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 supplement use along the socio-ecological model. They should also be tailored to a woman's reproductive life course stage: adolescents, pregnancy, and nonpregnant 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

“…Our findings are in line with recent evidence 15 from rural Odisha, positing social and unequal gender norms in community that deprioritize women’s preventive health, especially in non-pregnant women of 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.…”

“…Our findings are in line with recent evidence 15 from rural Odisha, positing social and unequal gender norms in community that deprioritize women’s preventive health, especially in non-pregnant women of 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. Triangulating our quantitative evidence, derived from a nationally representative survey with qualitative understanding of barriers to anemia prevention, 15 adds strength to our argument, that socio-cultural norms, valuing women’s well-being, as captured by community-level women’s education is an important determinant of adolescent hemoglobin.…”

“…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. Triangulating our quantitative evidence, derived from a nationally representative survey with qualitative understanding of barriers to anemia prevention, 15 adds strength to our argument, that socio-cultural norms, valuing women’s well-being, as captured by community-level women’s education is an important determinant of adolescent hemoglobin.…”

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.…”

Determinants of work capacity (predicted VO2max) in non-pregnant women of reproductive age living in rural India

“…For example, they tend to eat only after everyone else in the family has eaten and thus, are often left with inadequate and poor quality food. Anemia is then exacerbated in these women, as they tend not to seek medical care for their own health and physical weakness is understood to be part of their identity as women [ 11 ].…”