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 Table of Contents  
Year : 2023  |  Volume : 30  |  Issue : 1  |  Page : 75-80

The role of social support and interpersonal trust to improve compliance of iron supplementation amongst adolescent girls: A qualitative approach

1 Doctoral Program of Public Health, Faculty of Public Health, Universitas Airlangga; Department of Public Health, Preventive Medicine, Community Medicine, Faculty of Medicine, Universitas Ciputra, Surabaya, Indonesia
2 Department of Epidemiology, Biostatistics, Population Studies and Health Promotion, Faculty of Public Health, Universitas Airlangga, Indonesia
3 Department of Psychology, Faculty of Psychology, Universitas Airlangga, Surabaya, Indonesia
4 Nutrition Study Program, Faculty of Public Health, Universitas Airlangga, Surabaya, Indonesia

Date of Submission15-Oct-2022
Date of Decision05-Nov-2022
Date of Acceptance02-Jan-2023
Date of Web Publication09-Feb-2023

Correspondence Address:
Lutfi Agus Salim
Kampus C Unair, Mulyorejo, Kec. Mulyorejo, Kota SBY, Jawa Timur 60115
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/npmj.npmj_277_22

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Context: Adolescence is a crucial phase in preventing and controlling anaemia. One of the efforts made by the Indonesian government to overcome adolescent girl's anaemia is the iron and folic acid (IFA) supplementation programme. This programme is one of the most effective interventions that various countries have used to overcome anaemia. The key to the success of the supplementation of IFA is the compliance of adolescent girls. Aims: This study investigates the compliance and its contributing factors of IFA supplementation and the role of social support and interpersonal trust as a source of information and reminder amongst adolescent girls in Sidoarjo, Indonesia. Methods: This research was a qualitative study using the in-depth interview to collect data. Thirteen adolescent girls from three high schools in Sidoarjo, Indonesia, were recruited using a snowball sampling technique. Results: Most of the girls did not comply with IFA supplementation. Contributing factors were the influence of peers, influence of teachers, parental influence, risk and benefit of taking IFA tablet and also failure to remember to take IFA tablet. The social environment that provided information and reminder came from teacher, parent, peer and also health worker. Interpersonal trust was needed to have positive perceived social support. Conclusions: Compliance with the consumption of IFA supplements requires the cooperation of various parties (teachers, parents, peers and health workers) and also interpersonal trust between adolescent girls to their social environment so the programme could be run optimally.

Keywords: Adolescent, anaemia, compliance, interpersonal trust, iron and folic acid supplement

How to cite this article:
Silitonga HT, Salim LA, Nurmala I, Hargono R, Notobroto HB, Hartini N, Purwandini S. The role of social support and interpersonal trust to improve compliance of iron supplementation amongst adolescent girls: A qualitative approach. Niger Postgrad Med J 2023;30:75-80

How to cite this URL:
Silitonga HT, Salim LA, Nurmala I, Hargono R, Notobroto HB, Hartini N, Purwandini S. The role of social support and interpersonal trust to improve compliance of iron supplementation amongst adolescent girls: A qualitative approach. Niger Postgrad Med J [serial online] 2023 [cited 2023 Mar 31];30:75-80. Available from: https://www.npmj.org/text.asp?2023/30/1/75/369310

  Introduction Top

The most common anaemia in adolescents is iron deficiency anaemia.[1] One commonly used solution to the problem of anaemia worldwide is weekly iron and folic acid supplementation (WIFAS). Some of the advantages of this programme include: more effective in reducing anaemia, effective in preventing the incidence of anaemia, cost-effective, fewer side effects and operationally easy to manage at the community level.[2] Studies on WIFAS in India effectively increased adolescent girls' haemoglobin levels. The prevalence of schoolchildren's anaemia decreased from 92.6% to 58.0% within 6 months.[2]

