Double Fortified Salt (DFS) Program in Uttar Pradesh, India: Lessons from the Implementation of a Salt Fortification Intervention in a Nutritionally Insecure Region (P10-098-19)

Objectives Iron deficiency prevalence is high in the state of Uttar Pradesh (UP), India. With an aim to reduce iron deficiency anemia, the state introduced double fortified salt (DFS) – salt fortified with iodine and iron – through its widespread network of fair price shops (FPS). FPS sell subsidized food grains among other goods to eligible households, and DFS was added to this package in 10 districts. In this study, we examined the coverage of the DFS program in UP and assessed the drivers/barriers to DFS utilization at the household level. Methods A midline coverage survey was conducted ∼8 months after program roll-out, in which data was collected from 1200 FPS cardholder households on their purchase and consumption of DFS. Additionally, in-depth interviews were administered to 10 household caregivers – to assess DFS consumption – as well as 20 FPS owners, 5 health workers, and 5 program staff – to examine the fidelity of DFS program implementation and identify programmatic bottlenecks. Results 82% of the households had heard of DFS and 70% had purchased it at least once. However, knowledge about DFS was sub-optimal - 81% of households had no knowledge of DFS benefits. High DFS purchase rates were not driven by higher consumption but by bundled FPS sales, where each item was sold only as part of a package and not individually. 37% of households typically used DFS in their cooking, and only 24% used DFS exclusively (no other salt present in the house). Several issues arising from poor DFS awareness were identified in the in-depth interviews – few understood why DFS turned their food darker; respondents said they could see ‘tiny stones in the salt’ (referring to the iron in the fortification premix). However, some households, especially in rural areas, adopted mitigation strategies to overcome DFS issues, like using it only for darker colored dishes. Conclusions DFS consumption was low among the population. Distribution through FPS, with state subsidies, made DFS available and affordable to households, but its benefits remain unknown and its potential unexplored. A strong communication strategy is missing in the program; habitual food practices and poor awareness levels are key barriers to regular DFS use. Limited implementation of awareness and behavior change campaigns related to DFS hampered the strategy from achieving its full potential. Funding Sources Bill and Melinda Gates Foundation.