Testing effectiveness of interventions on increasing IFA compliance among pregnant women in India
Summary:
In India, over 50% of pregnant women between the ages of 18-49 are anemic which can lead to negative impacts like premature delivery, low birth weight and maternal mortality. Intake of Iron and Folic Acid (IFA) tablet, provided free of cost by the Indian government, is a proven method to combat anemia. However, self-reported compliance of the tablet amongst pregnant women remains low. The key barriers to IFA tablet uptake and adherence are a lack of knowledge on coping with IFA side-effects, and forgetfulness. We test the effectiveness of two interventions, i) Counselling card on IFA side-effects coping strategy and ii) Goal-tracking device to track IFA dosage, on IFA compliance. Using a Randomized Control Trial setup, we tested interventions among a sample of close to 1300 rural pregnant women. The interventions were delivered through Frontline Health Workers (FLWs) in two districts of Madhya Pradesh, India. We analysed the impact of interventions on participants after a period of 30 days from the time of intervention delivery. On IFA, we measured participants adherence, perception and knowledge of the IFA tablet. We also measured participants knowledge on anemia and side-effects. The study also collected ethnographic and qualitative data during intervention delivery. The final analysis drew from analysis of quantitative, ethnographic and qualitative data. We find that the interventions were successful in increasing self-reported adherence. We also found additional results on IFA side-effects, knowledge and messaging around anemia.
Background/Objectives:
In India, over 50 % of pregnant women between the ages of 18-49 are anemic, which can lead to negative impacts like premature delivery, low birth weight and contribution to maternal mortality. Taking the Iron and Folic Acid (IFA) tablet everyday, is a proven method to combat anemia. Key behavioural barriers around adherence to IFA tablet are lack of knowledge on coping with side-effects, and forgetfulness. We tested the effectiveness of two interventions, i) a counselling card to address barriers of IFA side-effects and ii) a goal-tracking device to address the barrier of forgetfulness.
Description of Intervention and/or Methods/Design:
This study was setup as a Randomized Controlled Trial (RCT) with participation from close to 1300 rural pregnant women in two districts of the Indian state of Madhya Pradesh. The interventions were delivered by Front Line Health Workers (FLWs). The sample was categorized into four groups at baseline. These were, i) Control, which received no intervention; ii), Treatment 1, received FLW counselling using a counselling card with visual graphics on IFA tablet side-effect coping strategy; iii) Treatment 2, received IFA goal-tracking device, containing scratch boxes for marking IFA dosage; and iv) Treatment 3, received combination of Treatment 1 and 2. The endline survey was conducted 30 days after the baseline. Outcomes were measured using self-reported adherence, along with list randomization and biological markers. The study also collected ethnographic and qualitative data during intervention delivery. The final insights drew from an analysis of quantitative, ethnographic and qualitative data.
Results/Lessons Learned:
Compared to the control, the goal-tracking device and counselling card increased the adherence to IFA tablet by 11 percent and 9 percent, respectively and when combined together, increased adherence by 7 percent. Amongst measures for knowledge and recall, the goal-tracking device proved to be effective in helping women remember when to stop taking the IFA tablet by 14 percent. Despite a high prevalence of anemia amongst pregnant women, 56.4 percent, women incorrectly identify symptoms like lower back pain to anemia. On side-effects, we found that women in the counselling card treatment were less likely to stop IFA tablet intake on experiencing any side-effects by 7 percent. Women also reported experiencing side-effects for a period of 8-10 days as opposed to the previously expected 3-7 days. Additionally we found that women perceive anemia to be more dangerous to the unborn baby than the mother.
Discussion/Implications for the Field:
The results offer important insights on communication around the IFA tablet and anemia. Messages which focus on, smoother delivery, information on anemia and its symptoms and healthy baby can prove effective in increasing IFA and anemia awareness. We found the interventions to be effective in addressing key barriers to IFA tablet compliance in a scalable manner. Based on feedback from ethnographic and qualitative interviews, we found that such interventions also proved to be useful job aids for FLWs. The study highlights the need for more hypothesis backed, actionable research to design interventions targeting behaviours for better health outcomes.