The government has implemented the WIFAS programme for adolescent girls in Indonesia since 2016.[3] Several factors influence this programme's success, including sufficient supply of IFA tablets, awareness of adolescent girls, support of teachers and parents and acceptance of adolescent girls to WIFAS.[4],[5] In 2018, 76.2% of adolescent girls' received IFA supplements nationally. However, only 1.4% consumed tablets regularly.[6] Previous research in Indonesia stated that the main reason for the irregular consumption of IFA supplements was the low awareness of adolescent girls about the importance of taking IFA supplements.[7] Another study in other developing countries stated that the low compliance of adolescents was caused by a lack of nutritional education, low-quality of tablets, not being provided drinking water and lack of monitoring in schools.[8],[9]

In Indonesia, intervention in schools starts with UKS' (School Health Business) teachers' training, followed by school teachers counselling students and parents. Students who get counselling are expected to be able to conduct counselling with other students (peers) so that they are expected to change students' knowledge and attitudes and they want to consume IFA supplements. Schools should have a sufficient supply of tablets to distribute to their students weekly throughout the year. IFA supplement can be given by determining the day of taking IFA supplements together every week. Recording students' IFA supplement consumption is carried out independently in the Nutritional Supplementation Card, distributed with supervision by UKS. Health promotion media is carried out through leaflets, TV spots, pocketbooks and return sheets.[10]

Social support is one of the determinants of adolescent compliance in consuming IFA supplements. A study shows that social support obtained from peers positively correlates with intensive exercise.[11] Other studies have shown that social support was significant in helping improve adherence and the ability to deal with the disease in patients with diabetes mellitus. This is mainly because social support can reduce emotional stress.[12] Many studies about social support positively affect health behaviour. Research also shows interpersonal relationships can have double functions for adolescents, which are a source of social support or stressors.[13] The social support that can result in adolescent behaviour change is social support based on trust for adolescents until finally, the adolescent can change their health behaviours. However, research on social support and its relationship with compliance with IFA supplement consumption as anaemia prevention is still limited. Therefore, this study aims to investigate the compliance and role of social support as source of information and reminder amongst adolescent girls in Sidoarjo, Indonesia.

  Methods Top

Study design and setting

This research is a qualitative study, where data were collected cross-sectionally through in-depth interviews with high school girls. This research was conducted in three schools in Sidoarjo Regency, East Java Province, Indonesia. WIFAS programme has been implemented in Sidoarjo Regency since 2016 following the circular letter of the Directorate General of Public Health of the Ministry of Health of the Republic of Indonesia Number HK.03.03/V/0595/2016. IFA supplement is distributed every 3 months from health care to schools ranging from grade 6 elementary to grade 3 high school.

Participants recruitment

Participants were recruited using the snowball sampling method, where samples were stopped being taken when there was no longer any repetition of information found. The recruitment of participants starts by obtaining permission from the principal to take data from students in their school. Three high schools, namely senior high school US (private school), MPR (private school) and TA (public school) granted permits. Then the teacher, as the class coordinator, explained to students and parents to gather information consent from their parents. Then the teachers gathered students in a WhatsApp group where researchers could select participants using the snowball sampling method. The research assistant contacted the participants about their willingness to be interviewed. Once participants were willing, a schedule was arranged to conduct in-depth interviews online. Information for assent was sent online using Google forms. Assent was obtained by selecting the assent option at the link provided. At the initial stage, researchers conducted interviews with five people. From these results, the data obtained were still diverse, so the recruitment process was carried out again. The recruitment process was stopped when the data obtained were saturated. A total of 13 participants were interviewed. This research received ethical approval from the Health Research Ethics Committee of Ciputra University Surabaya.

Data collection

The interview process took about 20–30 min. Interview guides were used in data collection. The content of the interview guide has been validated by research team who are experts in conducting qualitative research. The researcher conducted the interview and was assisted by one research assistant in recording the interview results through zoom recording and notetaking. Interviews were conducted online using zoom media, where researchers, research assistants and participants were in their respective places. Then, the record was transcribed verbatim by the research assistant.

The interview was opened by introducing researchers and research assistants. Then, the interviewer explained again about the research and ensured the confidentiality of the interview results so that participants could talk openly because the participants' names would not be notified to the school. The researchers asked the first question of compliance to take IFA supplements and the reasons for taking or not taking them. The second question related to who provided information related to IFA supplementation and examined the participants' trust level in the source of information. The third question related to who reminded participants to take IFA supplements and explored the explanation of participant trust level in the reminder.

