Background Iron deficiency anemia remains as one of the most common nutritional problems in Iran, especially in women and girls. A process evaluation study of the national iron supplementation program targeting girls attending high schools was conducted to examine degree of exposure and satisfaction of the targets with the intervention components, and to assess the delivery (quantity), fidelity (quality), and environmental mediators of the intervention. Methods Three assessment tools were developed and used for the process evaluation. A total of 8 schools were selected using a simple randomization method. Data were collected from students (n?=?658 of 661 participants), teachers (n?=?80), and school principals (n?=?7 of 8). For the qualitative measures semi-structured interviews were conducted with the three study groups. Results Mean continuous compliance was 62.3%. Intolerance to pills and no water supply in classrooms accounted for 47.72% and 36.21% of the refusals, respectively. The refusal rate was significantly correlated (p? Conclusions The findings suggest that the methods of delivery and the fidelity of the program components, education materials and training sessions were insufficient and need to be improved. Additionally, specific attention has to be given to contextual factors to ensure the success of the program.
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