# Acceptability and adherence of Balanced Energy Protein (BEP) supplementation among pregnant women in Addis Ababa, Ethiopia: A Formative Study

## TL;DR

This study explores how well pregnant women in Ethiopia accepted and adhered to a balanced energy protein supplement, finding it generally well-liked with some taste-related issues.

## Contribution

The study provides new insights into the acceptability and adherence of BEP supplementation among pregnant women in Ethiopia, highlighting practical considerations for implementation.

## Key findings

- High acceptability of BEP was reported, with positive feedback on texture, smell, color, and ease of consumption.
- Over half of participants found the supplement overly sweet, which occasionally caused nausea or reduced intake.
- Most participants showed high adherence, with provider counseling and family support playing key roles in supplement intake.

## Abstract

Balanced energy protein (BEP) supplements during pregnancy have shown promise in reducing small-for-gestational-age births and low birth weight in low- and middle-income countries, but practical gaps remain in implementing this supplementation. This formative study assessed the acceptability, adherence, and sharing practices of a ready-to-use BEP supplement among pregnant women in Addis Ababa, Ethiopia.

From January to February 2023, 45 pregnant women were purposively selected from nine public health centers and provided a 4-week BEP supply with usage guidance. Thirty-nine participants completed in-depth interviews. The framework analysis focused on acceptability, adherence, and sharing. Adherence was calculated as the proportion of sachets consumed or returned empty; partially used or unopened sachets were considered unconsumed.

Acceptability was high, with positive feedback on texture (32/39, 82.1%), smell (35/39, 89.7%), color (38/39, 97.4%), and ease of consumption (33/39, 84.6%). However, 23/39 participants (59%) found the taste overly sweet, which occasionally led to nausea or reduced intake. Over the one month, supplement consumption ranged from 0 to 30 sachets, with a mean intake of 21.9 (SD = 9.5). High adherence (≥80% consumption) was observed in 25/39 (64.1%) of participants. Intake was facilitated by provider counseling and family support, while fasting, travel, and weight concerns influenced consumption patterns. Sharing was minimal and discouraged through counseling. Most participants expressed willingness to continue supplementation, recommending reduced sweetness.

Pregnant women demonstrated high acceptability and adherence to the BEP supplement. Findings support its feasibility for informing intervention design in the main trial.