Data analysis

Data analysis was carried out by making transcripts of conversations. After that, open coding was done, namely looking for the main idea of each statement in the transcript. The main ideas were further grouped into categories that have similar concepts. After that, the thematisation is carried out based on the categories obtained. The results were arranged in the form of findings, open coding, conceptualization and theme. Two researchers carried out data analysis. Results were based on joint discussions and decisions.

  Result Top

Characteristics of respondents

The characteristics of each respondent given the A-M code are shown in [Table 1].
Table 1: Characteristics of respondents (n=13)

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Results of qualitative data analysis

The results of qualitative data analysis from in-depth interviews with 13 participants are shown in [Table 2].
Table 2: Findings, open coding, conceptualization and theme of in-depth int

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Theme 1: Compliance with the consumption of iron and folic acid supplements


Interviewed respondents showed varying degrees of compliance. The interview results found that compliance consisted of three levels: never take IFA at all, take IFA irregularly and take IFA regularly.

'(respondent) More often did not take supplements'(A).

'In early given, maybe for the first one or 2 weeks, I took the tablets, but after that I didn't consume it anymore'(B).

'I took it regularly, once a week'(C).

Theme 2: Reasons to take the iron and folic acid supplement

Influence of peers

The interviewer asked how influential peers' role in taking IFA supplements is. Respondents stated that peers were quite influential in taking the IFA consumption.

'Because I took it (IFA supplement) with friends, so I willingly took it. If friends didn't take it, maybe I didn't take it either'(C).

Influence of teachers

Some respondents did not consume IFA supplements because teachers did not oblige, making them feel that it was not important to consume them. In addition, they also assume that they are not anaemic.

'Because the teacher said it was up to us whether we wanted to take it or not. The cause of not taking was not because of forgot, but because of unwillingness. I was not anaemic'(G).

Parental influence

Some respondents stated that parents influence compliance with consuming IFA supplements.

'Had asked parents about IFA supplements, they asked me to take it because I had anaemia'(A).

Risks for not taking the iron and folic acid supplements

Respondents were asked if they knew about the risks of not consuming IFA supplements and whether it affected their desire to take IFA supplements.

'Wanted to take because I felt dizzy when I had menstruation. I think anaemia is risky, so (I) took supplement to increase blood. After that (took IFA supplement) I didn't get dizzy'(F).

Benefits of the iron and folic acid supplements

Respondents were asked if they knew the benefits of taking IFA supplements and whether it affected their interest in taking IFA supplements. Some stated they knew the benefits of consuming IFA supplements and this encouraged them to be willing to consume IFA supplements,

'(I) took this supplement to add iron and many other benefits'(E).


Some respondents also stated that they did not take IFA supplements because of forgot,

'Now I didn't drink because I forgot and wasn't reminded by the UKS staff. Actually, I understand the benefits (of taking IFA supplements), but no one reminded me continuously so I forgot'(L).

Theme 3: Information related to iron and folic acid supplement

Source of information about the iron and folic acid supplements

Most respondents stated that they were aware of the information about IFA supplements. They gained insights from teachers, health workers. However, there was respondent who stated that she never got any information about this tablet.

'I have been told by health workers, teachers, and others that this supplement' function is to increase blood volume because they have run out by menstruation. UKS team once told us (students) to take this tablet'(A).

'Never got IFA supplement information'(D).


Some respondents were asked if they believed the IFA supplement information they got. Some of them still question the correctness of the information, so it is still necessary to check with other media,

'I usually knew the information from the teacher first, then I continued to search on the internet, in google or youtube'(C).

Theme 4: Reminder support system


The interviewer asked if there was a reminder to take IFA supplements regularly. These reminders can be either individuals or objects. Some respondents answered that there was no reminder, such as a suggestion or obligation to record the tablets they consumed. Another respondent stated that her school had a student council work programme that provided recordings and reminders to take IFA supplements. Another respondent who had been ill and got an IFA supplement from the health centre got a book to record the schedule of taking IFA supplements.