Abstract submitted by:
Saksham Singh - Ashoka
Pooja Haldea - Ashoka
Purnima Mehrotra - Ashoka
Anisha Singh - Busara Center
Georgina Mburu - Busara Center
Esther Owelle - Busara Center
In India, over 50% of pregnant women between the ages of 18-49 are anemic which can lead to negative impacts like premature delivery, low birth weight and maternal mortality. Intake of Iron and Folic Acid (IFA) tablet, provided free of cost by the Indian government, is a proven method to combat anemia. However, self-reported compliance of the tablet amongst pregnant women remains low. The key barriers to IFA tablet uptake and adherence are a lack of knowledge on coping with IFA side-effects, and forgetfulness. We test the effectiveness of two interventions, i) Counselling card on IFA side-effects coping strategy and ii) Goal-tracking device to track IFA dosage, on IFA compliance. Using a Randomized Control Trial setup, we tested interventions among a sample of close to 1300 rural pregnant women. The interventions were delivered through Frontline Health Workers (FLWs) in two districts of Madhya Pradesh, India. We analysed the impact of interventions on participants after a period of 30 days from the time of intervention delivery. On IFA, we measured participants adherence, perception and knowledge of the IFA tablet. We also measured participants knowledge on anemia and side-effects. The study also collected ethnographic and qualitative data during intervention delivery. The final analysis drew from analysis of quantitative, ethnographic and qualitative data. We find that the interventions were successful in increasing self-reported adherence. We also found additional results on IFA side-effects, knowledge and messaging around anemia.
Background/Objectives:
In India, over 50 % of pregnant women between the ages of 18-49 are anemic, which can lead to negative impacts like premature delivery, low birth weight and contribution to maternal mortality. Taking the Iron and Folic Acid (IFA) tablet everyday, is a proven method to combat anemia. Key behavioural barriers around adherence to IFA tablet are lack of knowledge on coping with side-effects, and forgetfulness. We tested the effectiveness of two interventions, i) a counselling card to address barriers of IFA side-effects and ii) a goal-tracking device to address the barrier of forgetfulness.
Description of Intervention and/or Methods/Design:
This study was setup as a Randomized Controlled Trial (RCT) with participation from close to 1300 rural pregnant women in two districts of the Indian state of Madhya Pradesh. The interventions were delivered by Front Line Health Workers (FLWs). The sample was categorized into four groups at baseline. These were, i) Control, which received no intervention; ii), Treatment 1, received FLW counselling using a counselling card with visual graphics on IFA tablet side-effect coping strategy; iii) Treatment 2, received IFA goal-tracking device, containing scratch boxes for marking IFA dosage; and iv) Treatment 3, received combination of Treatment 1 and 2. The endline survey was conducted 30 days after the baseline. Outcomes were measured using self-reported adherence, along with list randomization and biological markers. The study also collected ethnographic and qualitative data during intervention delivery. The final insights drew from an analysis of quantitative, ethnographic and qualitative data.
Results/Lessons Learned:
Compared to the control, the goal-tracking device and counselling card increased the adherence to IFA tablet by 11 percent and 9 percent, respectively and when combined together, increased adherence by 7 percent. Amongst measures for knowledge and recall, the goal-tracking device proved to be effective in helping women remember when to stop taking the IFA tablet by 14 percent. Despite a high prevalence of anemia amongst pregnant women, 56.4 percent, women incorrectly identify symptoms like lower back pain to anemia. On side-effects, we found that women in the counselling card treatment were less likely to stop IFA tablet intake on experiencing any side-effects by 7 percent. Women also reported experiencing side-effects for a period of 8-10 days as opposed to the previously expected 3-7 days. Additionally we found that women perceive anemia to be more dangerous to the unborn baby than the mother.
Discussion/Implications for the Field:
The results offer important insights on communication around the IFA tablet and anemia. Messages which focus on, smoother delivery, information on anemia and its symptoms and healthy baby can prove effective in increasing IFA and anemia awareness. We found the interventions to be effective in addressing key barriers to IFA tablet compliance in a scalable manner. Based on feedback from ethnographic and qualitative interviews, we found that such interventions also proved to be useful job aids for FLWs. The study highlights the need for more hypothesis backed, actionable research to design interventions targeting behaviours for better health outcomes.
Abstract submitted by:
Saksham Singh - Ashoka
Pooja Haldea - Ashoka
Purnima Mehrotra - Ashoka
Anisha Singh - Busara Center
Georgina Mburu - Busara Center
Esther Owelle - Busara Center
Source
Approved abstract for the postponed 2020 SBCC Summit in Marrakech, Morocco. Provided by the International Steering Committee for the Summit. Image credit: Busara