Barriers and Facilitators for Diagnosing and Managing Iron Deficiency Anemia from Healthcare Professionals' Perspective in Alberta, Canada: A Qualitative Study

Background: Anemia in reproductive-age women is a significant global public health issue. In Canada, despite a universal healthcare system, the prevalence of anemia among these women has risen over the past decade. Iron deficiency anemia (IDA), the most common cause, disproportionately affects people from marginalized communities and is often underdiagnosed and inadequately managed. The barriers and facilitators to optimal management within universal healthcare systems are poorly understood.

Objective: This study aims to explore healthcare professionals' (HCPs) perspectives on the barriers and facilitators in managing and diagnosing IDA among women of reproductive age in Alberta with a focus on equity-deserving people, including Black, Indigenous, and People of Color (BIPOC), immigrants, refugees, and 2S/LGBTQIA+ individuals.

Methods:

We conducted a qualitative study using semi-structured interviews with HCPs who treat women with IDA. Participants were recruited through purposive and snowball sampling to ensure representation from diverse specialties. Participants discussed practice patterns, barriers, and facilitators to timely diagnosis and management of IDA, and the potential interventions to improve care for women of reproductive age. After achieving sample size sufficiency, we used Braun and Clarke's reflexive thematic analysis to code transcripts and generated themes through an iterative and inductive process.

Results:

We interviewed 13 participants from Alberta, specifically seven family physicians, two emergency medicine physicians, two obstetricians/gynecologists, one hematologist, and one pharmacist. Through our interviews with healthcare professionals, several themes underscored the complexities of managing IDA among women of reproductive age. One important theme is the supply and demand of resources. Participants noted various barriers, including financial and geographic challenges in obtaining iron replacement therapy, insufficient drug coverage under Alberta Healthcare insurance, lack of hospital privileges for family doctors, and extended wait times for specialty services. The scarcity of infrastructure for iron infusion units outside major cities further compounded these access issues. Physicians' knowledge, skills, and attitudes also played a pivotal role in the management of IDA. This encompassed their familiarity and adherence to clinical guidelines, ignoring or misattributing symptoms, efforts in patient education and engagement, and their approach to source control issues. Patient-centered care was also emphasized with the need to build trust in the healthcare system, address treatment intolerance, manage the burden of frequent monitoring, and validate the patient's quality of life. Another critical aspect highlighted was the importance of networking and integrating care. This included enhancing feedback from different care levels, integrating electronic health records, and improving coordination between acute care, primary care, and subspecialty services.

For vulnerable populations, the intersectionality of biopsychosocial factors such as race, poverty, homelessness, food insecurity, mental health disorders, and substance abuse further exacerbated existing challenges related to adherence and access to care. Moreover, pervasive mistrust in the healthcare system, the need for gender affirmation sensitivity, and issues related to the affordability and cultural appropriateness of iron-rich foods and supplements were highlighted. Language barriers and limited health literacy were additional challenges experienced. Identified facilitators include having a proper multidisciplinary team in the newcomers' clinic and providing appropriate screening care for infectious diseases in refugees and newcomers.

Conclusion:

Overall, these findings highlight the multifaceted barriers to effective IDA management. They underscore the necessity for comprehensive interventions, including updates to clinical guidelines and resources, alongside improvements at both the healthcare professional and patient levels. Such measures aim to develop a holistic multidisciplinary IDA management plan, ultimately reducing health inequities among women of reproductive age in Alberta. Future work will be targeted at gaining the patient's perspective on IDA and its management.

Zhu:Janssen Pharmaceuticals,: Membership on an entity's Board of Directors or advisory committees; Taiho: Consultancy, Membership on an entity's Board of Directors or advisory committees; Bristol Myers Squibb: Consultancy, Membership on an entity's Board of Directors or advisory committees. Khalife:Pfizer: Honoraria; Sanofi: Honoraria; Roche: Honoraria; CSL Behring: Consultancy, Honoraria; Novo Nordisk: Honoraria; Takeda: Honoraria; Bayer: Honoraria. Wu:BMS-Pfizer: Honoraria, Research Funding; Pfizer, Leo Pharma, Servier: Honoraria; Bayer: Research Funding. Sun:CSL Behring; Pfizer; Roche; Sobi: Consultancy.