'Usually after taking it was recorded in the book, given by the Health Centers. Just tick on the book'(F).


The interviewer asked if anyone reminded them who or what would be listened to the most. Respondents' answers about a trusted reminder to remind them of taking IFA supplements include parents, teachers, peers and doctors.

'Friends are the most effective reminder of taking IFA supplement because I spend most of the time with friends'(H).

The interview results found that the reminders most trusted by adolescent girls' to consume IFA supplements were parents, teachers, doctors and peers.

  Discussion Top

This study shows that most participants did not comply with IFA supplementation for several reasons. This study also shows that social support affects the compliance of adolescent girls in consuming IFA supplements. Social support comes from four primary sources: parents, peers, teachers and health workers. The support includes information about IFA supplements and anaemia and a reminder to consume IFA supplements regularly. This study is in line with other studies that state that social support can increase adherence to IFA supplement consumption.[14],[15],[16],[17],[18]

Some adolescents feel that their parents are highly respected figures, so they trust and are willing to do the advice their parents give.[19] Thus, the role of parents as information providers and reminders becomes influential. Parents who meet with adolescent girls daily are considered effective in providing information about IFA supplements and anaemia, and reminders.[20] In addition, parents can also act as role models to exemplify adolescent girls that IFA supplement consumption is important by consuming it. The influence of parents on compliance with the consumption of IFA supplement of adolescent girls following various other studies conducted.[21]

Peers become a figure who is very attached to the lives of adolescents and can influence the internal behaviour of adolescents.[19] Some respondents are much more confident in peers' words when conveying information and reminders about consuming IFA supplements. The reason is that peers are the people they meet most often at school, and close friendships can influence each other.[22] A study shows that health education by peer educators can be an effective way to improve the health of a teenager.[23] The role of peers can be considered to improve acceptance of IFA supplements amongst adolescent girls.[24]

The teacher is the main party providing information about IFA supplements and anaemia.[25] Teachers also play a role in regulating and supervising the consumption of IFA supplements in schools.[7],[16],[26] Teachers can design IFA supplement consumption strategies at school to minimise forgetting.[27] Various studies have shown that teachers who often provide information about supplementary IFA and anaemia are positively related to the knowledge and compliance of adolescent girls.[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29] In other studies, it is known that the teacher's role can be more than providing information and reminders but also as a role model. Adolescent girls will be more enthusiastic about consuming IFA supplements when teachers take them.[9],[30]

The role of health workers must not only ensure the distribution of IFA supplements runs well but also play an essential role in providing direct support to adolescent girls.[31] The provision of this information can be in the form of seminars/socialisation for adolescent girls and screening for anaemia regularly.[32] Previous studies found that the presence of health workers positively influenced the consumption of IFA supplements in adolescent girls.[33] These results align with research conducted on adolescent girls in India, which showed that health workers were associated with adherence to consuming IFA supplements.[16]

Relationships with social environments with peers, family, teachers and health workers also influence adolescent girls' decisions in consuming IFA supplements, according to the Social Support and Social Network theory and other research.[34],[35] Teachers and peer support can improve adolescent compliance in consuming IFA supplements in school.[28] Improving the compliance of adolescent girls can be done by providing knowledge about what can and should not be done when taking supplements. The teacher's role will help reduce anaemia in adolescent girls.[29] The limitation of this study was in data collection that was done only on adolescent girls and not their social environments, such as peers, families, teachers and health workers.

  Conclusions Top

The IFA supplementation program is one of the crucial government programs. Compliance with the consumption of IFA supplements in adolescent girls is influenced by many factors, not only by individuals but also by socio-environmental influences. The success of the IFA supplementation programme requires support from various parties, including parents, peers, teachers and health workers. Here, we need people who are experienced or trained to be able to explain well and can be trusted by adolescent girls.


School principals and teachers from three high schools in Sidoarjo, for supporting us by participating in this research. Also, thirteen high school students from three schools in Sidoarjo participated in this research as respondents. Ciputra University funded this research.

Financial support and sponsorship

This research was funded by Ciputra University.

Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2]


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