scholarly journals Unpacking How a Social Norms-Based Intervention Affects Iron Folic Acid Supplement Use Among Rural Indian Women

2021 ◽  
Vol 5 (Supplement_2) ◽  
pp. 685-685
Author(s):  
Erica Sedlander ◽  
Ichhya Pant ◽  
Jeffrey Bart Bingenheimer ◽  
Lipika Patro ◽  
Hagere Yilma ◽  
...  
Keyword(s):  
Folic Acid ◽  
Reproductive Age ◽  
Iron Supplement ◽  
Folic Acid Supplement ◽  
Women Of Reproductive Age ◽  
Community Based ◽  
Group Education ◽  
Iron Supplements ◽  
Supplement Use ◽  
Iron Folic Acid

Abstract Objectives More than a third of women worldwide and more than half of women in India have iron deficiency anemia. In 2012, the World Health Assembly made a global target of a 50% reduction in anemia among all women of reproductive age by the year 2025. Based on formative research, the Reduction in Anemia through Normative Innovations (RANI) project designed a social norms-based intervention to increase iron folic acid supplement use among women of reproductive age in Odisha, India. The objective of this paper is to examine midline data to understand which intervention components had the most effect on taking iron supplements and to suggest intervention modifications accordingly. Methods We collected and analyzed longitudinal data at baseline from the control and treatment arms and again from the same two arms at midline, six months later (n = 1,966 and n = 1,987). For this analysis, our sample includes non-pregnant women of reproductive age (15 – 49 years old). Using nested models, we analyzed data from the different intervention components: monthly community-based testing for anemia, attending participatory group education sessions, and watching locally made videos targeted at different referent groups. We also examined if age, caste, education, and communicating about the intervention moderated the effect of the intervention on iron supplement use. Results After controlling for iron supplement use at baseline, we found that simply being in the treatment arm increased the odds of taking supplements by more than 16 times (OR = 16.73; p = < .001). Being exposed to each of the intervention components separately and as reported here, all together, also increased use. Getting tested for anemia increased a woman's odds of taking iron supplements by 38% (OR = 1.38; p = < .001) followed by watching videos which increased the odds by 26% (OR 1.26; p < .001).Participating in group education sessions had the smallest effect (OR = 1.09; p = < .01). There was not a significant difference in how the intervention affected iron supplement use by age, caste, or education level. Similarly, interpersonal communication did not have an effect. Conclusions While all intervention components increased iron supplement use, community-based anemia testing had the greatest effect. In the final stage of this trial, more resources will go towards anemia testing. Funding Sources The Bill and Melinda Gates Foundation.

scholarly journals Examining the Multilevel Barriers and Facilitators to Iron Folic Acid Supplement Use and Anemia Reduction in Rural India (OR25-07-19)

2019 ◽  
Vol 3 (Supplement_1) ◽  
Author(s):  
Erica Sedlander ◽  
Rajiv Rimal ◽  
Michael Long ◽  
Ashita Munjral ◽  
Hagere Yilma ◽  
...  
Keyword(s):  
Folic Acid ◽  
Health Workers ◽  
Reproductive Age ◽  
World Health ◽  
Women Of Reproductive Age ◽  
Individual Level ◽  
Supplement Use ◽  
The Government ◽  
Iron Folic Acid ◽  
Health Organization

Abstract Objectives Over half of women of reproductive age in India are anemic so the World Health Organization recommends daily iron folic acid (IFA) for all women of reproductive age. The government has distributed free IFA for over four decades but initial uptake and adherence remain inadequate. Objectives 1) to understand the multilevel factors that hinder IFA use and adherence; and 2) to inform a behavioral intervention to increase IFA use to reduce anemia. Methods We conducted this study in four rural villages in the state of Odisha, India. We held 25 key informant interviews with front-line health workers, 16 focus groups with women of reproductive age, husbands, and mothers-in-law (n = 148) and 18 direct observations in health centers, pharmacies and women's groups. We purposively sampled key informants and randomly sampled focus group participants from an enumeration of all eligible residents of each village, and stratified them by sex, age and relation to a woman of reproductive age. We analyzed the data using applied thematic analysis and Nvivo software. Results At the individual level, we found that most people knew that IFA prevents anemia, but they did not recognize its widespread prevalence, believing instead that it was rare in their community. They also believed that taking too many IFA supplements during pregnancy would “make your baby big” causing a painful birth and possibly the need for a cesarean section. At the interpersonal level, mothers-in-law were not supportive of their daughters-in-law taking IFA too often because they themselves did not take them when they were younger. Husbands were more supportive. At the policy level, frontline health workers distribute IFA but are not incentivized to follow up on adherence. Finally, state and national policies are not consistent around which sub-populations should take IFA (e.g., whether all non-pregnant women of reproductive age should take them). Conclusions To address these multilevel barriers to IFA use and adherence, interventions should take a normative approach that includes a woman's social network and targets both descriptive norms (ideas about how many women in the community have anemia and are taking IFA) and injunctive norms around who should be taking IFA (e.g., all women of reproductive age). Funding Sources The Bill and Melinda Gates Foundation. Supporting Tables, Images and/or Graphs

