Table 2.
Summary of qualitative findings
| No | Summary of qualitative review findings | Contributing qualitative studies | Overall CERQual assessment | Explanation of overall assessment |
| Knowledge and learning | ||||
| 1.1 | Women’s knowledge about pre-eclampsia/eclampsia: Most women had limited knowledge about pre-eclampsia/eclampsia, and pre-eclampsia/eclampsia was not typically considered as a serious problem by women. General symptoms of pre-eclampsia/eclampsia such as swollen feet, severe headache, blurred vision and vomiting were considered normal in pregnancy, while seizures were linked to evil attacks or nutritional deficiencies | 26 27 34 | High confidence | Due to no or very minor concerns on coherence, minor concerns on methodological limitations (reflexivity and ethics), moderate concerns on relevance (1 out of 3 studies are indirectly relevant to our review aim and small number of countries), and minor concerns of adequacy (3 out of 6 contributed with 2 thick and 1 thin data) |
| 1.2 | Information provision to women: Women felt they did not receive adequate information during pregnancy from health workers about pre-eclampsia/eclampsia and calcium supplementation and would like to be given more information regardless of their risk status. Women believed that having this essential information could help them to make informed choices and to actively participate in their care. There were, however, mixed opinions from health workers, where some feared that more information could generate anxiety for women, while others were supportive of providing information to women | 13 34 | Low confidence | Minor concerns on methodological limitations (ethics and reflexivity), moderate concerns on coherence (no clear understanding on why some health workers worry in generating anxiety to women while the others are not), moderate concerns on relevance (small number of countries) and serious concerns on adequacy (2 out of 6 contributed with 1 thick and 1 thin data) |
| 1.3 | Learning about calcium supplementation: Women typically learnt about calcium, including pre-eclampsia and eclampsia symptoms, from health workers, and considered health workers as the most trusted and reliable source of information. They reported feeling confident about taking calcium after receiving adequate information from their health workers. Women also appreciated receiving information on calcium supplementation and pre-eclampsia/eclampsia from information, education and communication (IEC) (materials like) videos, media and trusted websites | 13 27 34 | High confidence | Due to no or very minor concerns on coherence, minor concerns on relevance (small number of countries), minor concerns on methodological limitations (reflexivity and ethics), and minor concerns on adequacy (3 out of 6 contributed, 1 moderate thick and 2 thin data) |
| Believe about the intervention | ||||
| 2.1 | Fears about side effects as barriers to calcium uptake among women: Fears about side effects impact adherence to calcium consumption by women. Women highlighted that assurance of safe use of calcium is a key facilitator to consistent use. However, some women felt safety was not assured by health workers and were told by their families or communities that any pills consumed during pregnancy could be harmful, especially when the intervention was perceived as ‘experimental’ | 11 13 27 34 | High confidence | Due to no or very minor concerns on coherence, minor concerns on relevance (small number of countries), minor concerns on adequacy (small number of studies contributing to the qualitative evidence synthesis) and minor concerns on methodological limitations (reflexivity and ethics) |
| 2.2 | Experiences of side effects: Some women reported experiencing side effects after taking calcium and iron folic acid, which include dizziness, vomiting, nausea, stomach-ache, loss appetite, tiredness, diarrhoea, bloating and burping, yet noted that the side effects subsided with time. Women also reported to keep consuming the medication despite experiencing the side effects | 11 13 27 | High confidence | Due to no or very minor concerns on coherence, minor concerns on methodological limitations (ethics and reflexivity), moderate concerns on relevance (only low-income and lower-middle-income country and small number of countries) and minor concerns on adequacy (3 out of 6 studies contributed with 2 thick and 1 with thin data) |
| 2.3 | Concerns of being stigmatised as HIV patient: Women expressed concerns about being stigmatised as HIV patients if they ingested calcium, which was a reported barrier to use. Some women were afraid of being stigmatised as their community often associated supplement consumption) and accompanying reminder posters with HIV | 13 34 | Moderate confidence | Due to no or very minor concerns on methodological limitations, no or very minor concerns on coherence, minor concerns on relevance (small number of countries) and serious concerns on adequacy (2 out of 6 study contributed) |
