and sustainability (Peters et al., 2013; Proctor et al., 2011). Formative research conducted prior to randomised controlled trials of intravenous iron treatment for pregnant women with anaemia in Malawi and Nigeria revealed concerns among stakeholders. Specifically, they noted that primary health facilities might lack the necessary resources and physical space to test pregnant women for anaemia and safely administer intravenous iron (Akinajo et al., 2024; Mamani-Mategula et al., 2024). Additionally, they felt that it might not be feasible for health workers to take on the role of treating pregnant women with anaemia using intravenous iron within already strained health systems (Akinajo et al., 2024; Mamani-Mategula et al., 2024). However, no research has specifically evaluated organisational readiness for implementing change – a key determinant of successful intervention uptake (Aarons et al., 2017; Bach-Mortensen et al., 2018; Kotter, 1996). Organisational readiness typically involves both structural components (e.g., availability of resources at health facilities) and psychological components (e.g., motivation of health workers) (Caci et al., 2025; Holt & Vardaman, 2013). Assessing these factors can help accelerate and improve the implementation of evidence-based interventions by identifying areas that require attention (Weiner et al., 2020). Therefore, as part of the EDIVA demonstration project, we aimed to evaluate organisational readiness for implementing anaemia testing and intravenous iron treatment for pregnant women in Bangladesh’s primary health care system. Methods Study Design This study employs a multi-phase, mixed-methods, parallel convergent design, which is depicted in Fig. 1 (Creswell & Plano Clark, 2011 ). As part of the formative research for the EDIVA demonstration project, we first conducted a baseline health facility readiness assessment for anaemia testing and intravenous iron treatment (16–27 October 2022). Subsequently, during the parallel process evaluation of the project, we administered the Organisational Readiness for Implementing Change (ORIC) questionnaire (Shea et al., 2014 ) and conducted qualitative interviews with health workers (21–28 October 2024). The process evaluation followed a parallel convergent design, in which quantitative and qualitative data were collected and analysed concurrently (Creswell & Plano Clark, 2011 ). This paper synthesises and presents findings from the baseline health facility readiness assessment, ORIC questionnaire, and qualitative interviews with health workers. Together, these findings provide a holistic evaluation of organisational readiness for implementing anaemia testing and intravenous iron treatment for pregnant women in Bangladesh’s primary health care system. The study is reported in accordance with the ASSESS tool (Ryan et al., 2022 ). Ethics approval was obtained from the Ethical Review Committee at [organisation name removed for peer-review] (PR-20125), the Human Research Ethics Committee at [organisation name removed for peer-review] (21/5), and the Office of Research Ethics and Training at the [organisation name removed for peer-review] (2022-24388-31967-4). An author reflexivity statement is included in S1 Appendix. (PLACE FIGURE 1 HERE) Participants The baseline health facility readiness assessment was conducted in 20 primary health facilities in Bandar upazila, including Community Clinics, Union Health and Family Welfare Centres, and the Upazila Health Complex. The manager of each health facility was contacted by [organisation name removed for peer-review] field research assistants via telephone to schedule an appropriate visit day and time. The assessment was completed by the health worker most involved in antenatal care at each health facility (e.g., Family Welfare Visitors at Union Health and Family Welfare Centres). Using a complete enumeration sampling approach, all health workers involved in the EDIVA demonstration project were recruited to complete an adapted version of the ORIC questionnaire (Cochran, 1977 ; Shea et al., 2014 ). We then used quota sampling, which specifies the categories and the minimum number of participants required, to recruit a subset of health workers for qualitative interviews (Robinson, 2014 ). For home-based testing we aimed to recruit at least six Family Welfare Assistants, with at least two from each union (Dhamgar, Madanpur, and Musapur). Similarly, for health facility-based testing, we aimed to recruit at least six Community Health Care Providers or Family Welfare Visitors, with at least three from each union (Bandar and Kalagachhia). For intravenous iron treatment, we aimed to recruit at least five nurses and three doctors. No health workers declined to participate in the ORIC questionnaire or qualitative interviews. Data Collection and Analysis The interviewer-administered baseline health facility readiness assessment was developed by adapting the WHO Service Availability and Readiness Assessment and the Bangladesh Health Facility Assessment Tool (National Institute of Population Research and Training and ICF, 2019 ; World Health Organization, 2015c ). [initials removed for peer-review] trained three [organisation name removed for peer-review] researchers [initials removed for peer-review] in data collection over three days, with the questionnaire piloted at two health facilities on the fourth day. Specifically, as the questionnaire was in English, translation into oral Bangla was tested to ensure consistency in language. Data collection was paper-based. The questionnaire consisted of several sections, including general characteristics, amenities, protocol/guidelines and training, equipment – antenatal care, and resources – intravenous iron treatment (S2 Appendix) . Data were entered into Excel immediately following data collection. If an item in the baseline health facility readiness assessment was available and functional, it received a score of 1; if it was unavailable or nonfunctional, it received a score of 0 (World Health Organization, 2015b ). Items within the questionnaire related to anaemia testing (equipment and guidelines) and intravenous iron treatment (equipment and room for administration and monitoring) were analysed descriptively using Stata 17 software (StataCorp. 2021. Stata Statistical Software: Release 17 . College Station, TX: StataCorp LLC) and presented as frequencies. The ORIC is a 12 item measure consisting of two subscales: (1) change commitment, defined as a shared willingness among health workers to implement an intervention (questions 1–5), and (2) change efficacy, defined as the collective ability of health workers to implement an intervention (questions 6–12) (Shea et al., 2014 ). The ‘intervention’ referred to anaemia testing and intravenous iron treatment (S3 Appendix) . The ORIC questionnaire exhibits “good” to “excellent” psychometric properties, including reliability, structural validity, and known-groups validity (Shea et al., 2014 ; Weiner et al., 2020 ) and it has been successfully translated for use in non-English-speaking countries (Ruest et al., 2019 ; Storkholm et al., 2018 ). For our study, the questionnaire was translated from English to Bangla and interviewer-administered by [organisation name removed for peer-review] researchers [initials removed for peer-review] in a private room at the health workers’ facility. Data were collected electronically using Kobo Toolbox software (Cambridge, MA, USA). Descriptive analyses of total ORIC scores (mean and standard deviation), as well as commitment and efficacy subscale scores, were conducted using Stata 17 software (StataCorp. 2021. Stata Statistical Software: Release 17 . College Station, TX: StataCorp LLC). Mean total ORIC scores range from 12 to 60, with higher scores indicating greater organisational readiness to implement the intervention (Shea et al., 2014 ). The ORIC represents a continuum, with no specific cut-off scores to distinguish between high and low readiness. Following completion of the ORIC questionnaire, qualitative interviews were conducted with a sample of health workers to gain deeper insight into the factors influencing their organisational readiness to provide anaemia testing or intravenous iron treatment. Separate interview guidelines were developed for anaemia testing and intravenous iron treatment (S4 Appendix) . Health workers were asked about their experiences with anaemia testing or intravenous iron treatment as part of the EDIVA demonstration project, as well as their perceptions of the feasibility and acceptability of integrating these practices into routine antenatal care within Bangladesh’s primary health care system. Qualitative interviews were conducted face-to-face in Bangla by the same [organisation name removed for peer-review] researchers who administered the ORIC questionnaire [initials removed for peer-review]. Interviews lasted 45–87 minutes for anaemia testing and 14–37 minutes for intravenous iron treatment. Interviews were audio-recorded and transcribed verbatim to Bangla. The Bangla transcripts were then translated to English by [organisation name removed for peer-review] researchers fluent in both languages and familiar with the study context. We used inductive thematic analysis to analyse the qualitative interviews (Braun & Clarke, 2006 ). The field research team [initials removed for peer-review] met in the evenings following interviews to discuss and review emerging themes from the data. Based on these discussions, [initials removed for peer-review] and [initials removed for peer-review] developed the initial coding frameworks for anaemia testing and intravenous iron treatment. In the months following data collection, [initials removed for peer-review] and [initials removed for peer-review] refined and finalised the frameworks through online discussions. [initials removed for peer-review] then used the finalised frameworks to code all transcripts using NVivo (version 15). Themes were subsequently deductively mapped to the Capability, Opportunity, and Motivation model of Behaviour Change (COM-B) by [initials removed for peer-review] and [initials removed for peer-review] (Michie et al., 2014 ). The COM-B model has been widely used in health worker research to identify which components need to change for a behaviour change intervention to be effective (West & Michie). It suggests that for health workers to engage in a specific behaviour, they must have the capability and opportunity to do so, and they must be more motivated to perform that behaviour than to engage in alternative actions (West & Michie). Capability refers to an individual’s physical or psychological capacity to perform the behaviour, including the necessary knowledge and skills. Opportunity involves external physical or social conditions that enable the behaviour, such as access to resources or support from others. Motivation encompasses both reflective (e.g., conscious decision-making) and automatic (e.g., emotional responses) processes that influence and drive behaviour (Michie et al., 2014 ). We integrated data across sources to provide a comprehensive evaluation of organisational readiness for implementing anaemia testing and intravenous iron treatment for pregnant women in Bangladesh’s primary health care system. For both anaemia testing and intravenous iron treatment, we started with the total mean ORIC score and the mean scores of its subscales: change efficacy and change commitment. We then used findings from the qualitative interviews with health workers and baseline health facility readiness assessment to contextualise these scores and strengthen our evaluation of overall organisational readiness. Written informed consent was received from health workers prior to their participation in the baseline health facility readiness assessment, the ORIC questionnaire, and qualitative interviews. Findings The results are organised into two sections: anaemia testing and intravenous iron treatment. For each, we begin by describing the characteristics of the data sources, followed by an evaluation of organisational readiness. Anaemia testing The baseline health facility readiness assessment was conducted in all 20 primary health facilities in Bandar upazila; most were Community Clinics (14/20, 70%) (Table 1). The ORIC questionnaire was administered to 23 of the 25 health workers involved in the implementation of the EDIVA demonstration project (the other two were Family Welfare Visitors on extended leave). Most were women and well-established in their roles, with ≥ 6 years of experience. Qualitative interviews were then conducted with 13 of the 23 health workers. These included seven Family Welfare Assistants involved in home-based testing, and four Community Health Care Providers and two Family Welfare Visitors who were engaged in health facility-based testing. Table 1. Characteristics of data sources used to evaluate organisational readiness for implementing anaemia testing for pregnant women in Bangladesh’s primary health care system Baseline health facility readiness assessment ORIC questionnaire Qualitative interviews Sample 20 23 13 n (%) n (%) n (%) Primary health facility Community Clinic 14 (70.0) n/a n/a Union Health and Family Welfare Centre 4 (20.0) n/a n/a Union Health Sub Centre 1 (5.0) n/a n/a Upazila Health Complex 1 (5.0) n/a n/a Health worker Family Welfare Assistant (home-based) n/a 15 (65.2) 7 (53.8) Community Health Care Provider (health facility-based) n/a 6 (26.1) 4 (30.8) Family Welfare Visitor (health facility-based) n/a 2 (8.7) 2 (15.4) Gender Woman n/a 21 (91.3) 11 (84.6) Man n/a 2 (8.7) 2 (15.4) Age (years) <30 years n/a 1 (4.3) 1 (7.7) ≥30 ≤40 years n/a 11 (47.8) 9 (69.2) ≥41 years n/a 11(47.8) 3 (23.1) Experience in current role (years) ≤5 years n/a 2 (8.7) 2 (15.4) ≥6 years ≤10 years n/a 5 (21.7) 4 (30.8) ≥11 years ≤20 years n/a 7 (30.4) 5 (38.5) ≥ 21 years n/a 9 (39.1) 2 (15.4) Overall, ORIC scores and qualitative data suggest that organisational readiness for implementing anaemia testing using the HemoCue device was high, with primary health workers showing strong commitment and confidence in their ability to provide this service to pregnant women. However, effective and sustained implementation beyond the EDIVA demonstration project would require mitigating the additional workload for health workers and ensuring adequate government support in the form of resources and equipment. Primary health workers had a mean total ORIC score of 55.0/60, indicating high organisational readiness to test pregnant women for anaemia using the HemoCue device. The mean ‘change commitment’ subscale score was 24.1/25, suggesting a strong collective desire to implement the service (Table 2). Qualitative interviews revealed that health workers were motivated to conduct HemoCue testing due to perceived advantages over other methods. For example, a Community Health Care Provider explained that clinical assessment for anaemia (inspection of the conjunctiva, tongue, and palms) “couldn’t precisely measure haemoglobin levels,” while a Family Welfare Assistant described the point-of-care HemoCue test as desirable because results were available “immediately,” unlike a full blood count, which required laboratory processing (Table 2). Health workers also described widespread community demand for anaemia testing and felt empowered to offer this service to pregnant women. Some health workers even reported that it had enhanced their “acceptance in the field [community].” The ORIC questionnaire showed a mean ‘change efficacy’ subscale score of 30.9/35, suggesting that primary health workers felt capable to implement anaemia testing using a HemoCue device for pregnant women. Qualitative interviews supported this finding, with most health workers expressing confidence in their ability to use the device. As one Family Welfare Assistant noted: “I think everyone will be able to