Improving Uptake of Iron and Folic Acid Supplementation Among Pregnant Women

Scaling iron-folic acid (IFA) supplementation is crucial to addressing iron-deficiency anaemia. Daily iron supplementation provides more protection against declining iron levels in pregnant women than other strategies. However, adherence to daily tablet consumption is a habitual individual behaviour, which is often challenging to trigger without environmental cues or explicitly visible goals. Existing supply-side infrastructure to ensure delivery of IFA tablets and their proven efficacy in reducing anaemia make improving the uptake of IFA supplementation a critical behavioural challenge to solve.

Introduction

India is among the worst-performing countries in the world for anaemia among women, and over 50% of pregnant women between the ages of 15-49 are anaemic (NFHS-5). An effective way to combat anaemia is to increase the consumption of an Iron and Folic Acid (IFA) supplement for 180 days during pregnancy. However, compliance with supplement consumption remains low. In 2014, self-reported compliance among pregnant women in India was 30%. In spite of the fact that centrally sponsored schemes focused on anaemia reduction in India have been running since the 1970s, anaemia continues to be a prevalent disease. The problem, therefore, points to unaddressed demand-side factors. To address challenges accompanying high rates of anaemia, CSBC adopted a behavioural approach to target IFA adherence.

Key results

From our experiments, we learnt that goal tracking increases the likelihood of following through with the desired behaviour when attached to a potential incentive. Our two most effective interventions were a counselling card and a goal-tracking calendar. Interestingly, we found that the calendar used in conjunction with the counselling card did not significantly increase the level of adherence to IFA consumption. This may be due to cognitive overload. Thus, a key finding is that information, when presented in the simplest terms, increases the likelihood of pregnant women adhering to daily IFA consumption.

Description and methodology

The project began in 2018, and the first step was to identify and categorise the varying factors that hinder the consumption of IFA tablets. CSBC worked with RTI International to conduct an extensive literature review of India's current context of anaemia.

Based on this review, CSBC developed five behavioural interventions and tested them in a remote lab in Sonipat, Haryana, in late 2018. The interventions included a counselling card, a calendar intervention, IVR message reminders, and testimonials.

The purpose of the interventions was to increase recall and comprehension of the counselling messages, increase awareness regarding coping strategies for side effects of IFA tablets, and test whether an authority figure (i.e., a doctor's word) would add more credibility to the intervention.

Based on the results of the lab-in-the-field experiments, CSBC conducted an in-field randomised control trial in two districts of Madhya Pradesh in 2019. Taking successful interventions from the previous mobile pilot, CSBC administered a randomised control trial of the counselling card and calendar interventions with a sample size of 1,200 pregnant women. The aim was to measure whether the significant results in increased consumption of IFA tablets from the initial experimental testing conducted in 2018 were consistent when we applied the interventions to a larger sample size.

In September 2020, CSBC conducted a randomised control trial in 2 districts of Uttar Pradesh, Bahraich and Shrawasti. The RCT aimed to examine whether framing anaemia as a disease, which increases the risk perceived by pregnant women, would lead to an increase in adherence consumption of IFA tablets.

CSBC conducted this trial in a sample of 1900 pregnant women who received phone counselling (risk-framed) followed by personalised SMS prescriptions, visual colour scale cards, or IVRS reminders. Additionally, CSBC administered a baseline and endline survey to gauge the risk and value perception of IFA tablets before and after the counselling.

Results and highlights

The initial literature review suggested increased dietary intake and focused educational campaigns can increase IFA uptake. Also, approaches that targeted IFA supplementation coupled with disease control initiatives and other micronutrient programmes could effectively reduce rates of anaemia. Additional recurring barriers that hindered efforts to reduce anaemi's prevalence at both district and state levels included inadequate funding, coverage, and availability of supplies. In addition, community healthcare workers had low compliance rates and participation rates.

The counselling card and calendar reminder proved to be the most effective of the five interventions tested in the mobile pilot. In particular, we found that:

1. Visual information is more memorable: The counselling card intervention effectively increased recall and comprehension of shared information. 21% of women in the treatment group correctly recalled that "taking the pill before going to bed" was the best strategy to help with side effects, as opposed to 13% in the control group.
2. An interactive daily tracking tool increased adherence by 14%: Participants who took home a calendar to track the proxy behaviour (missed-calling the number we provided) recorded higher adherence levels. There was no significant difference between pregnant and non-pregnant women in carrying out this behaviour.
3. Showing the food equivalency of IFA pills can increase value perception: After administering the intervention, we measured participants' willingness to contribute to an IFA fund to purchase additional pills in the event of a shortage. The difference in the average amount committed between treatments was statistically significant, indicating that the food equivalency images increased participants' value perception of IFA pills. However, the difference in contribution between pregnant and non-pregnant women was not statistically significant.
4. IVR is cost-effective but difficult to implement for this group: Field implementation for the IVR intervention proved to have challenges that hindered data collection and subsequent analysis of success.

The randomised control trial results were consistent with the results from the lab-in-the-field experiment:

1. Pregnant women who received any treatment recorded higher self-reported adherence than those in the control group (p < 0.05).
2. The calendar intervention increased adherence by 11% in reminding women when to stop consuming IFA tablets.
3. Counselling cards reduced women's likelihood to stop consuming IFA tablets due to their side effects by 9%

In the next stage of this project, we developed comprehensive guidelines to facilitate the scale-up of the IFA interventions across India. More information about this work is available here.