| 2.4 | Positive perceptions about calcium: Women reported that both their perceptions about expected benefits and previous experiences of taking calcium and iron-folic acid were facilitators of use. Women believed that consuming pills could compensate for suboptimal nutrition during pregnancy and that consuming nutrient supplementation during pregnancy would help keep the baby safe | 11 13 27 28 34 | High confidence | Due to no or very minor concerns on coherence, minor concerns on methodological limitations (ethics and reflexivity), minor concerns on relevance (1 study indirectly relevant to review aim and small number of countries) and adequacy (small number of studies contributing to the qualitative evidence synthesis) |
| Medication characteristics and doses | ||||
| 3.1 | Varying preferences about characteristics of calcium tablets: Positive perceptions about the characteristics of the calcium tablet played a role in motivating women to take it. Some women preferred the chewable, sweet-tasting tablets that could be swallowed without water, while others preferred the hard tablets which were smaller in size, had no smell and needed to be taken with water. Based on individual preference, the taste, smell, size and convenience were instrumental in uptake of the calcium supplements | 11 27 | Moderate confidence | Due to no or very minor concerns on coherence, minor concerns on methodological limitations (reflexivity), moderate concerns on relevance (all low or lower-middle-income countries and small number of countries) and moderate concerns on adequacy (2 out of 6 studies contributed with moderate to thick data) |
| 3.2 | Medication dosing as a barrier of use: Women described that they could feel overwhelmed with the number of calcium pills they had to take per day, this includes women with comorbidities who need to take additional medications to manage their health condition. Women felt that 3–4 pills per day at multiple times was overly onerous and recommended combining them into one pill could ease the burden | 11 13 27 | High confidence | No or very minor concerns on coherence, minor concerns on methodological limitations (reflexivity), minor concerns on adequacy (3 out of 6 studies contributed with moderate to thick data), and moderate concerns on relevance (small number of countries) |
| 4 | Routine and food insecurity | |||
| 4.1 | Adherence challenges due to routines: Adherence to calcium consumption was challenging for some women because of conflicting activities in women’s daily routine such as consuming other medications, travelling, being away from home and household chores, which make women forgetting to take their medication | 11 13 27 | High confidence | Due to no or very minor concerns with coherence, minor concerns on methodological limitations (reflexivity), moderate concerns on relevance (small number of countries) and moderate concerns on adequacy (small number of studies contributing to qualitative evidence synthesis) |
| 4.2 | Food insecurity as a barrier to calcium uptake: Women believed that adequate foo d was necessary to be able to take the supplements, to avoid nausea associated with the supplement and perceived it as a standard practice to eat before consuming any medication. However, women reported that food insecurity was a critical barrier to calcium uptake | 13 27 | Moderate confidence | Due to no or very minor concern with coherence, minor concerns on methodological limitations (reflexivity), moderate concerns on adequacy (2 out 6 studies contributed with 1 thick and 1 thin data) and moderate concerns on relevance (small number of countries) |
| Strategies to improve use | ||||
| 5.1 | Implementation of reminders to promote adherence: Women and health workers perceived reminders as beneficial in promoting women’s adherence in consuming calcium. Several reminder strategies were deemed to be useful by women and health workers, such as home-based posters, calendars with illustrations and daily reminders, and integrating supplement consumption) into the women’s daily routine such as at mealtime | 11 13 26 27 | High confidence | Due to no or very minor concerns on methodological limitations, no or very minor concerns on coherence, minor concerns on adequacy (small number of studies contributing to qualitative evidence synthesis), moderate concerns on relevance (due to all studies coming from low-income or lower-middle-income country and small number of countries) |
| 5.2 | Importance of family support and adherence partner implementation: Having family support was instrumental to women in adhering to calcium use and could be leveraged by notifying them on the importance of women’s adherence to consumption and appointing someone to be woman’s ‘adherence partner’ to help remind woman in taking the supplement. Both women and health workers were positive about adherence partners in providing support in terms of encouraging them to take the supplements, providing food, helping them around the house, emotional support, improving family relationships, and increased partner or husband involvement in pregnancy | 11 13 26 28 | High confidence | No or very minor concerns on methodological limitations, no or very minor concerns on coherence, minor concerns on adequacy (small number of studies contributing to qualitative evidence synthesis), and moderate concerns on relevance (due to all studies coming from low income or lower-middle-income country only, 2 of 5 studies has indirectly relevant aim, and small number of countries) |
