Iron and Folic Acid Consumption and Changing Social Norms: Cluster Randomized Field Trial, Odisha, India

"...results show that social norms can be improved and that these improvements are associated with positive behavioural changes."

More than half of Indian women of reproductive age have iron deficiency anaemia, which leads to fatigue and can cause preterm delivery and maternal mortality. Reduction in Anaemia through Normative Innovations (RANI) project is a multi-year effort to lower rates of anaemia among women in Odisha, India, using a social norms approach. This study considered whether a field experiment could improve social norms and thereby improve iron and folic acid consumption.

As the researchers explain, social norm theories assert that people's behaviours are guided, to some extent, by the behaviours of others in their midst and their own understanding of the expectations of other people. Research shows that three types of social norms can influence behaviours: Individuals engage in a behaviour when they believe other people are also engaging in this behaviour (i.e., descriptive norms) and that other people approve of that behaviour (i.e., injunctive norms). Collective norms refer to the true prevalence of a behaviour within a community.

Beginning in January of 2019, the researchers conducted a 6-month mixed-method formative research project in two out of eight blocks (Kishorenagar and Athmalik) in Angul district in Odisha. The findings of this research led to the decision to adopt a gender perspective in RANI that reached out not only women of reproductive age (the focal audience) but also their social networks (e.g., husbands and mothers-in-law) and community leaders. The researchers also identified the need to provide education to communicate that fatigue was part of anaemia and that anaemia could be treated by taking iron and folic acid tablets.

Delivered from the beginning of September 2019 until the end of February 2020, RANI consisted in:

• Educational modules (4Ts):
  1. Teaching: educating community facilitators about the social, behavioural, biomedical, and normative aspects of anaemia;
  2. Training: coaching the facilitators on how to convey this information through 10 locally relevant 1-hour modules featuring interactive activities and games structured around prevailing norms identified during the formative research;
  3. Tuning: adapting the overall intervention approach as new information becomes available; and
  4. Talking: promoting discussions to spread campaign messages.
• Haemoglobin testing of 15 women every month: After the test, women received blood-shaped cards of different colours indicating anaemia severity, together with relevant behavioural suggestions and recommendations for consuming iron-rich foods and iron and folic acid tablets. The researchers shared test results with participants in three forms of feedback: ipsative (comparing the woman's current haemoglobin reading with her readings in the past); normative (comparing the woman's current haemoglobin result with those of other people in her community); and aspirational (comparing the woman's current haemoglobin reading with healthy haemoglobin levels). All women received normative and aspirational feedback; only women who had had previous haemoglobin tests within the project received ipsative feedback. The researchers also tabulated the readings for each community for the purposes of comparison, sharing them (aggregated to protect privacy) with key stakeholders such as policymakers.
• Communication videos: During the formative research, the researchers collected local stories to develop short videos, which were shot locally using local residents as actors. The videos highlighted the key messages of the programme (including modelling positive social norms around iron and folic acid consumption) and addressed barriers identified during the formative research. The researchers showed the videos to small groups on tablet computers, and individual viewers watched them on smartphones.
• Supply monitoring, including advocacy efforts with the local administration officials and training of frontline workers to monitor and proactively act when the iron and folic acid supply appeared to be falling.

To bring about change in descriptive norms, the intervention materials communicated that more and more women were beginning to consume iron and folic acid to reduce anaemia. To bring about change in injunctive norms, the intervention materials depicted the level of support that women of reproductive age could expect to receive from others in their communities, including their mothers-in-law, husbands, friends and government officials.

The researchers assessed changes in these norms and self-reported iron and folic acid consumption in control and intervention arms after 6 months. They collected data from control (n=2,048) and intervention (n=2,060) arms at baseline and follow-up (n=1,966 and n=1,987, respectively). For collective norms, the researchers calculated the average number of iron and folic acid tablets consumed in each village (minus the respondent's score to reduce biased covariance with the outcome) at baseline and follow-up.

The results indicate that, at follow-up, mean scores in self-reported iron and folic acid consumption in the control arm had decreased from 0.39 to 0.31 (21% decrease; not significant). In the intervention arm, mean scores increased from 0.39 to 1.62 (315% increase; P<0.001). The difference between the two arms was statistically significant (P<0.001). Each of the three norms also improved at significantly higher rates in the intervention than in the control arm (P<0.001 for each norm). Changes in descriptive and collective norms (but not injunctive norms) were associated with changes in self-reported iron and folic acid consumption (P<0.001 for both norms).

In short, RANI was found to have improved descriptive, injunctive, and collective norms associated with self-reported iron and folic acid consumption. Improvement in these norms, in turn, affected self-reported iron and folic acid consumption behaviours. "These norms-related findings highlight that perceptions matter: when people believe other people are engaging in a behaviour and perceive pressures to conform, they are more likely to adopt this behaviour. Therefore, interventions to address anaemia need to communicate information about the consumption behaviours of other people to their target audience, highlighting the improving environment." The researchers suspect that through the monthly haemoglobin testing sessions, information about improvements in the community was passed on to other women, i.e., that more and more women were taking iron and folic acid, which was improving their health.

In conclusion, the researchers suggest that the study's rural setting "shares similar challenges to those faced by other middle-income countries where women's reduced levels of empowerment, decision-making and autonomy combine to suppress progress on their health and well-being (as has been the case for anaemia in India)....[A] social norms-based approach, of the type adopted in this project, can shift the responsibility for change from women themselves to their larger community..."