Designing a socio-normative intervention to reduce anemia in Odisha India: A formative research protocol

Abstract

Background: More than half of women of reproductive age in India are anemic. Anemia is associated with increased risk of preterm delivery, higher maternal mortality and contributes to fatigue, which affects women’s work productivity. The World Health Organization (WHO) recommends daily oral iron and folic acid (IFA) supplements during pregnancy and weekly supplements for women of reproductive age. Government programs and global donors have distributed and promoted IFA supplements in India for over four decades. However, initial intake and compliance remain inadequate. Objectives: This protocol describes the formative research phase of a larger study, which will test, through a randomized controlled trial, the hypothesis that a social norms-based behavioral intervention in Odisha, India will improve uptake of IFA supplements and reduce anemia among reproductive age women as compared to usual care. The focus of this paper is on the formative research required to develop a sound intervention. We will examine socio-normative barriers to and facilitators of IFA supplement uptake. Methods and analysis: Based on the Theory of Normative Social Behavior, we will adopt a mixed-method, multilevel approach. We will collect data using focus groups, in-depth interviews, observations, Rapid Participatory Ethnographic Evaluation and Research (PEER) techniques, and perceptual mapping methods. Our sample includes reproductive age women (pregnant and not pregnant), their husbands, their mothers/in law and key stakeholders. After analyzing the results, we will hold a convening in India to collaboratively design the intervention. Following the intervention design, we will test components of the intervention, gather user feedback and tweak as necessary. Additionally, to improve adoption and sustainability of the intervention, we will conduct policy dialogue with stakeholders throughout the formative research. Impact: This study will contribute to the social norms and behavioral intervention research and inform policymakers about the value of adopting a socio-normative approach.

Strategies to address anaemia among pregnant and lactating women in India: a formative research study

“…A campaign being conducted in Bihar, India, uses visual reinforcementblood-drop-shaped stickers to be pasted into a booklet with an outline of a babyto show that each IFA tablet helps to create a complete, healthy baby (50) . Another formative research study conducted in Odisha, India, is examining barriers and facilitators to IFA use and adherence using the theory of normative social behaviour to contribute to the development of a large-scale intervention at the individual, interpersonal and community levels to improve uptake of IFA supplements and reduce anaemia among women of reproductive age (14) . These strategies are promising, although they need to be tested to determine efficacy.…”

“…poor adherence can be attributed to supplement side effects; low literacy; unclear instructions that may result in improper dosage (10) ; constipation, gastritis and vomiting among pregnant and lactating women; forgetfulness and misunderstanding the need to continue taking supplements throughout pregnancy (11)(12)(13) . Other low-adherence factors include lack of awareness of anaemia symptoms and not understanding the consequences or the benefits of prevention, low agency within one's household, beliefs about pill consumption during pregnancy, poor utilisation of timeappropriate antenatal services and insufficient counselling by healthcare providers (14,15) .…”

Weight, height, and midupper arm circumference are associated with haemoglobin levels in adolescent girls living in rural India: A cross‐sectional study

“…Out of 110 million Indian adolescent girls, between Anaemia, particularly during the early years of life, may lead to compromised cognitive development affecting school performance and education advancement (Mason et al, 2012), and it has negative influences on social and economic development. The cost of anaemia is estimated to be 6% of India's Gross Domestic Product (Sedlander, Rimal, Talegawkar, Yilma, & Munar, 2018; approximate annual loss of 135 billion USD). India also has a very high prevalence of malnutrition in young children and adolescents.…”

Is fatigue a cue to obtain iron supplements in Odisha, India? A mixed methods investigation

“…The overall goals of the formative research components were larger than the research questions presented here; all of the goals of the formative research beyond this study are outlined the RANI project formative research protocol. 48 …”

“…A more detailed explanation of the perceptual mapping procedure can be found in the Formative Research Protocol. 48 …”