Promoting iron folic acid consumption using social norms as a mechanism of change in the Reduction in Anemia through Normative Innovations (RANI) project: a randomized controlled trial.

backgroundMore than 60% of women of reproductive age in Odisha, India are anemic. The national long-term efforts in reducing anemia have focused mostly on the supply side, with a paucity of campaigns on the demand side. Social norms serve as significant determinants of human behavior, but there are few interventions that adopt a social-norms approach to reducing anemia. An intervention was implemented to change descriptive, injunctive, and collective social norms to improve iron folic acid consumption behaviors among women of reproductive age.

methodsA longitudinal cluster randomized controlled trial was conducted to collect data at baseline, six months later at midline, and a year after that at end-line. All villages in our study area were formed into clusters, randomly assigned to either the treatment (50 clusters with 130 villages) or the control (39 clusters with 109 villages) arm. Women were eligible for inclusion if they aged between15 and 49, spoke Odiya, and did not plan to move in the next year. Women living in treatment communities received the intervention package that comprised community-based education sessions, health communication videos, and hemoglobin testing.

resultsData analyses included 2,061 women in the treatment arm and 2,049 women in the control arm enrolled in the trial at baseline. Hierarchical linear models revealed that all three types of social norms improved significantly more in treatment than in control communities (all p's < 0.001) at midline. Two of the norms (descriptive and collective but not injunctive norms) predicted iron folic acid consumption at end-line. The relative improvement in iron folic acid consumption over time was significantly greater in treatment communities (p <.001).

conclusionsIt appears that a social norms-based intervention can change longer-term iron and folic acid consumption behaviors to reduce anemia. Future practice may merit having norms-based strategies to promote adherence to micronutrient supplementation and medical guidelines among women. This demand-side approach will be particularly useful in resource-limited settings where the health system is inadequately prepared to procure and distribute supplements.

trial registrationThis trial was registered with Clinical Trials Registry- India (CTRI) (CTRI/2018/10/016186) on 29 October 2018.