Stakeholder perceptions and experiences of girl-led education promoting iron-folic acid supplementation among pregnant women in rural Ethiopia: a qualitative study

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Abstract Iron deficiency anemia remains a significant public health challenge in Ethiopia, with low adherence to iron-folic acid supplementation (IFAS) among pregnant women contributing to adverse maternal and neonatal outcomes. Peer-led education interventions have shown promise in improving health behaviors in resource-limited settings, yet limited evidence exists on how acceptable and feasible adolescent-led approaches are, when viewed from the perspectives of multiple stakeholders in rural Ethiopia. The aim of this qualitative study was to explore the perceived acceptability and feasibility of a trained high school girl-led participatory educational intervention promoting IFAS among pregnant women in rural Angecha Woreda, Kembata Zone, Ethiopia, and to examine how experiences and interpretations varied across stakeholder groups. This qualitative study was conducted from December 1–30, 2025, following a community-based cluster randomized controlled trial. Purposive sampling was used to select 62 participants: pregnant women ( n = 24), trained high school girls ( n = 12), health extension workers ( n = 8), facility healthcare providers ( n = 4), community leaders ( n = 4), and husbands ( n = 10). Data were collected through in-depth interviews and focus group discussions, and analyzed using Braun and Clarke's reflexive thematic analysis. Particular attention was paid to divergent and dissenting perspectives within and across stakeholder groups. Four major themes emerged: (1) perceived benefits of peer-led education, including improved knowledge, enhanced social connection, and increased adherence confidence, yet peer educators simultaneously described emotional burdens and role ambiguity; (2) facilitators of acceptability, including cultural appropriateness, accessibility, and trust, though trust was initially contested, especially among older and multiparous women, and remained conditional on health worker supervision and community leader endorsement; (3) perceived barriers, including logistical and resource constraints, side effects, and socio-economic inequities that undermined adherence despite educational gains; and (4) recommendations for successful implementation, including strengthening peer educator support, enhancing community engagement, and integration with existing health systems, which revealed tensions between peer educators' desires for formal recognition and integration, and health professionals' concerns about preserving clinical boundaries. While pregnant women and peer educators emphasized empowerment and relatability, health workers framed benefits primarily in terms of extended reach. Husbands highlighted spillover knowledge but also competing economic priorities and community leaders noted that poverty constrained what education alone could achieve. The intervention was perceived as acceptable and feasible, but stakeholder experiences were not uniform. The approach produced mutual benefits for pregnant women and adolescent educators, yet its sustainability depends on resolving tensions around supervision, resource allocation, professional scope of practice, and structural economic barriers. Integration into routine maternal health programs is recommended, provided that health system support, clear role delineation, and material resources are secured. Trial registration: Pan African Clinical Trial Registry database (PACTR202504579977002) registered on 08/04/2025.

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