scholarly journals ‘After they finish their meals, I have my meal from the leftovers; I have to adjust:” Examining How Gender Norms Affect Anemia Rates in Odisha India (P04-122-19)

2019 ◽  
Vol 3 (Supplement_1) ◽  
Author(s):  
Erica Sedlander ◽  
Chandni Ladwa ◽  
Sameera Talegawkar ◽  
Rohini Ganjoo ◽  
Rajiv Rimal
Keyword(s):  
Folic Acid ◽  
Focus Group ◽  
Pregnant Women ◽  
Gender Norms ◽  
Reproductive Age ◽  
Deficiency Anemia ◽  
Women Of Reproductive Age ◽  
Iron Supplements ◽  
Rich Food ◽  
Iron Folic Acid

Abstract Objectives Half of women of reproductive age in India have iron deficiency anemia compared to only 23% of men. Most research focuses on biological reasons for this discrepancy and access to iron-folic acid and iron-rich foods. However, recent research in India shows that inequitable gender norms may affect a woman's ability or desire to take iron supplements and to eat iron-rich food. The objective of this study is to examine how and why gender norms may be affecting high and persistent rates of anemia in India. Methods We conducted 25 key informant interviews and 16 focus group discussions with women of reproductive age, adolescents, husbands and mothers-in-law (n = 148) in Odisha, India. We purposively sampled key informants and randomly sampled focus group participants. We analyzed the data using applied thematic analysis in Nvivo software. Results Our data shows that unequal gender norms impact behaviors that are directly related to high rates of anemia. Women are often serving their husband, children, and in-laws first and “adjusting” to whatever is leftover which may be poor in nutritional qualities and less iron rich. Men are also the main breadwinners but often spend their money on alcohol, money that could be spent on iron-rich food for the household. Women reported that extreme fatigue is a normal part of being a woman and that a woman's plight is to take care of her family at any cost. Given that fatigue, the primary symptom of anemia is normalized; women may be less likely to seek treatment. Women tend to prioritize the health of their family over her own which could affect her ability or desire to go to the health center to get tested for anemia or to obtain iron supplements. Pregnant women are more likely to take iron supplements for the health of the baby, not her own health. While non-pregnant women of reproductive age who were not diagnosed with anemia were not focused on preventive health, only major illnesses and thus, were not taking supplements at all. Conclusions More upstream barriers, like gender norms, may be impinging on a woman's ability to take iron folic acid and to eat iron rich foods. Understanding how gender norms contribute to anemia could change the narrative from a biomedical issue to a social justice issue. Funding Sources The Bill and Melinda Gates Foundation. Supporting Tables, Images and/or Graphs

scholarly journals Examining intentions to take iron supplements to inform a behavioral intervention: The Reduction in Anemia through Normative Innovations (RANI) project

PLoS ONE ◽  
2021 ◽  
Vol 16 (5) ◽  
pp. e0249646
Author(s):  
Erica Sedlander ◽  
Michael W. Long ◽  
Jeffrey B. Bingenheimer ◽  
Rajiv N. Rimal
Keyword(s):  
Social Norms ◽  
Pregnant Women ◽  
Behavioral Intervention ◽  
Self Efficacy ◽  
Reproductive Age ◽  
Iron Supplement ◽  
Injunctive Norms ◽  
Women Of Reproductive Age ◽  
Iron Supplements ◽  
Supplement Use