operate it. It’s not that difficult.” Health workers noted that while the HemoCue test did not take long to conduct, their workload increased substantially when a pregnant woman was diagnosed with anaemia. This was due to the additional time needed to counsel the woman and her family on attending the Upazila Health Complex for intravenous iron treatment. Since intravenous iron is not a common treatment for anaemia in Bangladesh, community members often expressed a need for more information about its safety for both the pregnant woman and the fetus. As one Community Health Care Provider explained: “And if the [pregnant woman’s] haemoglobin is low [anaemic], the entire day is basically gone!” Health workers explained in qualitative interviews that prior to the EDIVA demonstration project, they were unable to test pregnant women for anaemia due to the government not providing them with the necessary resources and equipment. The baseline health facility readiness assessment supported this, finding that no primary health facilities had guidelines or standard operating procedures for testing pregnant women for anaemia, and only 30% (6/20) had haemoglobin testing capacity (either full blood count or point-of-care device) (Table 2 and S5 Appendix). Table 2. Findings from data sources used to evaluate organisational readiness for implementing anaemia testing for pregnant women in Bangladesh’s primary health care system COM-B domain Supporting data/qualitative themes Exemplar quote Mean (SD) total ORIC score: 55.0/60 (4.5) Mean (SD) change commitment score (shared willingness among health workers to implement an intervention): 24.1/25 (1.3) Reflective motivation HemoCue testing is more accurate than clinical assessment “We observed physical signs like pale eyes, tongue, skin, and nails. These visual checks couldn’t precisely measure haemoglobin levels.” (Community Health Care Provider, #01) Reflective motivation HemoCue testing results are easier to interpret than those from a colour scale or the Tallquist method “Now I can test sitting here, and the machine provides instant results in points, whereas we got the results in percentages [Tallquist book] (Family Welfare Visitor, #02) Reflective motivation HemoCue testing results are available immediately, unlike those from a full blood count “They [pregnant women] get the results immediately. At the hospital, it takes minimum of 2–3 days for the report [haemoglobin levels] to be delivered. It’s a quick process.” (Family Welfare Assistant, #01) Reflective motivation Testing pregnant women for anaemia has empowered primary health workers “It’s good and acceptable. Because when I test their [pregnant women’s] blood, my acceptance in the field [community] increases since people see it as helpful, especially because it’s free. It helps us.” (Family Welfare Assistant, #01) Social opportunity HemoCue testing is acceptable to both pregnant women and community members “The demand is positive, I will say, it’s good. People [pregnant women] come, even hearing from others, they are interested and want to do it.” (Community Health Care Provider, #04) Mean (SD) change efficacy score (collective ability of health workers to implement an intervention): 30.9/35 (4.0) Physical and psychological capability Primary health workers are capable of using the HemoCue device to test pregnant women for anaemia “I think everyone will be able to operate it [HemoCue]. It’s not that difficult.” (Family Welfare Assistant, #05) Physical opportunity The workload of primary health workers has increased due to counselling pregnant women diagnosed with anaemia about intravenous iron treatment “And if the haemoglobin level is low, the entire day is basically gone!” (Community Heath Care Provider, #04) Physical opportunity Haemoglobin levels are already included in the antenatal care register books used by primary health workers “I’ll incorporate the haemoglobin screening into my regular tasks. It’s a part of ANC check-ups, so it will be done with weight, blood pressure, and other ANC tasks… there’s already a column for haemoglobin levels in our ANC register book where we write it.” (Family Welfare Visitor, #02) Physical opportunity Remuneration for primary health workers is not aligned with their increasing workload “For 13 years… we have been working on the same salary, while the government keeps adding extra tasks over time.” (Community Health Care Provider, #01) Physical opportunity Anaemia testing equipment and resources were unavailable in primary health facilities before the EDIVA demonstration project Baseline health facility readiness assessment Of the 20 primary health facilities included in the assessment, none had guidelines or standard operating procedures for testing pregnant women for anaemia. Six had haemoglobin testing capacity (either full blood count or point-of-care device) (S5 Appendix) “We didn’t have the equipment or resources for that [anaemia testing], there wasn’t such supplies provided by the government.” (Family Welfare Assistant, #01) Intravenous iron treatment The baseline health facility readiness assessment was conducted in six primary health facilities in Bandar upazila (Table 3). Community Clinics were excluded because intravenous infusions are outside the scope of services provided at these facilities. The ORIC questionnaire was administered to all 12 health workers involved in the implementation of the EDIVA demonstration project. Most were women and well-established in their roles, with ≥ 6 years of experience. Qualitative interviews were then conducted with eight of the 12 health workers: five nurses and three doctors. Table 3. Characteristics of data sources used to evaluate organisational readiness for implementing intravenous iron treatment for pregnant women in Bangladesh’s primary health care system Baseline health facility readiness assessment ORIC questionnaire Qualitative interviews Sample 6 12 8 n (%) n (%) n (%) Primary health facility Union Health and Family Welfare Centre 4 (66.7) n/a n/a Union Health Sub Centre 1 (16.7 n/a n/a Upazila Health Complex 1 (16.7) n/a n/a Health worker Nurse n/a 9 (75.0) 5 (62.5) Doctor n/a 3 (25.0) 3 (37.5) Gender Woman n/a 11 (91.7) 7 (87.5) Man n/a 1 (8.3) 1 (12.5) Age (years) <30 years n/a 1 (8.3) 0 ≥30 ≤40 years n/a 5 (41.7) 3 (37.5) ≥41 years n/a 6 (50.0) 5 (62.5) Experience in current role (years) ≤5 years n/a 4 (33.3) 3 (37.5) ≥6 years ≤10 years n/a 2 (16.7) 1 (12.5) ≥11 years ≤20 years n/a 2 (16.7) 1 (12.5) ≥ 21 years n/a 4 (33.3) 3 (37.5) Overall, ORIC scores and qualitative data suggest that organisational readiness for implementing intravenous iron treatment was high, with nurses and doctors showing strong commitment and confidence in their ability to safely provide this service to pregnant women with anaemia. However, sustainable implementation beyond the EDIVA demonstration project would require addressing resource constraints – particularly the shortage of nurses and doctors. Nurses and doctors had a mean total ORIC score of 50.7/60, indicating high organisational readiness to treat pregnant women with anaemia using intravenous iron (Table 4). The mean ‘change commitment’ subscale score was 21.7/25, suggesting a strong collective desire to implement the intravenous iron treatment. Qualitative interviews revealed that health workers perceived advantages of intravenous iron over the standard-of-care (oral iron and folic acid supplements), with one nurse stating: “Many people forget to take oral tablets, or they experience constipation but if you take intravenous iron, it will help you to avoid such issues.” (Table 4). Doctors and nurses also reported that pregnant women readily accepted intravenous iron as a treatment option, as illustrated by this nurse: “… They [pregnant women] are very pleased… even the caregivers who come with them are also very pleased.” This acceptance was often due to the treatment being provided free of charge and available at a government health facility. The ORIC questionnaire showed a mean ‘change efficacy’ subscale score of 29.0/35, suggesting that nurses and doctors felt capable of implementing an intravenous iron treatment for pregnant women with anaemia. Participants in qualitative interviews emphasised that they had the knowledge and skills to administer intravenous iron safely, as one nurse explained: “No, no, it’s easy. We always give intravenous fluids to our regular patients, continuously. There’s nothing difficult about it.” Additionally, participants expressed confidence in managing potential adverse events, such as “hypersensitivity reactions.” However, interviews also revealed that high patient loads often required nurses and doctors to delay intravenous iron administration by up to an hour and limited the time available to monitor pregnant women during the infusion. Monitoring pregnant women during and after intravenous iron administration is essential to ensure the treatment is well tolerated and to promptly detect and manage rare but potential serious adverse events, such as anaphylaxis. These challenges were commonly attributed to structural deficiencies in the health system, particularly staffing shortages. As one doctor reported: “If the manpower would be increased, we might be able to work effectively.” In addition to staffing concerns, the unavailability of equipment, medicines, and beds was also identified as a challenge to sustaining intravenous iron treatment for pregnant women with anaemia beyond the EDIVA demonstration project. The baseline health facility readiness assessment found that while some items were routinely available, others were not. For example, among the six primary health facilities assessed, all had a weight machine to determine the appropriate dose of intravenous iron; three had a room with auditory and visual privacy; none had 20ml syringes for administration; and only one had adrenaline available to manage potential serious adverse events (Table 4 and S5 Appendix). Overall, key resources required for the safe administration of intravenous iron were inconsistently available. Table 4. Findings from data sources used to evaluate organisational readiness for implementing intravenous iron treatment for pregnant women in Bangladesh’s primary health care system COM-B domain Supporting data/qualitative themes Exemplar quote Mean (SD) total ORIC score: 50.7/60 (5.0) Mean (SD) change commitment score (shared willingness among health workers to implement an intervention): 21.7/25 (2.8) Reflective motivation Intravenous iron overcomes barriers that limit pregnant women’s adherence to oral iron and folic acid supplements “Many people forget to take oral tablets, or they experience constipation but if you take intravenous iron, it will help you to avoid such issues.” (Nurse, #04) Reflective motivation Intravenous iron has fewer risks than a blood transfusion “I think blood transfusions have more risk because there can be reactions because you don’t know more about the blood donor.” (Nurse, #03) Social opportunity Intravenous iron is acceptable to both pregnant women and community members “Yes, they’re [pregnant women] very pleased… even the caregivers who come with them are also very pleased.” (Nurse, #01) Mean (SD) change efficacy score (collective ability of health workers to implement an intervention): 29.0/35 (3.4) Physical and psychological capability Nurses and doctors already have the skills to administer intravenous infusions “No, no, it’s easy. We always give intravenous fluids to our regular patients, continuously. There’s nothing difficult about it.”(Nurse, #03) Physical and psychological capability Nurses and doctors are capable of managing potential serious adverse events associated with intravenous iron “If there are adverse side effects like hypersensitivity reactions, I think, we can manage it here.” (Doctor, #03) Physical opportunity High workload of nurses and doctors causes delays in administering intravenous iron to pregnant women “How will I describe about the timeliness; we can’t administer the intravenous iron immediately when the patient arrives. We usually have routine activities in the wards that need to be done first. (Nurse, #03) Physical opportunity High workload among nurses and doctors results in insufficient time to adequately monitor pregnant women during and after the intravenous iron infusion “Approximately 10 to 15 minutes, I spend with patients [pregnant women receiving intravenous iron] which is required for cannulation. I can’t give more time due to work in the wards. I leave as early as possible after completion of cannulation.” (Nurse, #05) Physical opportunity Availability of equipment necessary for intravenous iron treatment was low prior to the EDIVA demonstration project Baseline health facility readiness assessment Equipment, a private room, and specific medicines are required for intravenous iron treatment. In the six primary health facilities assessed, we found that while some items were available, others were not. For example, all health facilities had a weight machine to determine the appropriate dose of intravenous iron; three had a room with both auditory and visual privacy; none had 20ml syringes for administration, and only one had adrenaline available for managing potential serious adverse events (S5 Appendix) “I am thinking about the issue that the government has no iron saline or syringe. Even we don’t have saline set right now. So, when we ask the general patients to buy these things, they become annoyed.” (Nurse, #02) Physical opportunity Bed shortages “We have huge pressure of patient flow compared to earlier times. In the last two to three days, an average of 2 to 3 patients were admitted against a single bed.” (Nurse, #02) Social opportunity High number of staff vacancies “We have about seven vacancies here. Also, three of our staff are in higher education, BSc [Bachelor of Science] in nursing, left.” (Nurse, #01) Discussion The integration of data from the baseline health facility readiness assessment, the ORIC questionnaire, and qualitative interviews allowed for a comprehensive evaluation of organisational readiness for implementing anaemia testing and intravenous iron treatment for pregnant women in Bangladesh’s primary health care system. We found high organisational readiness for anaemia testing using the point-of-care HemoCue device and for intravenous iron treatment, with health workers demonstrating strong commitment and confidence in their ability to provide these services to pregnant women. However, sustaining both interventions beyond the EDIVA demonstration project would require addressing resource constraints, including the unavailability of necessary equipment and shortage of nurses and doctors. We found that structural health system deficiencies may affect the sustainable implementation of anaemia testing using the HemoCue device and intravenous iron treatment for pregnant women in Bangladesh’s primary health care system. Before the EDIVA demonstration project, anaemia testing equipment and related resources were often unavailable. When supplied with the HemoCue device during the project, health workers described how their workload increased due to the time spent counselling pregnant women following an anaemia diagnosis. However, this additional investment of time may ultimately reduce their workload, as more pregnant women could receive timely treatment, avoiding complications from anaemia that require more time-consuming care. In addition, nurses and doctors described how staffing shortages commonly led to delays in administering intravenous iron and limited the time they could spend monitoring pregnant women during infusions. Our findings align with previous research showing that most primary health facilities at the union and ward levels in Bangladesh lack haemoglobin testing capacity and that the country is facing a severe shortage of health workers (Hakim et