Organisational readiness, facilitators and barriers to the uptake of intravenous iron for the treatment of maternal anaemia in Nigeria: a mixed-methods pre-implementation assessment

This mixed-methods study conducted in Lagos, Nigeria, reveals that healthcare facilities possess high organisational readiness to adopt intravenous iron for maternal anaemia, driven by strong provider motivation and perceived effectiveness, though successful implementation will require strategic planning to address cost, infrastructure, and awareness barriers.

The Gist

The Big Picture: A New Tool for a Big Problem

Imagine pregnancy as a long, demanding marathon. For many women in Nigeria (and other developing countries), they are running this marathon while carrying a heavy backpack of anaemia (low iron in the blood). This makes them weak, tired, and at high risk of serious complications or even death.

Traditionally, the solution has been giving them oral iron pills. But this is like trying to fill a leaking bucket with a tiny teaspoon. Many women can't swallow the pills because they make them nauseous, they forget to take them, or the pills just don't work fast enough.

Enter Intravenous (IV) Iron. Think of this as a high-pressure fire hose. It delivers a massive dose of iron directly into the bloodstream, fixing the problem quickly and bypassing the stomach issues. It's a "game-changer" tool that works wonders in rich countries, but it hasn't been used much in Nigeria yet.

The Question: Before we hand out these "fire hoses" to every hospital, we need to know: Are the hospitals ready to use them? Do the staff know how to handle them? What might stop them from working?

This study is like a pre-flight checklist for Nigerian hospitals to see if they are ready to start using this new, life-saving treatment.

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The Investigation: Checking the Engine Room

The researchers went to six different hospitals in Lagos (from small local clinics to big university hospitals) to check the "readiness" of the staff. They used two methods:

1. A Survey (The Scorecard): They asked 74 healthcare workers to rate how ready they felt on a scale of 1 to 5.
2. Interviews & Group Talks (The Storytelling): They sat down with doctors, nurses, and managers to hear their real fears, hopes, and ideas.

The Good News: The Team is Ready to Go!

The results were surprisingly positive. The "readiness scores" were incredibly high.

• The Analogy: Imagine a sports team that has just been given a new, high-tech playbook. You might expect them to be confused or scared. Instead, these Nigerian healthcare workers said, "We are 100% committed to this, and we are confident we can do it!"
• Why? They saw the new IV iron as a superior tool. They realized it was faster than pills, safer than blood transfusions (which are hard to get), and could save lives quickly. They felt a strong sense of urgency to start using it.

The Hurdles: The Bumps in the Road

Even though the team is ready, there are some obstacles in the stadium that need fixing before the game starts.

1. The Price Tag (The Cost Barrier)

• The Issue: Right now, the research project is paying for the iron. But what happens when the project ends?
• The Metaphor: It's like being given a free, luxury car for a month. You love driving it, but you're terrified of the bill when the month is over.
• The Fear: Doctors worry that once the free supply runs out, patients won't be able to afford it, and they'll go back to the "leaky bucket" (pills). They need a plan for insurance or government subsidies to keep the car running.

2. The "Scary Needle" Factor (Side Effects)

• The Issue: Some staff and patients are scared of injections. They remember older, dangerous versions of IV iron from the past.
• The Metaphor: It's like people being afraid of flying because they remember a plane crash 30 years ago, even though modern planes are the safest way to travel.
• The Fix: The new iron is safe, but people need to be educated to overcome their fear.

3. The Crowded Waiting Room (Space & Staff)

• The Issue: Hospitals are already short-staffed and crowded. Giving an IV iron takes time and space to monitor the patient.
• The Metaphor: Imagine a small, busy coffee shop trying to add a complex new drink that requires a special machine and a 20-minute wait. The baristas are worried they don't have enough counter space or enough hands to make it without spilling coffee everywhere.
• The Reality: Some clinics don't have enough chairs, drip stands, or nurses to watch patients while the iron drips in.

4. The Knowledge Gap

• The Issue: Not everyone knows about this new treatment yet. Some patients in rural areas have never heard of it, and some staff haven't been trained.
• The Metaphor: It's like having a new smartphone in the house, but only one person knows how to use it. The rest of the family is confused and doesn't know why they need it.

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The Verdict: We Have the Engine, We Just Need Fuel

The study concludes that Nigerian hospitals are absolutely ready to adopt this treatment. The doctors and nurses are motivated, confident, and eager to help their patients.

However, readiness isn't enough on its own.

• The Analogy: You can have a Ferrari (the IV iron) and a team of expert drivers (the nurses), but if you don't have gas (money/insurance) or a clear road (space/policies), the car isn't going anywhere.

What Needs to Happen Next?

To make this work for real, the researchers suggest:

1. Fix the Wallet: Get the government or insurance companies to pay for the iron so it's not just a "free trial."
2. Educate Everyone: Run campaigns to tell patients, "This new shot is safe and fast," so they aren't scared.
3. Make Space: Rearrange clinics to give nurses room to work and ensure there are enough supplies.
4. Keep Training: As new nurses join the team, make sure they learn how to use the "fire hose" correctly.

In short: The Nigerian healthcare system has the heart and the skill to save more mothers with IV iron. They just need the right support to turn that potential into a permanent reality.