| 5.3 | Counselling facilitates calcium uptake: Both women and health workers and acknowledged that the counselling they received from health workers was a motivator to calcium uptake. Women valued the discussion they have with health workers and felt more confident to take calcium supplements when they received counselling on information of pre-eclampsia/eclampsia and the benefits of calcium from their health workers | 13 27 | Moderate confidence | No or very minor concerns on methodological limitations, no or very minor concerns on coherence, moderate concerns on relevance (due to all studies coming from low or lower-middle-income country and small number of countries) and moderate concerns on adequacy (2 out 6 studies contributed with thick data) |
| Knowledge and training | ||||
| 6.1 | Varied knowledge about pre-eclampsia or eclampsia among health workers: Health workers’ knowledge about pre-eclampsia and eclampsia was variable among health workers, and some health workers felt that pre-eclampsia or eclampsia is not a priority health concern in their area and reported never having encountered any case | 26 27 30 | Moderate confidence | Due to no or very minor concerns on methodological limitations and coherence, moderate concerns on relevance (due to all studies coming from low-income or lower-middle-income countries and small number of studies) and moderate concerns on adequacy (2 out 6 studies contributed with thick data) |
| 6.2 | Inadequate training to diagnose and treat pre-eclampsia and eclampsia: While some health workers mentioned that training about pre-eclampsia/eclampsia and calcium supplementation was adequate, others reported that their training lacked depth and continuity, and thus felt unprepared to diagnose and offer information about pre-eclampsia/eclampsia and calcium to pregnant women. Health workers expressed the needs to have more and continuous training to manage the condition and to address any concerns and resistance from the community | 13 26 27 | High confidence | No or very minor concerns on methodological limitations, coherence, moderate concerns on relevance (due to all studies coming from low income or lower-middle-income country and small number of countries) and minor concerns on adequacy (3 out of 6 studies contributed with 2 thick and 1 thin data) |
| Beliefs on the intervention | ||||
| 7.1 | Perceived overmedicalisation when prescribing calcium supplementation: Both health workers and women perceived that prescribing more pills to general low-risk women during pregnancy was a form of overmedicalisation of pregnancy. Some health workers, however, felt that calcium supplementation during pregnancy was a way to prevent further medicalisation when complications occurred | 34 | Low confidence | No or very minor concerns on coherence, minor concerns on methodological limitations (reflexivity and ethics), serious concerns on relevance (evidence coming from high income country only), serious concerns on adequacy (1 out of 6 study contributed) |
| 7.2 | Beliefs that pre-eclampsia is not a serious problem in their settings: Health workers generally had positive beliefs about calcium supplementation and there was optimism that calcium could be delivered through antenatal care health workers. Some facilitators motivating health workers in prescribing calcium supplementation include belief in its prevention value and expected benefits, women liked the calcium supplements, and benefits experienced by women, and perceived lack of knowledge on how to treat pre-eclampsia which motivated health workers to side towards prevention | 13 27 34 | High confidence | No or very minor concerns on coherence, minor concerns on relevance (small number of countries), minor concerns on methodological limitations (ethics and reflexivity), and minor concerns on adequacy (3 out of 6 studies contributed with 2 thick and 1 thin data) |
| Structural factors | ||||
| 8.1 | Increased workload In general, health workers felt that their workload increased by including calcium supplementation in the services they were providing to pregnant women. Health workers reported inadequate number of staff providing care, yet they needed to provide additional counselling and prescribing to women, especially pregnant women with comorbidities. | 13 27 | Moderate confidence | No or very minor concerns on methodological limitations, no or very minor concerns on coherence, minor concerns on relevance (due to all studies coming from low income or lower-middle-income countries and small number of countries) and serious concerns on adequacy (2 out 6 studies contributed) |
CERQual, Confidence in the Evidence from Reviews of Qualitative research.