al., 2022 ; United Nations Bangladesh, 2024 ). For example, in 2022, there were only 13 doctors, nurses, and midwives per 10,000 people in Bangladesh, compared to a global median of 49 (United Nations Bangladesh, 2024 ). Our findings are also consistent with a recent global qualitative evidence synthesis, which found that health workers’ ability to manage anaemia in pregnant women is affected by staffing shortages, heavy workloads, insufficient facilities and space, and poor working conditions (Verbunt, Corona, et al., 2025 ). These structural barriers to testing and treating anaemia in pregnant women highlight the importance of investing in prevention strategies, such as oral iron and folic acid supplements. Despite concerns about structural health system deficiencies, we found that health workers were committed and confident in their ability to test pregnant women for anaemia using the HemoCue device and to administer intravenous iron treatment. Qualitative interviews suggest this may be because health workers had considered the benefits of these services for pregnant women compared to other options. For example, health workers reflected on how HemoCue testing was more accurate than clinical assessment, while nurses and doctors explained that intravenous iron treatment addressed barriers, such as gastrointestinal side effects, that often prevent pregnant women from taking oral iron and folic acid supplements. Our findings contradict those from a study in Ghana, where health workers expressed concerns about the quality and accuracy of results from point-of-care devices, with some preferring to use clinical assessment (not recommended by WHO) to diagnose pregnant women with anaemia (Palmer et al., 2020 ; World Health Organization, 2016 ). This difference may be explained by health workers in our study receiving extensive training on how to test pregnant women for anaemia using the HemoCue device as part of the EDIVA demonstration project (Prang et al., 2025 ). Ongoing training for health workers should therefore be considered a key implementation strategy for scaling up the use of the HemoCue device across Bangladesh’s primary health care system (Powell et al., 2015 ). Consistent with our findings, health workers in Nigeria identified several advantages of intravenous iron compared to the standard-of-care (oral iron) for the treatment of anaemia in pregnancy, including women responding more rapidly to treatment and assured adherence (Akinajo et al., 2024 ). Overall, our findings align with other studies assessing organisational readiness for implementing change (Esan et al., 2022 ; van de Water et al., 2024 ). For example, a study in Nigeria, although focused on respectful maternity care rather than anaemia services, also found high organisational readiness for change despite limited perceived resources (Esan et al., 2022 ). Implications for Research and Policy, including the EDIVA Demonstration Project Our study findings have several implications for research and policy, including for the EDIVA demonstration project. To address the identified challenges to organisational readiness for implementing anaemia testing and intravenous iron treatment for pregnant women in Bangladesh’s primary health care system, future research could involve co-designing strategies with health workers. For example, health workers, in collaboration with pregnant women and their families, could develop educational materials to raise awareness about anaemia and intravenous iron treatment in advance. These materials could be disseminated to women by Family Welfare Assistants during their routine home visits to register new couples and pregnancies, and to provide antenatal care counselling (World Health Organization. Regional Office for the Western Pacific, 2015 ). This approach could help reduce the time health workers spend counselling pregnant women about intravenous iron treatment at the point of anaemia diagnosis. Human resource constraints at the Upazila Health Complex were a common barrier to nurses and doctors treating pregnant women with anaemia using intravenous iron. In partnership with WHO, the Ministry of Health and Family Welfare is in the process of creating Bangladesh’s first National Medical Education Strategy (United Nations Bangladesh, 2024 ). This strategy aims to address the shortage of trained health workers by strengthening key aspects of medical education, such as curriculum development and accreditation (United Nations Bangladesh, 2024 ). There is also potential for Family Welfare Visitors and Sub Assistant Community Medical Office at Union and Health and Family Welfare Centres to administer intravenous iron to pregnant women with anaemia (World Health Organization. Regional Office for the Western Pacific, 2015 ). However, their ability to do so safely would need to be assessed and formally approved by the government. Ultimately, for anaemia testing and intravenous iron treatment for pregnant women to be sustained in the primary health care system, the Bangladesh government would need to support implementation and provide the necessary resources. Findings from our study – as well as from the wider EDIVA programme, including an economic evaluation to understand the costs associated with implementing an intravenous iron intervention – will help guide government decision-making (Australian New Zealand Clinical Trials Registry, 2021 ; Hasan et al., 2024 ; Prang et al., 2025 ). Additionally, our findings may inform the design and implementation of an intravenous iron intervention for pregnant women with anaemia in other low- and middle-income countries. Strengths and Limitations We used a multi-phase, mixed-methods, parallel convergent design, which enhanced the validity and reliability of our findings through data triangulation. For example, qualitative interviews provided explanations for the high mean scores on the ORIC questionnaire, while the baseline health facility readiness assessment helped quantify themes that emerged from the interviews. Additionally, we administered the ORIC questionnaire and conducted qualitative interviews approximately halfway through the EDIVA demonstration project. This timing allowed health workers to embed either anaemia testing or intravenous iron treatment into their routine practice, enabling findings to reflect the condition present during implementation activities (Caci et al., 2025 ). However, we acknowledge that conditions in health facilities often change, and that repeating our assessment of organisational readiness at different time points could have provided valuable additional insights (Caci et al., 2025 ). The EDIVA demonstration project was conducted in only one upazila, Bandar, which limited the sample size of health facilities and health workers. Bandar is also more urbanised than the average upazila, with our findings potentially not transferable to more rural areas in Bangladesh (World Health Organization. Regional Office for the Western Pacific, 2015 ). Conclusions We conducted a comprehensive evaluation of organisational readiness for implementing anaemia testing and intravenous iron treatment for pregnant women in Bangladesh’s primary health care system. We found high organisational readiness for anaemia testing using the HemoCue device and intravenous iron treatment, with health workers demonstrating strong commitment and confidence in their ability to provide these services to pregnant women. However, sustaining both interventions beyond the EDIVA demonstration project would require addressing resource constraints, including the unavailability of necessary equipment and shortage of nurses and doctors. Ultimately, government support for implementation and resource provision will be essential to ensure ongoing delivery of anaemia testing and intravenous iron treatment in Bangladesh’s primary health care system. Findings from our study may help inform government decision-making. Declarations Competing Interests SRP reports consultancy fees from CSL-Vifor Pharma, ITL-Biomedical and Atomo Diagnostica. He is Director of the WHO Collaborating Centre for Anaemia Detection and Control (unfunded). All other authors declare no competing interests. Ethics approval: Ethics approval was obtained from the Ethical Review Committee at [organisation name removed for peer-review] (PR-20125), the Human Research Ethics Committee at [organisation name removed for peer-review] (21/5), and the Office of Research Ethics and Training at the [organisation name removed for peer-review] (2022-24388-31967-4). Disclaimer The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Funding: This work was supported, in whole or in part, by the Gates Foundation [GR-02015]. The conclusions and opinions expressed in this work are those of the author(s) alone and shall not be attributed to the Foundation. Under the grant conditions of the Foundation, a Creative Commons Attribution 4.0 License has already been assigned to the Author Accepted Manuscript version that might arise from this submission. Please note works submitted as a preprint have not undergone a peer review process. [initials removed for peer-review] is supported by the University of Melbourne Human Rights Scholarship. [initials removed for peer-review] time is supported by an Australian National Health and Medical Research Council Investigator Grant (2025634) and Dame Kate Campbell Fellowship. [initials removed for peer-review] is funded by the Australian National Health and Medical Research Council Fellowships (GNT1158696 and GNT2009047). Author Contribution Contributors: Funding acquisition: JH, SRP. Study design: EV, KHP. Conceptualisation: EV, KHP. Methods: EV, ABMR, BKS, AMQR, KHP. Data analysis: EV, ABMR. Supervision: KHP, MAB, CV. Writing – original draft: EV. Writing – review and editing: All authors. Guarantor: EV. Acknowledgement First, we thank the primary health workers in Bandar upazila for taking the time to participate in our study. We also thank icddr,b researchers Nadia Sultana, Maksuda Khanum, Shakila Afrin, Shamima Akter, Fatama Khatun, Abid Bin Siddique, and Abu Yousuf Shazid for their assistance with data collection. We thank the icddr,b field research assistants Rahima Khanam and Fahmida Zaman for their support in organising data collection. 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(2011). Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Administration And Policy In Mental Health , 38 (2), 65–76. https://doi.org/10.1007/s10488-010-0319-7 Robinson, O. C. (2014). Sampling in Interview-Based Qualitative Research: A Theoretical and Practical Guide. Qualitative Research in Psychology , 11 (1), 25–41. https://doi.org/10.1080/14780887.2013.801543 Rogozińska, E., Daru, J., Nicolaides, M., Amezcua-Prieto, C., Robinson, S., Wang, R., Godolphin, P. J., Saborido, C. M., Zamora, J., Khan, K. S., & Thangaratinam, S. (2021). Iron preparations for women of reproductive age with iron deficiency anaemia in pregnancy (FRIDA): a systematic review and network meta-analysis. Lancet Haematol , 8 (7), e503–e512. https://doi.org/10.1016/s2352-3026(21)00137-x Ruest, M., Léonard, G., Thomas, A., Desrosiers, J., & Guay, M. (2019). French cross-cultural adaptation of the Organizational Readiness for Implementing Change (ORIC). BMC Health Services Research , 19 (1), 535. https://doi.org/10.1186/s12913-019-4361-1 Ryan, N., Vieira, D., Gyamfi, J., Ojo, T., Shelley, D., Ogedegbe, O., Iwelunmor, J., & Peprah, E. (2022). Development of the ASSESS tool: a comprehenSive tool to Support rEporting and critical appraiSal of qualitative, quantitative, and mixed methods implementation reSearch outcomes. Implementation Science Communications , 3 (1), 34. https://doi.org/10.1186/s43058-021-00236-4 Safiri, S., Kolahi, A. A., Noori, M., Nejadghaderi, S. A., Karamzad, N., Bragazzi, N. L., Sullman, M. J. M., Abdollahi, M., Collins, G. S., Kaufman, J. S., & Grieger, J. A. (2021). Burden of anemia and its underlying causes in 204 countries and territories, 1990–2019: results from the Global Burden of Disease Study 2019. Journal of Hematology & Oncology , 14 (1), 185. https://doi.org/10.1186/s13045-021-01202-2 Sanchis-Gomar, F., Cortell-Ballester, J., Pareja-Galeano, H., Banfi, G., & Lippi, G. (2013). Hemoglobin point-of-care testing: the HemoCue system. J Lab Autom , 18 (3), 198–205. https://doi.org/10.1177/2211068212457560 Sanin, K. I., Alam Shaun, M., Rita, R. S., Hasan, M. K., Khanam, M., & Haque, M. A. (2023). What Makes Bangladeshi Pregnant Women More Compliant to Iron-Folic Acid Supplementation: A Nationally Representative Cross-Sectional Survey Result. Nutrients , 15 (6). https://doi.org/10.3390/nu15061512 Sarker, B. K., Rahman, M., Rahman, T., Rahman, T., Khalil, J. J., Hasan, M., Rahman, F., Ahmed, A., Mitra, D. K., Mridha, M. K., & Rahman, A. (2020). Status of the WHO recommended timing and frequency of antenatal care visits in Northern Bangladesh. PLoS One , 15 (11), e0241185. https://doi.org/10.1371/journal.pone.0241185 Shea, C. M., Jacobs, S. R., Esserman, D. A., Bruce, K., & Weiner, B. J. (2014). Organizational readiness for implementing change: a psychometric assessment of a new measure. Implementation Science , 9 (1), 7. https://doi.org/10.1186/1748-5908-9-7 Siekmans, K., Roche, M., Kung'u, J. K., Desrochers, R. E., & De-Regil, L. M. (2018). Barriers and enablers for iron folic acid (IFA) supplementation in pregnant women. Matern Child Nutr 14 Suppl , 5 (Suppl 5), e12532. https://doi.org/10.1111/mcn.12532 Stoffel, N. U., von Siebenthal, H. K., Moretti, D., & Zimmermann, M. B. (2020). Oral iron supplementation in iron-deficient women: How much and how often? Molecular Aspects of Medicine , 75 , 100865. https://doi.org/10.1016/j.mam.2020.100865 Storkholm, M. H., Mazzocato, P., Tessma, M. K., & Savage, C. (2018). Assessing the reliability and validity of the Danish version of Organizational Readiness for Implementing Change (ORIC). Implementation Science , 13 (1), 78. https://doi.org/10.1186/s13012-018-0769-y United Nations Bangladesh (2024). 05 March 2024). Advancing Healthcare Excellence: WHO's Role in Developing the First National Medical Education Strategy in Bangladesh . Retrieved 15 Aug from https://bangladesh.un.org/en/262291-advancing-healthcare-excellence-whos-role-developing-first-national-medical-education van de Water, B. J., Longacre, A. H., Hotchkiss, J., Sonnie, M., Mann, J., & Lemor, E. (2024). Implementing the organizational readiness for change survey during a novel midwifery preceptor program in Sierra Leone: stakeholder results. Bmc Health Services Research , 24 (1), 961. https://doi.org/10.1186/s12913-024-11435-9 Verbunt, E., Corona, M. V., Tunçalp, Ö., Rogers, L. M., Prang, K. H., Vaughan, C., & Bohren, M. A. (2025). Perceptions and experiences of the prevention, testing, and treatment of anaemia in pregnant women: A qualitative evidence synthesis. PLOS Global Public Health , 5 (10), e0005158. https://doi.org/10.1371/journal.pgph.0005158 Verbunt, E., Hasan, M., Davidson, E., Ahmed, S., McLean, A., Rahman, A., Bhuiyan, M., Tipu, S., Sarker, B., Hamadani, J., Pasricha, S., Vaughan, C., Bohren, M., & Prang, K. (2025). Testing and treating anaemia in pregnant women in Bangladesh: a cross-sectional survey. BMJ Public Health , 3 (2). https://doi.org/10.1136/bmjph-2024-002167 Weiner, B. J., Clary, A. S., Klaman, S. L., Turner, K., & Alishahi-Tabriz, A. (2020). Organizational Readiness for Change: What We Know, What We Think We Know, and What We Need to Know. In B. Albers, A. Shlonsky, & R. Mildon (Eds.), Implementation Science 3.0 (pp. 101–144). Springer International Publishing. https://doi.org/10.1007/978-3-030-03874-8_5 West, R., & Michie, S. A brief introduction to the COM-B Model of behaviour and the PRIME Theory of motivation. Qeios . https://doi.org/10.32388/WW04E6 WOMAN-2 trial collaborators. (2023). Maternal anaemia and the risk of postpartum haemorrhage: a cohort analysis of data from the WOMAN-2 trial. Lancet Glob Health , 11 (8), e1249–e1259. https://doi.org/10.1016/s2214-109x(23)00245-0 World Health Organization (2011). Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity (Vitamin and Mineral Nutrition Information System, Issue. https://iris.who.int/bitstream/handle/10665/85839/WHO_NMH_NHD_MNM_11.1_eng.pdf?sequence=22 World Health Organization (2015a). The global prevalence of anaemia in 2011 . World Health Organization (2015b). Service Availability and Readiness Assessment (SARA): An annual monitoring system for service delivery. Implementation guide . World Health Organization (2015c). Service Availability and Readiness Assessment (SARA): An annual monitoring system for service delivery. Reference Manual . World Health Organization (2016). WHO recommendations on antenatal care for a positive pregnancy experience . World Health Organization (2025a). Anaemia in women and children . Retrieved 12 May from https://www.who.int/data/gho/data/themes/topics/anaemia_in_women_and_children World Health Organization (2025b). 2021-04-19). Prevalence of anaemia in pregnant women (aged 15–49) (%) . World Health Organization. Retrieved 13th Mar from https://www.who.int/data/gho/data/indicators/indicator-details/GHO/prevalence-of-anaemia-in-pregnant-women-(- ). World Health Organization (2025c). 2025-04-29). Prevalence of anaemia in women of reproductive age (aged 15–49) (%), by pregnancy status . Retrieved 12 May from https://www.who.int/data/gho/data/indicators/indicator-details/GHO/prevalence-of-anaemia-in-women-of-reproductive-age-(-) World Health Organization. Regional Office for the Western Pacific (2015). Bangladesh health system review (Health systems in transition vol.5, no.3, Issue. http://iris.wpro.who.int/handle/10665.1/11357 Yilmaz, E., Soysal, C., Icer, B., Yilmaz, Z. V., Ozkan, S., & Kucukozkan, T. (2019). The impact of iron deficiency anemia on health related quality of life in the last trimester of pregnancy. EJMI , 3 (3), 182–188. https://doi.org/10.14744/ejmi.2019.65035 Young, M. F., Oaks, B. M., Tandon, S., Martorell, R., Dewey, K. G., & Wendt, A. S. (2019). Maternal hemoglobin concentrations across pregnancy and maternal and child health: a systematic review and meta-analysis. Annals Of The New York Academy Of Sciences , 1450 (1), 47–68. https://doi.org/10.1111/nyas.14093 Additional Declarations Competing interest reported. SRP reports consultancy fees from CSL-Vifor Pharma, ITL-Biomedical and Atomo Diagnostica. He is Director of the WHO Collaborating Centre for Anaemia Detection and Control (unfunded). All other authors declare no competing interests. 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SRP reports consultancy fees from CSL-Vifor Pharma, ITL-Biomedical and Atomo Diagnostica. He is Director of the WHO Collaborating Centre for Anaemia Detection and Control (unfunded). All other authors declare no competing interests.","formattedTitle":"From testing to treatment: a mixed-methods study assessing organisational readiness for intravenous iron for pregnant women with anaemia in Bangladesh","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAnaemia in pregnancy is a major public health problem, affecting 29.2 million women in 2023 (World Health Organization, 2025c). Women in low- and middle-income countries are disproportionately impacted, particularly those living in Africa (10.9 million women affected) and South-East Asia (8.9 million women affected) (World Health Organization, 2025a). Anaemia during pregnancy increases women\u0026rsquo;s risks of maternal death, postpartum haemorrhage, stillbirth, low birth weight, puerperal sepsis, and both antenatal and postnatal depression (Azami et al., 2019; Dama et al., 2018; Daru et al., 2018; Jung et al., 2019; Melkie \u0026amp; Dagnew, 2021; WOMAN-2 trial collaborators, 2023; Young et al., 2019). Symptoms of anaemia include fatigue, dizziness, and weakness \u0026ndash; all of which can affect a woman\u0026rsquo;s physical and emotional wellbeing, as well as her ability to engage in paid work or home care (Ogunbode \u0026amp; Ogunbode, 2021; Yilmaz et al., 2019). Iron-deficiency is the most common cause of anaemia in pregnant women, due to the increased blood volume required to support the growing fetus and placenta (McMahon, 2010; Safiri et al., 2021; World Health Organization, 2015a).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo prevent anaemia, the World Health Organisation (WHO) recommends that pregnant women take a daily oral supplement of iron (30 to 60 mg) and folic acid (0.4 mg) (World Health Organization, 2016). Folic acid should be started pre-conception, and iron as early as possible after conception, with both continued throughout a woman\u0026rsquo;s pregnancy (World Health Organization, 2016). WHO also recommend that pregnant women be tested for anaemia using a full blood count (World Health Organization, 2016), with clinical and public health guidelines recommending testing at the woman\u0026rsquo;s first antenatal care visit and again at 28 weeks gestation (American College of Obstetricians and Gynecologists\u0026apos; Committee on Practice Bulletins - Obstetrics, 2021; Pavord et al., 2019). In settings where laboratory facilities and qualified personnel are unavailable, WHO recommend point-of-care haemoglobinometers over colour scales for testing (World Health Organization, 2016). For women diagnosed with anaemia during pregnancy, WHO advises increasing the daily iron dose to 120 mg (World Health Organization, 2016). Once anaemia is corrected, the standard daily dose should be resumed to prevent recurrence. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAlthough not currently included in WHO recommendations, intravenous iron is an alternative treatment option for anaemia in pregnant women. In many high-income countries, intravenous iron is recommended during the second or third trimester for women with moderate to severe anaemia who do not respond to, or cannot tolerate, oral iron and folic acid supplements (ACOG Practice Bulletin, 2021; Nowak et al., 2019; Pavord et al., 2019). Modern formulations, such as ferric carboxymaltose, can rapidly replenish iron stores and haemoglobin levels with a single 15-minute dose (Auerbach \u0026amp; Deloughery, 2016; Pasricha, Moya, Ata\u0026iacute;de, et al., 2025; Rogozińska et al., 2021). Importantly, these formulations are safe, with a very low risk of anaphylaxis and no marked difference in adverse events compared to oral iron\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e(Afolabi et al., 2024; Dave et al., 2022; Pasricha, Moya, Ataide, et al., 2025). Despite clear recommendations for managing anaemia during pregnancy, implementation remains inconsistent in many settings. \u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eAnaemia management in pregnant women in Bangladesh\u0026nbsp;\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eIn Bangladesh, anaemia affects over one-third of pregnant women (World Health Organization, 2025b). Oral iron and folic acid supplements are provided for free as part of routine antenatal care at government health facilities (Directorate General of Health Services, 2017). However, only approximately 20% of women complete the recommended regimen during pregnancy (Sanin et al., 2023). This is likely due to several factors, including inadequate counselling by health workers about the benefits of supplements, gastrointestinal side-effects such as vomiting and constipation, misconceptions that they increase fetal growth and consequently difficult childbirth, and challenges in remembering to take them (Alam et al., 2015; Siekmans et al., 2018; Verbunt, Corona, et al., 2025)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDespite the high burden of anaemia in Bangladesh and its importance for timely and appropriate treatment,\u0026nbsp;only about half of pregnant women are tested during routine antenatal care (Verbunt, Hasan, et al., 2025). Most pregnant women (95.8%) are tested using a full blood count, which although the WHO recommended method, is more resource-intensive than collecting capillary blood using point-of-care haemoglobinometers (Verbunt, Hasan, et al., 2025; World Health Organization, 2016).\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ePortable devices such as the HemoCue could increase anaemia testing rates due to their suitability for use in government primary health facilities, which are widely available in rural areas (Sanchis-Gomar et al., 2013; Verbunt, Hasan, et al., 2025; World Health Organization, 2011; World Health Organization. Regional Office for the Western Pacific, 2015).\u003c/p\u003e\n\u003cp\u003eMost pregnant women (73.3%) diagnosed with anaemia are treated with oral iron and folic acid supplements only (Verbunt, Hasan, et al., 2025). However, many women in Bangladesh initiate antenatal care in the second trimester, delaying the diagnosis and treatment of anaemia \u0026ndash; an important concern, as supplements may require up to six months to fully replenish iron stores (Brittenham, 2018; Sarker et al., 2020; Stoffel et al., 2020). Intravenous iron is not formally available as a treatment option within the government health care system. As a result, only a small proportion of pregnant women (5.9%) receive intravenous iron only for the treatment of anaemia (Verbunt, Hasan, et al., 2025).\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eThe EDIVA Programme Demonstration Project\u0026nbsp;\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eAlongside investments to ensure that all pregnant women in Bangladesh are tested for anaemia, and the promising use of intravenous iron to improve its treatment, the EDIVA programme: \u0026lsquo;\u003cstrong\u003eE\u003c/strong\u003efficacy and \u003cstrong\u003eD\u003c/strong\u003eemonstration of\u003cstrong\u003e\u0026nbsp;I\u003c/strong\u003entra\u003cstrong\u003eV\u003c/strong\u003eenous iron for \u003cstrong\u003eA\u003c/strong\u003enaemia in pregnancy\u0026rsquo; was launched in 2021. The programme is led by the research institute [organisation name removed for peer-review] in Bangladesh, in collaboration with [organisation name removed for peer-review] and the [organisation name removed for peer-review] in Australia. It consists of a maternal anaemia prevalence survey (Ahmed et al., 2024),\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003erandomised controlled trial (Australian New Zealand Clinical Trials Registry, 2021),\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eand demonstration project (Prang et al., 2025). This paper focuses on the EDIVA demonstration project, with results from other programme components reported elsewhere (Hasan et al., 2024).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe EDIVA demonstration project aims to assess the feasibility and acceptability of implementing an intravenous iron intervention within the Bangladesh primary health care system (Prang et al., 2025). It was conducted in Bandar upazila (sub-district) in Narayanganj district, which is part of the urban sprawl surrounding the capital city of Dhaka. The study area was chosen due to existing relationships with the community and local health authorities, established during a previous randomised controlled trial conducted in Narayanganj district (Hasan et al., 2017; Pasricha et al., 2021). Bandar upazila is comprised of five unions \u0026ndash; Dhamgar, Madanpur, Musapur, Bandar, and Kalagachhia. Formative research was conducted in preparation for implementation of the demonstration project (October 2021-December 2023), and the demonstration project ran from March 2024 to May 2025 (14 months). Anaemia testing for pregnant women was performed using a HemoCue\u0026reg; Hb 301 device, and ferric carboxymaltose was the intravenous iron formulation used. Health workers who provided usual care received relevant training, and all necessary equipment and materials were provided by the EDIVA programme (Prang et al., 2025).\u003c/p\u003e\n\u003cp\u003eTo compare the feasibility and acceptability of different anaemia testing pathways, Bandar upazila was divided into two areas: the North (Dhamgar, Madanpur, and Musapur unions), where home-based testing was conducted by Family Welfare Assistants (n = 15), and the South (Bandar and Kalagachhia unions), where health facility-based testing was conducted by Community Health Care Providers (n = 6) and Family Welfare Visitors (n = 4). All women diagnosed with anaemia (Hb \u0026lt;10 g/dL) and who fit other components of the inclusion criteria were referred to the Upazila Health Complex for intravenous iron administered by nurses (n = 9) or doctors (n = 3) (Prang et al., 2025). A parallel process evaluation was conducted approximately halfway through the EDIVA demonstration project, at around seven months in, to allow sufficient time for health workers to integrate either anaemia testing or intravenous iron treatment into their routine responsibilities.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eImplementation research seeks to reduce the time it takes for evidence-based interventions to be translated into real-world settings (Eccles \u0026amp; Mittman, 2006). This is achieved through multi-method inquiry that explores the context in which the intervention is to be implemented, ultimately enhancing outcomes including acceptability, feasibility, fidelity, adoption, and sustainability (Peters et al., 2013; Proctor et al., 2011). Formative research conducted prior to randomised controlled trials of intravenous iron treatment for pregnant women with anaemia in Malawi and Nigeria revealed concerns among stakeholders. Specifically, they noted that primary health facilities might lack the necessary resources and physical space to test pregnant women for anaemia and safely administer intravenous iron (Akinajo et al., 2024; Mamani-Mategula et al., 2024). Additionally, they felt that it might not be feasible for health workers to take on the role of treating pregnant women with anaemia using intravenous iron within already strained health systems (Akinajo et al., 2024; Mamani-Mategula et al., 2024). However, no research has specifically evaluated organisational readiness for implementing change \u0026ndash; a key determinant of successful intervention uptake (Aarons et al., 2017; Bach-Mortensen et al., 2018; Kotter, 1996). Organisational readiness typically involves both structural components (e.g., availability of resources at health facilities) and psychological components (e.g., motivation of health workers) (Caci et al., 2025; Holt \u0026amp; Vardaman, 2013). Assessing these factors can help accelerate and improve the implementation of evidence-based interventions by identifying areas that require attention (Weiner et al., 2020). Therefore, as part of the EDIVA demonstration project, we aimed to evaluate organisational readiness for implementing anaemia testing and intravenous iron treatment for pregnant women in Bangladesh\u0026rsquo;s primary health care system.