Technical Summary

1. Problem Statement

Maternal anaemia is a leading cause of morbidity and mortality in low- and middle-income countries (LMICs), with Nigeria bearing a disproportionate burden (estimated 45% of pregnant women affected). While oral iron is the conventional treatment, it suffers from poor adherence, gastrointestinal side effects, and slow hemoglobin correction. Intravenous (IV) iron formulations, specifically Ferric Carboxymaltose (FCM), offer clinical advantages including rapid correction and reduced adherence barriers. However, despite evidence of safety and efficacy, the adoption of IV iron in routine maternal care in LMICs like Nigeria remains limited due to systemic barriers, cost concerns, and lack of implementation readiness assessments. There is a critical gap in understanding the organizational readiness and context-specific determinants required to scale this intervention before real-world implementation.

2. Methodology

The study employed a mixed-methods pre-implementation design conducted across six diverse healthcare facilities in Lagos, Nigeria (representing primary, secondary, tertiary, and private sectors).

• Quantitative Component:
  • Instrument: The validated Organisational Readiness for Implementing Change (ORIC) survey, based on Weiner's theory, measuring two facets: Change Commitment and Change Efficacy.
  • Participants: 74 Healthcare Providers (HCPs) out of a target population of 118 (63% response rate).
  • Analysis: Descriptive statistics and ANOVA were used to compare scores across facility types and job cadres.
• Qualitative Component:
  • Framework: Guided by the Consolidated Framework for Implementation Research (CFIR) (2009 version, mapped to 2022 constructs).
  • Data Collection: 16 Key Informant Interviews (KIIs) with leadership and 11 Focus Group Discussions (FGDs) with frontline staff (doctors and nurses), totaling 80 qualitative participants.
  • Analysis: Thematic analysis using inductive coding followed by deductive grouping into CFIR domains.
• Study Context: The study was part of the IVON-IS project, where HCPs had already received training on FCM administration. Data collection occurred between August and September 2023.

3. Key Contributions

• Novelty: This is one of the first studies to assess organizational readiness for IV iron adoption specifically in an LMIC maternal health context using a rigorous mixed-methods approach.
• Theoretical Integration: It proposes a conceptual extension to the ORIC-CFIR framework tailored for LMICs, introducing "readiness modifiers" such as resource resilience, community-system interface, and adaptation agility.
• Evidence Base: It provides critical pre-implementation data to inform the scaling of the IVON-IS project and similar interventions, moving beyond clinical efficacy trials to implementation science.

4. Key Results

A. Quantitative Findings (Organisational Readiness)

• High Readiness: The study found substantial organizational readiness across all six facilities.
  • Mean ORIC scores were 56.8 (pregnancy) and 56.6 (postpartum) out of a maximum of 60.
  • Change Commitment mean score: 23.7/25 (94.8%).
  • Change Efficacy mean score: 33/35 (94.3%).
• Consistency: There were no statistically significant differences in readiness scores across different facility types (primary, secondary, tertiary, private) or job cadres (nurses, doctors, pharmacists, etc.), indicating a unified willingness to adopt the intervention.

B. Qualitative Findings (Facilitators and Barriers)

Using the CFIR domains, the study identified specific drivers and obstacles:

Facilitators:

• Intervention Characteristics: High perceived effectiveness, relative advantage over oral iron (faster correction, no adherence issues) and blood transfusion (safer, less resource-intensive), and perceived ease of administration.
• Inner Setting: Strong shared understanding between management and staff, existing electronic medical records (in some facilities), and high motivation/eagerness among HCPs.
• Implementation Process: Well-defined roles, collaboration among health teams, and willingness to collect data on barriers.
• Outer Setting: Potential for community engagement (family decision-makers) to drive uptake.

Barriers:

• Intervention Characteristics:
  • Cost: Major concern regarding sustainability once project funding ends; fear of non-affordability for patients.
  • Safety: Persistent fear of side effects (despite training) and apprehension regarding the "blood-like" color of the drug.
• Inner Setting:
  • Infrastructure: Shortages of space (especially in busy clinics), lack of screening instruments (centrifuges, point-of-care tests), and insufficient drip stands/PPE.
  • Workforce: Staffing levels are critically low due to "brain drain" (migration of HCPs) and high turnover, necessitating continuous retraining.
  • Compatibility: Challenges in integrating postnatal monitoring in Primary Health Centers (PHCs) which lack routine postnatal clinics.
• Individuals: Low patient awareness and literacy in surrounding communities.

Synthesis: The study noted that high motivation and perceived effectiveness (facilitators) appeared to buffer against structural barriers (resource constraints), maintaining high readiness scores despite infrastructure limitations.

5. Significance and Implications

• Policy & Practice: The findings suggest that Nigerian health facilities are ready to adopt IV iron, but strategic implementation planning is required to translate this readiness into sustained practice.
  • Cost Strategies: Urgent need for government subsidies, health insurance inclusion, and policy changes to include IV iron in the national essential medicines list.
  • Capacity Building: Continuous training is vital to address staff turnover and mitigate fears of side effects.
  • Infrastructure: Optimizing clinic spaces and ensuring availability of screening tools are prerequisites for scale-up.
• Implementation Science: The study highlights that in resource-constrained settings, provider motivation and community engagement can compensate for structural deficits. It advocates for adaptive strategies and continuous quality improvement (CQI) to navigate dynamic barriers.
• Future Research: Calls for cost-effectiveness studies comparing FCM to oral iron in LMICs and further research on implementation barriers during the active rollout phase.

Conclusion: The study affirms that the Nigerian health system possesses the organizational readiness to adopt IV iron for maternal anaemia. Success depends on addressing cost sustainability, infrastructure gaps, and patient/provider education to ensure equitable and lasting impact on maternal health outcomes.