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