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eThis study employs a multi-phase, mixed-methods, parallel convergent design, which is depicted in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e (Creswell \u0026amp; Plano Clark, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). As part of the formative research for the EDIVA demonstration project, we first conducted a baseline health facility readiness assessment for anaemia testing and intravenous iron treatment (16\u0026ndash;27 October 2022). Subsequently, during the parallel process evaluation of the project, we administered the Organisational Readiness for Implementing Change (ORIC) questionnaire (Shea et al., \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) and conducted qualitative interviews with health workers (21\u0026ndash;28 October 2024). The process evaluation followed a parallel convergent design, in which quantitative and qualitative data were collected and analysed concurrently (Creswell \u0026amp; Plano Clark, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). This paper synthesises and presents findings from the baseline health facility readiness assessment, ORIC questionnaire, and qualitative interviews with health workers. Together, these findings provide a holistic evaluation of organisational readiness for implementing anaemia testing and intravenous iron treatment for pregnant women in Bangladesh\u0026rsquo;s primary health care system. The study is reported in accordance with the ASSESS tool (Ryan et al., \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Ethics approval was obtained from the Ethical Review Committee at [organisation name removed for peer-review] (PR-20125), the Human Research Ethics Committee at [organisation name removed for peer-review] (21/5), and the Office of Research Ethics and Training at the [organisation name removed for peer-review] (2022-24388-31967-4). An author reflexivity statement is included in \u003cb\u003eS1 Appendix.\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e(PLACE FIGURE \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e HERE)\u003c/h2\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eThe baseline health facility readiness assessment was conducted in 20 primary health facilities in Bandar upazila, including Community Clinics, Union Health and Family Welfare Centres, and the Upazila Health Complex. The manager of each health facility was contacted by [organisation name removed for peer-review] field research assistants via telephone to schedule an appropriate visit day and time. The assessment was completed by the health worker most involved in antenatal care at each health facility (e.g., Family Welfare Visitors at Union Health and Family Welfare Centres). Using a complete enumeration sampling approach, all health workers involved in the EDIVA demonstration project were recruited to complete an adapted version of the ORIC questionnaire (Cochran, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e1977\u003c/span\u003e; Shea et al., \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2014\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWe then used quota sampling, which specifies the categories and the minimum number of participants required, to recruit a subset of health workers for qualitative interviews (Robinson, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). For home-based testing we aimed to recruit at least six Family Welfare Assistants, with at least two from each union (Dhamgar, Madanpur, and Musapur). Similarly, for health facility-based testing, we aimed to recruit at least six Community Health Care Providers or Family Welfare Visitors, with at least three from each union (Bandar and Kalagachhia). For intravenous iron treatment, we aimed to recruit at least five nurses and three doctors. No health workers declined to participate in the ORIC questionnaire or qualitative interviews.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eData Collection and Analysis\u003c/h3\u003e\n\u003cp\u003eThe interviewer-administered baseline health facility readiness assessment was developed by adapting the WHO Service Availability and Readiness Assessment and the Bangladesh Health Facility Assessment Tool (National Institute of Population Research and Training and ICF, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; World Health Organization, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e2015c\u003c/span\u003e). [initials removed for peer-review] trained three [organisation name removed for peer-review] researchers [initials removed for peer-review] in data collection over three days, with the questionnaire piloted at two health facilities on the fourth day. Specifically, as the questionnaire was in English, translation into oral Bangla was tested to ensure consistency in language. Data collection was paper-based. The questionnaire consisted of several sections, including general characteristics, amenities, protocol/guidelines and training, equipment \u0026ndash; antenatal care, and resources \u0026ndash; intravenous iron treatment \u003cb\u003e(S2 Appendix)\u003c/b\u003e. Data were entered into Excel immediately following data collection.\u003c/p\u003e \u003cp\u003eIf an item in the baseline health facility readiness assessment was available and functional, it received a score of 1; if it was unavailable or nonfunctional, it received a score of 0 (World Health Organization, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e2015b\u003c/span\u003e). Items within the questionnaire related to anaemia testing (equipment and guidelines) and intravenous iron treatment (equipment and room for administration and monitoring) were analysed descriptively using Stata 17 software (StataCorp. 2021. \u003cem\u003eStata Statistical Software: Release 17\u003c/em\u003e. College Station, TX: StataCorp LLC) and presented as frequencies.\u003c/p\u003e \u003cp\u003eThe ORIC is a 12 item measure consisting of two subscales: (1) change commitment, defined as a shared willingness among health workers to implement an intervention (questions 1\u0026ndash;5), and (2) change efficacy, defined as the collective ability of health workers to implement an intervention (questions 6\u0026ndash;12) (Shea et al., \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). The \u0026lsquo;intervention\u0026rsquo; referred to anaemia testing and intravenous iron treatment \u003cb\u003e(S3 Appendix)\u003c/b\u003e. The ORIC questionnaire exhibits \u0026ldquo;good\u0026rdquo; to \u0026ldquo;excellent\u0026rdquo; psychometric properties, including reliability, structural validity, and known-groups validity (Shea et al., \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Weiner et al., \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) and it has been successfully translated for use in non-English-speaking countries (Ruest et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Storkholm et al., \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). For our study, the questionnaire was translated from English to Bangla and interviewer-administered by [organisation name removed for peer-review] researchers [initials removed for peer-review] in a private room at the health workers\u0026rsquo; facility. Data were collected electronically using Kobo Toolbox software (Cambridge, MA, USA).\u003c/p\u003e \u003cp\u003eDescriptive analyses of total ORIC scores (mean and standard deviation), as well as commitment and efficacy subscale scores, were conducted using Stata 17 software (StataCorp. 2021. \u003cem\u003eStata Statistical Software: Release 17\u003c/em\u003e. College Station, TX: StataCorp LLC). Mean total ORIC scores range from 12 to 60, with higher scores indicating greater organisational readiness to implement the intervention (Shea et al., \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). The ORIC represents a continuum, with no specific cut-off scores to distinguish between high and low readiness.\u003c/p\u003e \u003cp\u003eFollowing completion of the ORIC questionnaire, qualitative interviews were conducted with a sample of health workers to gain deeper insight into the factors influencing their organisational readiness to provide anaemia testing or intravenous iron treatment. Separate interview guidelines were developed for anaemia testing and intravenous iron treatment \u003cb\u003e(S4 Appendix)\u003c/b\u003e. Health workers were asked about their experiences with anaemia testing or intravenous iron treatment as part of the EDIVA demonstration project, as well as their perceptions of the feasibility and acceptability of integrating these practices into routine antenatal care within Bangladesh\u0026rsquo;s primary health care system. Qualitative interviews were conducted face-to-face in Bangla by the same [organisation name removed for peer-review] researchers who administered the ORIC questionnaire [initials removed for peer-review]. Interviews lasted 45\u0026ndash;87 minutes for anaemia testing and 14\u0026ndash;37 minutes for intravenous iron treatment. Interviews were audio-recorded and transcribed verbatim to Bangla. The Bangla transcripts were then translated to English by [organisation name removed for peer-review] researchers fluent in both languages and familiar with the study context.\u003c/p\u003e \u003cp\u003eWe used inductive thematic analysis to analyse the qualitative interviews (Braun \u0026amp; Clarke, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). The field research team [initials removed for peer-review] met in the evenings following interviews to discuss and review emerging themes from the data. Based on these discussions, [initials removed for peer-review] and [initials removed for peer-review] developed the initial coding frameworks for anaemia testing and intravenous iron treatment. In the months following data collection, [initials removed for peer-review] and [initials removed for peer-review] refined and finalised the frameworks through online discussions. [initials removed for peer-review] then used the finalised frameworks to code all transcripts using NVivo (version 15). Themes were subsequently deductively mapped to the Capability, Opportunity, and Motivation model of Behaviour Change (COM-B) by [initials removed for peer-review] and [initials removed for peer-review] (Michie et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). The COM-B model has been widely used in health worker research to identify which components need to change for a behaviour change intervention to be effective (West \u0026amp; Michie). It suggests that for health workers to engage in a specific behaviour, they must have the capability and opportunity to do so, and they must be more motivated to perform that behaviour than to engage in alternative actions (West \u0026amp; Michie). Capability refers to an individual\u0026rsquo;s physical or psychological capacity to perform the behaviour, including the necessary knowledge and skills. Opportunity involves external physical or social conditions that enable the behaviour, such as access to resources or support from others. Motivation encompasses both reflective (e.g., conscious decision-making) and automatic (e.g., emotional responses) processes that influence and drive behaviour (Michie et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2014\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWe integrated data across sources to provide a comprehensive evaluation of organisational readiness for implementing anaemia testing and intravenous iron treatment for pregnant women in Bangladesh\u0026rsquo;s primary health care system. For both anaemia testing and intravenous iron treatment, we started with the total mean ORIC score and the mean scores of its subscales: change efficacy and change commitment. We then used findings from the qualitative interviews with health workers and baseline health facility readiness assessment to contextualise these scores and strengthen our evaluation of overall organisational readiness.\u003c/p\u003e \u003cp\u003eWritten informed consent was received from health workers prior to their participation in the baseline health facility readiness assessment, the ORIC questionnaire, and qualitative interviews.\u003c/p\u003e"},{"header":"Findings","content":"\u003cp\u003eThe results are organised into two sections: anaemia testing and intravenous iron treatment. For each, we begin by describing the characteristics of the data sources, followed by an evaluation of organisational readiness.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eAnaemia testing \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe baseline health facility readiness assessment was conducted in all 20 primary health facilities in Bandar upazila; most were Community Clinics (14/20, 70%) \u003cstrong\u003e(Table 1).\u003c/strong\u003e The ORIC questionnaire was administered to 23 of the 25 health workers involved in the implementation of the EDIVA demonstration project (the other two were Family Welfare Visitors on extended leave). Most were women and well-established in their roles, with \u0026ge; 6 years of experience. Qualitative interviews were then conducted with 13 of the 23 health workers. These included seven Family Welfare Assistants involved in home-based testing, and four Community Health Care Providers and two Family Welfare Visitors who were engaged in health facility-based testing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Characteristics of data sources used to evaluate organisational readiness for implementing \u0026nbsp;anaemia testing for pregnant women in Bangladesh\u0026rsquo;s primary health care system \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"643\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline health facility readiness assessment\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eORIC questionnaire\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eQualitative interviews\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSample\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e20\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e13\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003en (%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003en (%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 643px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrimary health facility\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eCommunity Clinic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e14 (70.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eUnion Health and Family Welfare Centre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e4 (20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eUnion Health Sub Centre\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e1 (5.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eUpazila Health Complex\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e1 (5.0)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 643px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealth worker\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eFamily Welfare Assistant \u0026nbsp; (home-based) \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e15 (65.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e7 (53.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eCommunity Health Care Provider (health facility-based)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e6 (26.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e4 (30.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eFamily Welfare Visitor \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;(health facility-based)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e2 (8.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e2 (15.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 643px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eWoman\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e21 (91.3)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e11\u0026nbsp;(84.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Man\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e2 (8.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e2 (15.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 643px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026lt;30 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e1 (4.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e1 (7.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026ge;30 \u0026le;40 years\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e11 \u0026nbsp;(47.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e9 (69.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026ge;41 years\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e11(47.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e3 (23.