Validation Study of Adherence to Daily Multiple Micronutrient Supplementation by Palestine Refugee Women Attending United nations Relief and Works Agency for Palestine Refugees in the Near East Health Clinics in Jordan

Masako Horino; Luai Al-Khatib; Rami Habash; Tamara Al-Rahahleh; Akihiro Seita; Saifuddin Ahmed; Klaus Kraemer; Kristen M Hurley; Keith P West Jr

doi:10.1016/j.cdnut.2025.107588

Validation Study of Adherence to Daily Multiple Micronutrient Supplementation by Palestine Refugee Women Attending United nations Relief and Works Agency for Palestine Refugees in the Near East Health Clinics in Jordan

Curr Dev Nutr. 2025 Oct 30;9(12):107588. doi: 10.1016/j.cdnut.2025.107588. eCollection 2025 Dec.

Authors

Masako Horino^{1

2}, Luai Al-Khatib¹, Rami Habash¹, Tamara Al-Rahahleh¹, Akihiro Seita¹, Saifuddin Ahmed³, Klaus Kraemer^{2

4}, Kristen M Hurley^{2

5}, Keith P West Jr²

Affiliations

¹ United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA), Health Department, Amman, Jordan.
² Center of Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States.
³ Department of Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States.
⁴ Sight and Life Foundation, Basel, Switzerland.
⁵ Vitamin Angel Alliance, Goleta, CA, United States.

Abstract

Background: Multiple micronutrient supplementation (MMS) is a new standard of antenatal care emerging in lower-income countries. Assessing adherence, a key implementation outcome, requires validation.

Objectives: Validate antenatal adherence to daily MMS based on recalled tablet days missed during follow-up intervals in UNRWA clinics serving Palestine refugees in Jordan.

Methods: This study was conducted during an implementation trial of antenatal MMS versus standard-of-care iron-folic acid supplementation. In 13 clinics, at registration, pregnant women received daily MMS in 180-count bottles weighing 111 g (bottle with desiccant = 26 g, tablet = 0.47 g). At seven follow-up visits, returning bottles were weighed to nearest gram on digital scales, and recalled tablet days missed were recorded. Tablets removed from bottles, estimated from bottle weight decrements, were regressed on tablets taken, obtained by subtracting tablet days missed from interval lengths. Similar analyses were conducted for cumulative intervals since registration.

Results: Among 9754 registered women, 7608 (78%), 6,208 (63.6%), 4,833 (49.5%), 3,409 (34.9%), 2159 (22.1%), 1063 (10.9%), and 384 (3.9%) completed the first-to-seventh follow-up visits, respectively, with a decline mainly due to censoring at close-out. Approximately 25% of women failed to return bottles, whose tablet intakes were modestly lower than those of bottle-returnees. Notwithstanding, 75 to 84% in both groups recalled missing <2 d and <5.3% missing >30 d. Interval-specific regression slopes (β₁) were 0.88-0.78 [95% confidence intervals (CIs) within +0.06 for first 5 intervals], reflecting a ∼20% over-reporting by recall, with r = 0.77-0.58, and root mean square errors (RMSE) of 10-12 tablets, reflecting model error in prediction, normalized to 7%-10% of interval ranges. Cumulative models yielded β₁ = 0.83-0.77 with similarly narrow 95% CIs, r = 0.79-0.64, and RMSE = 12-24 tablets, normalized to 7%-13% of range.

Conclusions: Histories of recalled tablet days missed provide a reliable and reasonably valid estimate of tablet disappearance from MMS bottles. Further research is warranted to correct a consistently reported ∼20% average overestimate of tablet intake.

Keywords: Palestine refugees; adherence; antenatal care; implementation research; multiple micronutrient supplementation; validation.