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

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.

Community-level women’s education and hemoglobin level among Indian adolescents: A multilevel analysis of a national survey

“…We included a narrow age-range of adolescents in our analysis because of the data constraints. It is suggested that early (10 to 14) and late (15)(16)(17)(18)(19) adolescence differ in health status and its determinants. It is possible that younger adolescents (10 to 14 years), who likely have less autonomy than the older adolescents, could be more affected by several aspects related to norms of care, feeding practices, and other health behaviors, in the family; which in turn are arguably affected by the broader socio-cultural norms and behaviors of the educated women in the community.…”

“…reproductive age, as important beyond individual-level factor, resulting in poor uptake of iron supplementation. Although the focus of their qualitative inquiry was on exploring barriers to iron supplementation in women,15 they have identified the need for addressing social norms, as extra-individual level factors in reducing anemia burden in India. itself is a bar set too low.…”

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

“…The sample description is published elsewhere. 11 The final sample for the perceptual mapping and card sorting exercise comprised women of reproductive age (n=30), mothers-in-law (n=30) and men (n=30). All participants were required to live in the Angul District, speak Odiya, and give written consent before participating.…”

“…A more detailed description of the focus group discussion procedures can be found in a separate study. 11 …”

“…While the literature around the conceptualisation of fatigue as a symptom of illness is limited, recent research in India has shown that inequitable gender norms may indirectly affect a woman’s ability or desire to access iron supplements. 11–14 36 Other studies also show that women in Odisha tend to have less power within the household than their husbands, and carry the majority of the domestic workload burden. 37 As daily life is characterised by large amounts of physical labour (for both men and women), fatigue may be considered a normal part of everyday life, and thus, not a cue to obtain iron supplements.…”