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 643px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExperience in current role (years)\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026le;5 years\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e2 (8.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e2 (15.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026ge;6 years \u0026le;10 years\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e5 (21.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e4 (30.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026ge;11 years \u0026le;20 years\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e7 (30.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e5 (38.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026ge; 21 years\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003en/a\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e9 (39.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e2 (15.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;Overall, ORIC scores and qualitative data suggest that organisational readiness for implementing anaemia testing using the HemoCue device was high, with primary health workers showing strong commitment and confidence in their ability to provide this service to pregnant women. However, effective and sustained implementation beyond the EDIVA demonstration project would require mitigating the additional workload for health workers and ensuring adequate government support in the form of resources and equipment. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePrimary health workers had a mean total ORIC score of 55.0/60, indicating high organisational readiness to test pregnant women for anaemia using the HemoCue device. The mean \u0026lsquo;change commitment\u0026rsquo; subscale\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003escore was 24.1/25, suggesting a strong collective desire to implement the service \u003cstrong\u003e(Table 2).\u0026nbsp;\u003c/strong\u003eQualitative interviews revealed that health workers were motivated to conduct HemoCue testing due to perceived advantages over other methods. For example, a Community Health Care Provider explained that clinical assessment for anaemia (inspection of the conjunctiva, tongue, and palms) \u0026ldquo;couldn\u0026rsquo;t precisely measure haemoglobin levels,\u0026rdquo; while a Family Welfare Assistant described the point-of-care HemoCue test as desirable because results were available \u0026ldquo;immediately,\u0026rdquo; unlike a full blood count, which required laboratory processing \u003cstrong\u003e(Table 2).\u003c/strong\u003e Health workers also described widespread community demand for anaemia testing and felt empowered to offer this service to pregnant women. Some health workers even reported that it had enhanced their \u0026ldquo;acceptance in the field [community].\u0026rdquo;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe ORIC questionnaire showed a mean \u0026lsquo;change efficacy\u0026rsquo; subscale score of 30.9/35, suggesting that primary health workers felt capable to implement anaemia testing using a HemoCue device for pregnant women. Qualitative interviews supported this finding, with most health workers expressing confidence in their ability to use the device. As one Family Welfare Assistant noted: \u0026ldquo;I think everyone will be able to operate it. It\u0026rsquo;s not that difficult.\u0026rdquo; Health workers noted that while the HemoCue test did not take long to conduct, their workload increased substantially when a pregnant woman was diagnosed with anaemia. This was due to the additional time needed to counsel the woman and her family on attending the Upazila Health Complex for intravenous iron treatment. Since intravenous iron is not a common treatment for anaemia in Bangladesh, community members often expressed a need for more information about its safety for both the pregnant woman and the fetus. As one Community Health Care Provider explained: \u0026ldquo;And if the [pregnant woman\u0026rsquo;s] haemoglobin is low [anaemic], the entire day is basically gone!\u0026rdquo; Health workers explained in qualitative interviews that prior to the EDIVA demonstration project, they were unable to test pregnant women for anaemia due to the government not providing them with the necessary resources and equipment. The baseline health facility readiness assessment supported this, finding that no primary health facilities had guidelines or standard operating procedures for testing pregnant women for anaemia, and only 30% (6/20) had haemoglobin testing capacity (either full blood count or point-of-care device)\u003cstrong\u003e\u0026nbsp;(Table 2 and S5 Appendix).\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eTable 2.\u003c/strong\u003e Findings from data sources used to evaluate organisational readiness for implementing anaemia testing for pregnant women in Bangladesh\u0026rsquo;s primary health care system\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"926\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCOM-B domain\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 350px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSupporting data/qualitative themes \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 406px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExemplar quote\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 926px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean (SD) total ORIC score:\u0026nbsp;\u003c/strong\u003e55.0/60 (4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 926px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean (SD) change commitment score (shared willingness among health workers to implement an intervention):\u0026nbsp;\u003c/strong\u003e24.1/25 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eReflective motivation\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 350px;\"\u003e\n \u003cp\u003eHemoCue testing is more accurate than clinical assessment\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 406px;\"\u003e\n \u003cp\u003e\u0026ldquo;We observed physical signs like pale eyes, tongue, skin, and nails. These visual checks couldn\u0026rsquo;t precisely measure haemoglobin levels.\u0026rdquo; (Community Health Care Provider, #01)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eReflective motivation\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 350px;\"\u003e\n \u003cp\u003eHemoCue testing results are easier to interpret than those from a colour scale or the Tallquist method \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 406px;\"\u003e\n \u003cp\u003e\u0026ldquo;Now I can test sitting here, and the machine provides instant results in points, whereas we got the results in percentages [Tallquist book] \u0026nbsp; \u0026nbsp; (Family Welfare Visitor, #02)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eReflective motivation\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 350px;\"\u003e\n \u003cp\u003eHemoCue testing results are available immediately, unlike those from a full blood count\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 406px;\"\u003e\n \u003cp\u003e\u0026ldquo;They [pregnant women] get the results immediately. At the hospital, it takes minimum of 2\u0026ndash;3 days for the report [haemoglobin levels] to be delivered. It\u0026rsquo;s a quick process.\u0026rdquo;\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Family Welfare Assistant, #01)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eReflective motivation\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 350px;\"\u003e\n \u003cp\u003eTesting pregnant women for anaemia\u0026nbsp;has empowered primary health workers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 406px;\"\u003e\n \u003cp\u003e\u0026ldquo;It\u0026rsquo;s good and acceptable. Because when I test their [pregnant women\u0026rsquo;s] blood, my acceptance in the field [community] increases since people see it as helpful, especially because it\u0026rsquo;s free. It helps us.\u0026rdquo;\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Family Welfare Assistant, #01)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eSocial opportunity\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 350px;\"\u003e\n \u003cp\u003eHemoCue testing is acceptable to both pregnant women and community members\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 406px;\"\u003e\n \u003cp\u003e\u0026ldquo;The demand is positive, I will say, it\u0026rsquo;s good. People [pregnant women] come, even hearing from others, they are interested and want to do it.\u0026rdquo; (Community Health Care Provider, #04)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 926px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean (SD) change efficacy score (collective ability of health workers to implement an intervention):\u003c/strong\u003e 30.9/35 (4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003ePhysical and psychological capability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 350px;\"\u003e\n \u003cp\u003ePrimary health workers are capable of using the HemoCue device to test pregnant women for anaemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 406px;\"\u003e\n \u003cp\u003e\u0026ldquo;I think everyone will be able to operate it [HemoCue]. It\u0026rsquo;s not that difficult.\u0026rdquo; (Family Welfare Assistant, #05)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003ePhysical opportunity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 350px;\"\u003e\n \u003cp\u003eThe workload of primary health workers has increased due to counselling pregnant women diagnosed with anaemia about intravenous iron treatment \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 406px;\"\u003e\n \u003cp\u003e\u0026ldquo;And if the haemoglobin level is low, the entire day is basically gone!\u0026rdquo; (Community Heath Care Provider, #04)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003ePhysical opportunity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 350px;\"\u003e\n \u003cp\u003eHaemoglobin levels are already included in the antenatal care register books used by primary health workers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 406px;\"\u003e\n \u003cp\u003e\u0026ldquo;I\u0026rsquo;ll incorporate the haemoglobin screening into my regular tasks. It\u0026rsquo;s a part of ANC check-ups, so it will be done with weight, blood pressure, and other ANC tasks\u0026hellip; there\u0026rsquo;s already a column for haemoglobin levels in our ANC register book where we write it.\u0026rdquo;\u003c/p\u003e\n \u003cp\u003e(Family Welfare Visitor, #02) \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003ePhysical opportunity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 350px;\"\u003e\n \u003cp\u003eRemuneration for primary health workers is not aligned with their increasing workload\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 406px;\"\u003e\n \u003cp\u003e\u0026ldquo;For 13 years\u0026hellip; we have been working on the same salary, while the government keeps adding extra tasks over time.\u0026rdquo;\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(Community Health Care Provider, #01)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003ePhysical opportunity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 350px;\"\u003e\n \u003cp\u003eAnaemia testing equipment and resources were unavailable in primary health facilities before the EDIVA demonstration project\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline health facility readiness assessment\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eOf the 20 primary health facilities included in the assessment, none had guidelines or standard operating procedures for testing pregnant women for anaemia.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSix had haemoglobin testing capacity (either full blood count or point-of-care device) \u003cstrong\u003e(S5 Appendix)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 406px;\"\u003e\n \u003cp\u003e\u0026ldquo;We didn\u0026rsquo;t have the equipment or resources for that [anaemia testing], there wasn\u0026rsquo;t such supplies provided by the government.\u0026rdquo; (Family Welfare Assistant, #01)\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eIntravenous iron treatment \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe baseline health facility readiness assessment was conducted in six primary health facilities in Bandar upazila \u003cstrong\u003e(Table 3).\u003c/strong\u003e Community Clinics were excluded because intravenous infusions are outside the scope of services provided at these facilities. The ORIC questionnaire was administered to all 12 health workers involved in the implementation of the EDIVA demonstration project. Most were women and well-established in their roles, with \u0026ge; 6 years of experience. Qualitative interviews were then conducted with eight of the 12 health workers: five nurses and three doctors. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u0026nbsp;\u003c/strong\u003eCharacteristics of data sources used to evaluate organisational readiness for implementing intravenous iron treatment for pregnant women in Bangladesh\u0026rsquo;s primary health care system \u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"643\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline health facility readiness assessment\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eORIC questionnaire\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eQualitative interviews\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSample\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e6\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e8\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003en (%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003en (%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 643px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrimary health facility\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eUnion Health and Family Welfare Centre\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e4 (66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003en/a\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eUnion Health Sub Centre\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e1 (16.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eUpazila Health Complex\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003e1 (16.7)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 643px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealth worker\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eNurse \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e9 (75.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e5 (62.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eDoctor\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e3 (25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e3 (37.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 643px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eWoman \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e11 (91.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e7 (87.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003eMan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e1 (8.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e1 (12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 643px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026lt;30 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e1 (8.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e0\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026ge;30 \u0026le;40 years\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e5 (41.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e3 (37.