Knowledge, attitudes, practices, and adherence to multiple micronutrient supplementation among pregnant women in Rwanda: a mixed-methods study.

INTRODUCTION: Micronutrient deficiencies among pregnant women remain a public health concern in Rwanda. Multiple Micronutrient Supplementation (MMS) was introduced through routine antenatal care services to address this challenge. However, evidence on women's knowledge, attitudes, practices, and adherence to MMS is limited. This study assessed knowledge, attitudes, practices, and adherence to MMS among pregnant and lactating women and examined factors associated with knowledge, attitudes, and adherence. METHODS: A mixed-methods study was conducted in December 2024 in the Rwandan districts of Gasabo, Rutsiro, and Burera, where the MMS programme was implemented. Quantitative data were collected from 484 pregnant and lactating women using a structured questionnaire. Qualitative data were gathered through 18 focus group discussions, 12 exit interviews, and key informant interviews with healthcare providers and district officials. Quantitative data were analyzed using Stata, while qualitative data were analyzed thematically. RESULTS: Although adherence to MMS was high (92%), only 26.7% of participants demonstrated high knowledge, while 56.6% reported positive attitudes toward MMS. No socio-demographic factors were independently associated with high MMS knowledge. Positive attitudes were significantly associated with high knowledge (AOR = 5.10, 95% CI: 3.09-8.43), being a lactating mother (AOR = 2.30, 95% CI: 1.37-3.86), and employment, whereas women living farther from health facilities were less likely to report positive attitudes (AOR = 0.58, 95% CI: 0.36-0.93). Positive attitudes were the only independent predictor of adherence (AOR = 3.29, 95% CI: 1.42-7.61). Qualitative findings showed that perceived benefits, trust in healthcare providers, family support, and community follow-up facilitated adherence, whereas misconceptions, side effects, and limitations in counseling hindered optimal MMS use. CONCLUSIONS: High self-reported adherence to MMS was achieved despite limited knowledge, suggesting that positive attitudes, perceived benefits, and trust in healthcare providers are key drivers of adherence. Strengthening ANC counseling, addressing misconceptions, and promoting early ANC attendance may support the effective implementation and scale-up of MMS programmes in Rwanda and similar settings.