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

Abstract

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.

Study Characteristics of School Adolescent Girls on Iron Folic Acid Supplementation Program as the Prevention of Anemia in Adolescent

“…Age has a negative association with IFA intentions, targeting younger women could be more promising approach. While knowledge only had a minor association with intentions to take IFA (β =0.02, P<0.05) 21 .…”

How does a social norms-based intervention affect behaviour change? Interim findings from a cluster randomised controlled trial in Odisha, India

“…Specifically, we validated qualitative findings that very few non-pregnant women were taking IFA with a specific percentage (less than 3% of women) despite guidelines that all women should take them regularly to prevent anaemia. 21 Therefore, we decided to focus more on injunctive norms messaging (that all women of reproductive age should take IFA) rather than descriptive norms messaging (that women are taking IFA) in the beginning of the intervention.…”

A Social Norms-Based Intervention Improves Dietary Diversity among Women in Rural India: The Reduction in Anemia through Normative Innovations (RANI) Project

“…Social norms messaging was embedded throughout each module, including raising awareness around unequal gender norms, such as eating last and eating less ( Supplementary Table S1 ). We used both formative research and baseline data to examine existing social norms and to inform social norms messaging [ 25 ]. The intervention and the formative research used to design the intervention is described in full detail elsewhere [ 17 , 26 ].…”