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026ge;41 years\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e6 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e5 (62.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 643px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExperience in current role (years)\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026le;5 years\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e4 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e3 (37.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026ge;6 years \u0026le;10 years\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e2 (16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e1 (12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026ge;11 years \u0026le;20 years\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003en/a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e2 (16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e1 (12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u0026ge; 21 years\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp\u003en/a\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e4 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e3 (37.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;Overall, ORIC scores and qualitative data suggest that organisational readiness for implementing intravenous iron treatment was high, with nurses and doctors showing strong commitment and confidence in their ability to safely provide this service to pregnant women with anaemia. However, sustainable implementation beyond the EDIVA demonstration project would require addressing resource constraints \u0026ndash; particularly the shortage of nurses and doctors.\u003c/p\u003e\n\u003cp\u003eNurses and doctors had a mean total ORIC score of 50.7/60, indicating high organisational readiness to treat pregnant women with anaemia using intravenous iron \u003cstrong\u003e(Table 4).\u003c/strong\u003e The mean \u0026lsquo;change commitment\u0026rsquo; subscale\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003escore was 21.7/25, suggesting a strong collective desire to implement the intravenous iron treatment. Qualitative interviews revealed that health workers perceived advantages of intravenous iron over the standard-of-care (oral iron and folic acid supplements), with one nurse stating: \u0026ldquo;Many people forget to take oral tablets, or they experience constipation but if you take intravenous iron, it will help you to avoid such issues.\u0026rdquo; \u003cstrong\u003e(Table 4).\u0026nbsp;\u003c/strong\u003eDoctors and nurses also reported that pregnant women readily accepted intravenous iron as a treatment option, as illustrated by this nurse: \u0026ldquo;\u0026hellip; They [pregnant women] are very pleased\u0026hellip; even the caregivers who come with them are also very pleased.\u0026rdquo; This acceptance was often due to the treatment being provided free of charge and available at a government health facility.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe ORIC questionnaire showed a mean \u0026lsquo;change efficacy\u0026rsquo; subscale score of 29.0/35, suggesting that nurses and doctors felt capable of implementing an intravenous iron treatment for pregnant women with anaemia. Participants in qualitative interviews emphasised that they had the knowledge and skills to administer intravenous iron safely, as one nurse explained: \u0026ldquo;No, no, it\u0026rsquo;s easy. We always give intravenous fluids to our regular patients, continuously. There\u0026rsquo;s nothing difficult about it.\u0026rdquo; Additionally, participants expressed confidence in managing potential adverse events, such as \u0026ldquo;hypersensitivity reactions.\u0026rdquo; However, interviews also revealed that high patient loads often required nurses and doctors to delay intravenous iron administration by up to an hour and limited the time available to monitor pregnant women during the infusion. Monitoring pregnant women during and after intravenous iron administration is essential to ensure the treatment is well tolerated and to promptly detect and manage rare but potential serious adverse events, such as anaphylaxis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThese challenges were commonly attributed to structural deficiencies in the health system, particularly staffing shortages. As one doctor reported: \u0026ldquo;If the manpower would be increased, we might be able to work effectively.\u0026rdquo; In addition to staffing concerns, the unavailability of equipment, medicines, and beds was also identified as a challenge to sustaining intravenous iron treatment for pregnant women with anaemia beyond the EDIVA demonstration project. The baseline health facility readiness assessment found that while some items were routinely available, others were not. For example, among the six primary health facilities assessed, all had a weight machine to determine the appropriate dose of intravenous iron; three had a room with auditory and visual privacy; none had 20ml syringes for administration; and only one had adrenaline available to manage potential serious adverse events \u003cstrong\u003e(Table 4 and S5 Appendix).\u003c/strong\u003e Overall, key resources required for the safe administration of intravenous iron were inconsistently available.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4.\u003c/strong\u003e Findings from data sources used to evaluate organisational readiness for implementing intravenous iron treatment for pregnant women in Bangladesh\u0026rsquo;s primary health care system \u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"926\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCOM-B domain\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 350px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSupporting data/qualitative themes \u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 406px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExemplar quote\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 926px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean (SD) total ORIC score:\u0026nbsp;\u003c/strong\u003e50.7/60 (5.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 926px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean (SD) change commitment score (shared willingness among health workers to implement an intervention):\u0026nbsp;\u003c/strong\u003e21.7/25 (2.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eReflective motivation\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 350px;\"\u003e\n \u003cp\u003eIntravenous iron overcomes barriers that limit pregnant women\u0026rsquo;s adherence to oral iron and folic acid supplements\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 406px;\"\u003e\n \u003cp\u003e\u0026ldquo;Many people forget to take oral tablets, or they experience constipation but if you take intravenous iron, it will help you to avoid such issues.\u0026rdquo; (Nurse, #04)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eReflective motivation\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 350px;\"\u003e\n \u003cp\u003eIntravenous iron has fewer risks than a blood transfusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 406px;\"\u003e\n \u003cp\u003e\u0026ldquo;I think blood transfusions have more risk because there can be reactions because you don\u0026rsquo;t know more about the blood donor.\u0026rdquo; (Nurse, #03)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eSocial opportunity\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 350px;\"\u003e\n \u003cp\u003eIntravenous iron is acceptable to both pregnant women and community members\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 406px;\"\u003e\n \u003cp\u003e\u0026ldquo;Yes, they\u0026rsquo;re [pregnant women] very pleased\u0026hellip; even the caregivers who come with them are also very pleased.\u0026rdquo; (Nurse, #01)\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 926px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean (SD) change efficacy score (collective ability of health workers to implement an intervention):\u003c/strong\u003e 29.0/35 (3.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003ePhysical and psychological capability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 350px;\"\u003e\n \u003cp\u003eNurses and doctors already have the skills to administer intravenous infusions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 406px;\"\u003e\n \u003cp\u003e\u0026ldquo;No, no, it\u0026rsquo;s easy. We always give intravenous fluids to our regular patients, continuously. There\u0026rsquo;s nothing difficult about it.\u0026rdquo;(Nurse, #03)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003ePhysical and psychological capability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 350px;\"\u003e\n \u003cp\u003eNurses and doctors are capable of managing potential serious adverse events associated with intravenous iron \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 406px;\"\u003e\n \u003cp\u003e\u0026ldquo;If there are adverse side effects like hypersensitivity reactions, I think, we can manage it here.\u0026rdquo; (Doctor, #03) \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003ePhysical opportunity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 350px;\"\u003e\n \u003cp\u003eHigh workload of nurses and doctors causes delays in administering intravenous iron to pregnant women\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 406px;\"\u003e\n \u003cp\u003e\u0026ldquo;How will I describe about the timeliness;\u0026nbsp;we can\u0026rsquo;t administer the intravenous iron immediately when the patient arrives. We usually have routine activities in the wards that need to be done first. (Nurse, #03)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003ePhysical opportunity\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 350px;\"\u003e\n \u003cp\u003eHigh workload among nurses and doctors results in insufficient time to adequately monitor pregnant women during and after the intravenous iron infusion \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 406px;\"\u003e\n \u003cp\u003e\u0026ldquo;Approximately 10 to 15 minutes, I spend with patients [pregnant women receiving intravenous iron] which is required for cannulation. I can\u0026rsquo;t give more time due to work in the wards. I leave as early as possible after completion of cannulation.\u0026rdquo; (Nurse, #05)\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003ePhysical opportunity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 350px;\"\u003e\n \u003cp\u003eAvailability of equipment necessary for intravenous iron treatment was low prior to the EDIVA demonstration project\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline health facility readiness assessment\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eEquipment, a private room, and specific medicines are required for intravenous iron treatment. In the six primary health facilities assessed, we found that while some items were available, others were not.\u003c/p\u003e\n \u003cp\u003eFor example, all health facilities had a weight machine to determine the appropriate dose of intravenous iron; three had a room with both auditory and visual privacy; none had 20ml syringes for administration, and only one had adrenaline available for managing potential serious adverse events\u0026nbsp;\u003cstrong\u003e(S5 Appendix)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 406px;\"\u003e\n \u003cp\u003e\u0026ldquo;I am thinking about the issue that the government has no iron saline or syringe. Even we don\u0026rsquo;t have saline set right now. So, when we ask the general patients to buy these things, they become annoyed.\u0026rdquo; (Nurse, #02)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003ePhysical opportunity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 350px;\"\u003e\n \u003cp\u003eBed shortages\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 406px;\"\u003e\n \u003cp\u003e\u0026ldquo;We have huge pressure of patient flow compared to earlier times. In the last two to three days, an average of 2 to 3 patients were admitted against a single bed.\u0026rdquo; (Nurse, #02)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eSocial opportunity\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 350px;\"\u003e\n \u003cp\u003eHigh number of staff vacancies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 406px;\"\u003e\n \u003cp\u003e\u0026ldquo;We have about seven vacancies here. Also, three of our staff are in higher education, BSc [Bachelor of Science] in nursing, left.\u0026rdquo; (Nurse, #01) \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe integration of data from the baseline health facility readiness assessment, the ORIC questionnaire, and qualitative interviews allowed for a comprehensive evaluation of organisational readiness for implementing anaemia testing and intravenous iron treatment for pregnant women in Bangladesh\u0026rsquo;s primary health care system. We found high organisational readiness for anaemia testing using the point-of-care HemoCue device and for intravenous iron treatment, with health workers demonstrating strong commitment and confidence in their ability to provide these services to pregnant women. However, sustaining both interventions beyond the EDIVA demonstration project would require addressing resource constraints, including the unavailability of necessary equipment and shortage of nurses and doctors.\u003c/p\u003e \u003cp\u003eWe found that structural health system deficiencies may affect the sustainable implementation of anaemia testing using the HemoCue device and intravenous iron treatment for pregnant women in Bangladesh\u0026rsquo;s primary health care system. Before the EDIVA demonstration project, anaemia testing equipment and related resources were often unavailable. When supplied with the HemoCue device during the project, health workers described how their workload increased due to the time spent counselling pregnant women following an anaemia diagnosis. However, this additional investment of time may ultimately reduce their workload, as more pregnant women could receive timely treatment, avoiding complications from anaemia that require more time-consuming care. In addition, nurses and doctors described how staffing shortages commonly led to delays in administering intravenous iron and limited the time they could spend monitoring pregnant women during infusions. Our findings align with previous research showing that most primary health facilities at the union and ward levels in Bangladesh lack haemoglobin testing capacity and that the country is facing a severe shortage of health workers (Hakim et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; United Nations Bangladesh, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). For example, in 2022, there were only 13 doctors, nurses, and midwives per 10,000 people in Bangladesh, compared to a global median of 49 (United Nations Bangladesh, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Our findings are also consistent with a recent global qualitative evidence synthesis, which found that health workers\u0026rsquo; ability to manage anaemia in pregnant women is affected by staffing shortages, heavy workloads, insufficient facilities and space, and poor working conditions (Verbunt, Corona, et al., \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). These structural barriers to testing and treating anaemia in pregnant women highlight the importance of investing in prevention strategies, such as oral iron and folic acid supplements.