Background More than half of women of reproductive age in India have anemia. Over the last decade, India has made some progress towards reducing anemia in pregnant women, but non-pregnant women, who make up the largest sub group of people with anemia, are largely disregarded. Objectives The objective of this paper is to examine intentions to take iron supplements and factors associated with intentions to inform a social norms-based behavioral intervention to increase uptake of iron supplements and reduce anemia in Odisha, India. Methods We collected data from 3,914 randomly sampled non-pregnant women of reproductive age in 81 villages. We conducted a survey and took hemocue (anemia level) readings from each participant. We analyzed data using linear regression models beginning with demographics and social norms and adding other factors such as self-efficacy to take iron supplements, anemia risk perception, and knowledge about anemia in a subsequent model. Results 63% of women in our sample were anemic but less than 5% knew they were anemic. Despite national guidelines that all women of reproductive age should take weekly iron supplements to prevent anemia, less than 3% of women in our sample were currently taking them. While actual use was low, intentions were rather high. On a five point Likert scale where higher numbers meant more intentions to take supplements, average intentions were above the midpoint (M = 3.48, SD = 1.27) and intentions and iron supplement use were significantly correlated (r = .10, p < .001). Both injunctive norms and collective norms were associated with intentions to take iron supplements but descriptive norms were not. Other significant factors included age, breastfeeding, knowledge, self-efficacy, and outcome expectations. The final model accounted for 74% of the variance in iron supplement intentions. Conclusions In this context, where the actual behavior is low but intentions to enact the behavior are high, starting an intervention with injunctive norms messaging (expectations around the behavior) and self-efficacy to enact the behavior is the step we recommend based on our results. As an intervention unfolds and iron supplement use increases, descriptive norms messaging (that people are indeed taking iron supplements) may add value.

Government-Industry Partnership in Weekly Iron-Folic Acid Supplementation for Women of Reproductive Age in the Philippines: Impact on Iron Status

2005 ◽  
Vol 63 (12) ◽  
pp. 116-125 ◽  
Author(s):  
Imelda Angeles-Agdeppa ◽  
Lourdes S. Paulino ◽  
Adelisa C. Ramos ◽  
Unita Marie Etorma ◽  
Tommaso Cavalli-Sforza ◽  
...  
Keyword(s):  
Folic Acid ◽  
Iron Status ◽  
Folic Acid Supplementation ◽  
The Philippines ◽  
Reproductive Age ◽  
Women Of Reproductive Age ◽  
Acid Supplementation ◽  
Iron Folic Acid Supplementation ◽  
Iron Folic Acid

scholarly journals Moving beyond individual barriers and identifying multi-level strategies to reduce anemia in Odisha India

2020 ◽  
Author(s):  
Erica Sedlander ◽  
Michael Long ◽  
Satyanarayan Mohanty ◽  
Ashita Munjral ◽  
Jeffrey B. Bingenheimer ◽  
...  
Keyword(s):  
Pregnant Women ◽  
Ecological Model ◽  
Health Workers ◽  
Reproductive Age ◽  
Women Of Reproductive Age ◽  
Indian Government ◽  
Iron Supplements ◽  
Individual Level ◽  
Supplement Use ◽  
The Government

Abstract Background: To reduce the prevalence of anemia, the Indian government recommends daily iron and folic acid supplements (iron supplements) for pregnant women and weekly iron supplements for adolescents and all women of reproductive age. The government has distributed free iron supplements to adolescents and pregnant women for over four decades. However, initial uptake and adherence remain inadequate and non-pregnant women of reproductive age are largely ignored. The aim of this study is to examine the multilevel barriers to iron supplement use and to subsequently identify promising areas to intervene. Methods: We conducted a qualitative study in the state of Odisha, India. Data collection included key informant interviews, focus group discussions with women, husbands, and mothers-in-law, and direct observations in health centers, pharmacies and village health and nutrition days. Results: We found that at the individual level, participants knew that iron supplements prevent anemia but underestimated anemia prevalence and risk in their community. Participants also believed that taking too many iron supplements during pregnancy would “make your baby big” causing a painful birth and a costly cesarean section. At the interpersonal level, mothers-in-law were not supportive of their daughters-in-law taking regular iron supplements during pregnancy but husbands were more supportive. At the community level, participants reported that only pregnant women and adolescents are taking iron supplements, ignoring non-pregnant women altogether. Unequal gender norms are also an upstream barrier for non-pregnant women to prioritize their health to obtain iron supplements. At the policy level, frontline health workers distribute iron supplements to pregnant women only and do not follow up on adherence. Conclusions: Interventions should address multiple barriers to iron supplements use along the socio-ecological model. They should also be tailored to a woman’s reproductive life course stage: adolescents, pregnancy, and non-pregnant women of reproductive age because social norms and available services differ between the subpopulations.

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