\u003c/p\u003e \u003cp\u003eDespite concerns about structural health system deficiencies, we found that health workers were committed and confident in their ability to test pregnant women for anaemia using the HemoCue device and to administer intravenous iron treatment. Qualitative interviews suggest this may be because health workers had considered the benefits of these services for pregnant women compared to other options. For example, health workers reflected on how HemoCue testing was more accurate than clinical assessment, while nurses and doctors explained that intravenous iron treatment addressed barriers, such as gastrointestinal side effects, that often prevent pregnant women from taking oral iron and folic acid supplements. Our findings contradict those from a study in Ghana, where health workers expressed concerns about the quality and accuracy of results from point-of-care devices, with some preferring to use clinical assessment (not recommended by WHO) to diagnose pregnant women with anaemia (Palmer et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; World Health Organization, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). This difference may be explained by health workers in our study receiving extensive training on how to test pregnant women for anaemia using the HemoCue device as part of the EDIVA demonstration project (Prang et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Ongoing training for health workers should therefore be considered a key implementation strategy for scaling up the use of the HemoCue device across Bangladesh\u0026rsquo;s primary health care system (Powell et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Consistent with our findings, health workers in Nigeria identified several advantages of intravenous iron compared to the standard-of-care (oral iron) for the treatment of anaemia in pregnancy, including women responding more rapidly to treatment and assured adherence (Akinajo et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Overall, our findings align with other studies assessing organisational readiness for implementing change (Esan et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; van de Water et al., \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). For example, a study in Nigeria, although focused on respectful maternity care rather than anaemia services, also found high organisational readiness for change despite limited perceived resources (Esan et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eImplications for Research and Policy, including the EDIVA Demonstration Project\u003c/h2\u003e \u003cp\u003eOur study findings have several implications for research and policy, including for the EDIVA demonstration project. To address the identified challenges to organisational readiness for implementing anaemia testing and intravenous iron treatment for pregnant women in Bangladesh\u0026rsquo;s primary health care system, future research could involve co-designing strategies with health workers. For example, health workers, in collaboration with pregnant women and their families, could develop educational materials to raise awareness about anaemia and intravenous iron treatment in advance. These materials could be disseminated to women by Family Welfare Assistants during their routine home visits to register new couples and pregnancies, and to provide antenatal care counselling (World Health Organization. Regional Office for the Western Pacific, \u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). This approach could help reduce the time health workers spend counselling pregnant women about intravenous iron treatment at the point of anaemia diagnosis.\u003c/p\u003e \u003cp\u003eHuman resource constraints at the Upazila Health Complex were a common barrier to nurses and doctors treating pregnant women with anaemia using intravenous iron. In partnership with WHO, the Ministry of Health and Family Welfare is in the process of creating Bangladesh\u0026rsquo;s first National Medical Education Strategy (United Nations Bangladesh, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). This strategy aims to address the shortage of trained health workers by strengthening key aspects of medical education, such as curriculum development and accreditation (United Nations Bangladesh, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). There is also potential for Family Welfare Visitors and Sub Assistant Community Medical Office at Union and Health and Family Welfare Centres to administer intravenous iron to pregnant women with anaemia (World Health Organization. Regional Office for the Western Pacific, \u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). However, their ability to do so safely would need to be assessed and formally approved by the government.\u003c/p\u003e \u003cp\u003eUltimately, for anaemia testing and intravenous iron treatment for pregnant women to be sustained in the primary health care system, the Bangladesh government would need to support implementation and provide the necessary resources. Findings from our study \u0026ndash; as well as from the wider EDIVA programme, including an economic evaluation to understand the costs associated with implementing an intravenous iron intervention \u0026ndash; will help guide government decision-making (Australian New Zealand Clinical Trials Registry, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Hasan et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Prang et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Additionally, our findings may inform the design and implementation of an intravenous iron intervention for pregnant women with anaemia in other low- and middle-income countries.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eWe used a multi-phase, mixed-methods, parallel convergent design, which enhanced the validity and reliability of our findings through data triangulation. For example, qualitative interviews provided explanations for the high mean scores on the ORIC questionnaire, while the baseline health facility readiness assessment helped quantify themes that emerged from the interviews. Additionally, we administered the ORIC questionnaire and conducted qualitative interviews approximately halfway through the EDIVA demonstration project. This timing allowed health workers to embed either anaemia testing or intravenous iron treatment into their routine practice, enabling findings to reflect the condition present during implementation activities (Caci et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). However, we acknowledge that conditions in health facilities often change, and that repeating our assessment of organisational readiness at different time points could have provided valuable additional insights (Caci et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). The EDIVA demonstration project was conducted in only one upazila, Bandar, which limited the sample size of health facilities and health workers. Bandar is also more urbanised than the average upazila, with our findings potentially not transferable to more rural areas in Bangladesh (World Health Organization. Regional Office for the Western Pacific, \u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e2015\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eWe conducted a comprehensive evaluation of organisational readiness for implementing anaemia testing and intravenous iron treatment for pregnant women in Bangladesh\u0026rsquo;s primary health care system. We found high organisational readiness for anaemia testing using the HemoCue device and intravenous iron treatment, with health workers demonstrating strong commitment and confidence in their ability to provide these services to pregnant women. However, sustaining both interventions beyond the EDIVA demonstration project would require addressing resource constraints, including the unavailability of necessary equipment and shortage of nurses and doctors. Ultimately, government support for implementation and resource provision will be essential to ensure ongoing delivery of anaemia testing and intravenous iron treatment in Bangladesh\u0026rsquo;s primary health care system. Findings from our study may help inform government decision-making.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eCompeting Interests\u003c/h2\u003e\u003cp\u003eSRP reports consultancy fees from CSL-Vifor Pharma, ITL-Biomedical and Atomo Diagnostica. He is Director of the WHO Collaborating Centre for Anaemia Detection and Control (unfunded). All other authors declare no competing interests.\u003c/p\u003e\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthics approval:\u003c/strong\u003e \u003cp\u003e Ethics approval was obtained from the Ethical Review Committee at [organisation name removed for peer-review] (PR-20125), the Human Research Ethics Committee at [organisation name removed for peer-review] (21/5), and the Office of Research Ethics and Training at the [organisation name removed for peer-review] (2022-24388-31967-4).\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eDisclaimer\u003c/h2\u003e \u003cp\u003eThe funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eThis work was supported, in whole or in part, by the Gates Foundation [GR-02015]. The conclusions and opinions expressed in this work are those of the author(s) alone and shall not be attributed to the Foundation. Under the grant conditions of the Foundation, a Creative Commons Attribution 4.0 License has already been assigned to the Author Accepted Manuscript version that might arise from this submission. Please note works submitted as a preprint have not undergone a peer review process.\u003c/p\u003e \u003cp\u003e [initials removed for peer-review] is supported by the University of Melbourne Human Rights Scholarship. [initials removed for peer-review] time is supported by an Australian National Health and Medical Research Council Investigator Grant (2025634) and Dame Kate Campbell Fellowship. [initials removed for peer-review] is funded by the Australian National Health and Medical Research Council Fellowships (GNT1158696 and GNT2009047).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eContributors: Funding acquisition: JH, SRP. Study design: EV, KHP. Conceptualisation: EV, KHP. Methods: EV, ABMR, BKS, AMQR, KHP. Data analysis: EV, ABMR. Supervision: KHP, MAB, CV. Writing \u0026ndash; original draft: EV. Writing \u0026ndash; review and editing: All authors. Guarantor: EV.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eFirst, we thank the primary health workers in Bandar upazila for taking the time to participate in our study. We also thank icddr,b researchers Nadia Sultana, Maksuda Khanum, Shakila Afrin, Shamima Akter, Fatama Khatun, Abid Bin Siddique, and Abu Yousuf Shazid for their assistance with data collection. We thank the icddr,b field research assistants Rahima Khanam and Fahmida Zaman for their support in organising data collection. We also thank icddr,b project research physicians Dr Habiba Sultana Shorna, Dr Sharmin Binte Reza, and Dr Monia Islam Tripty for their role in the EDIVA demonstration project.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData is available from the author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAarons, G. A., Moullin, J. C., \u0026amp; Ehrhart, M. G. (2017). The Role of Organizational Processes in Dissemination and Implementation Research. \u003cem\u003eDissemination and Implementation Research in Health: Translating Science to Practice\u003c/em\u003e (pp. 121\u0026ndash;142). 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Maternal hemoglobin concentrations across pregnancy and maternal and child health: a systematic review and meta-analysis. \u003cem\u003eAnnals Of The New York Academy Of Sciences\u003c/em\u003e, \u003cem\u003e1450\u003c/em\u003e(1), 47\u0026ndash;68. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/nyas.14093\u003c/span\u003e\u003cspan address=\"10.1111/nyas.14093\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"global-implementation-research-and-applications","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"gira","sideBox":"Learn more about [Global Implementation Research and Applications](http://link.springer.com/journal/43477)","snPcode":"43477","submissionUrl":"https://submission.springernature.com/new-submission/43477/3","title":"Global Implementation Research and Applications","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"organisational readiness, implementation research, pregnant women, antenatal care, anaemia testing, intravenous iron treatment","lastPublishedDoi":"10.21203/rs.3.rs-8013520/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8013520/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"Anaemia affects over one-third of pregnant women in Bangladesh, leading to serious consequences such as maternal death and stillbirth. Yet, only about half of pregnant women are tested for anaemia, and few receive intravenous iron – a fast and effective treatment option. It remains unclear whether health facilities have the resources, and whether health workers are willing and able, to deliver these services. Embedded within a demonstration project, our study aimed to evaluate the organisational readiness of Bangladesh’s primary health care system to provide point-of-care anaemia testing and intravenous iron treatment for pregnant women. We employed a multi-phase, mixed-methods, parallel convergent design. Formative research included a baseline health facility readiness assessment (n=20). In the parallel process evaluation, health workers completed the Organisational Readiness for Implementing Change (ORIC) questionnaire (n=35), and a sample participated in qualitative interviews (n=21). Quantitative data were analysed descriptively, while qualitative data were analysed using inductive thematic analysis. We integrated findings across data sources to provide a comprehensive evaluation. We found high organisational readiness for implementing anaemia testing and intravenous iron treatment, with health workers demonstrating strong commitment and confidence in providing these services to pregnant women. However, sustaining both interventions beyond the demonstration project would require addressing resource constraints, including limited equipment and shortage of nurses and doctors. Ultimately, government support for implementation and resource provision will be essential to ensure the continued delivery of anaemia testing and intravenous iron treatment in Bangladesh’s primary health care system. Findings from our study may help inform government decision-making.","manuscriptTitle":"From testing to treatment: a mixed-methods study assessing organisational readiness for intravenous iron for pregnant women with anaemia in Bangladesh","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-16 18:18:16","doi":"10.21203/rs.3.rs-8013520/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-08T20:48:07+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-04T07:43:49+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-04T07:41:50+00:00","index":"","fulltext":""},{"type":"submitted","content":"Global Implementation Research and Applications","date":"2025-11-03T00:05:14+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"global-implementation-research-and-applications","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"gira","sideBox":"Learn more about [Global Implementation Research and Applications](http://link.springer.com/journal/43477)","snPcode":"43477","submissionUrl":"https://submission.springernature.com/new-submission/43477/3","title":"Global Implementation Research and Applications","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"9f9b86c7-3b1f-43bf-bb42-d725b64e4af6","owner":[],"postedDate":"January 16th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-14T01:08:17+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-16 18:18:16","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8013520","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8013520","identity":"rs-8013520","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}