Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2020 Apr 6;20(1):457.
doi: 10.1186/s12889-020-08574-z.

Moving beyond individual barriers and identifying multi-level strategies to reduce anemia in Odisha India

Erica Sedlander  1 , Michael W Long  2 , Satyanarayan Mohanty  3 , Ashita Munjral  4 , Jeffrey B Bingenheimer  2 , Hagere Yilma  2 , Rajiv N Rimal  2   5
Affiliations

Moving beyond individual barriers and identifying multi-level strategies to reduce anemia in Odisha India

Erica Sedlander et al. BMC Public Health. .

Abstract

Background: To reduce the prevalence of anemia, the Indian government recommends daily iron and folic acid supplements (iron supplements) for pregnant women and weekly iron supplements for adolescents and all women of reproductive age. The government has distributed free iron supplements to adolescents and pregnant women for over four decades. However, initial uptake and adherence remain inadequate and non-pregnant women of reproductive age are largely ignored. The aim of this study is to examine the multilevel barriers to iron supplement use and to subsequently identify promising areas to intervene.

Methods: We conducted a qualitative study in the state of Odisha, India. Data collection included key informant interviews, focus group discussions with women, husbands, and mothers-in-law, and direct observations in health centers, pharmacies and village health and nutrition days.

Results: We found that at the individual level, participants knew that iron supplements prevent anemia but underestimated anemia prevalence and risk in their community. Participants also believed that taking too many iron supplements during pregnancy would "make your baby big" causing a painful birth and a costly cesarean section. At the interpersonal level, mothers-in-law were not supportive of their daughters-in-law taking regular iron supplements during pregnancy but husbands were more supportive. At the community level, participants reported that only pregnant women and adolescents are taking iron supplements, ignoring non-pregnant women altogether. Unequal gender norms are also an upstream barrier for non-pregnant women to prioritize their health to obtain iron supplements. At the policy level, frontline health workers distribute iron supplements to pregnant women only and do not follow up on adherence.

Conclusions: Interventions should address multiple barriers to iron supplement use along the socio-ecological model. They should also be tailored to a woman's reproductive life course stage: adolescents, pregnancy, and non-pregnant women of reproductive age because social norms and available services differ between the subpopulations.

Keywords: Gender norms; India; Iron deficiency anemia; Social norms.

PubMed Disclaimer

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Behaviors by reproductive life course stage
Fig. 2
Fig. 2
How factors interact to influence behavior
Fig. 3
Fig. 3
Suggested intervening factors
See this image and copyright information in PMC

References

    1. Aguayo VM, Paintal K, Singh G. The adolescent girls’ Anaemia control Programme: a decade of programming experience to break the intergenerational cycle of malnutrition in India. Public Health Nutr. 2013;16(9):1667–1676. doi: 10.1017/S1368980012005587. - DOI - PMC - PubMed
    1. Alam A, Rasheed S, Khan NU, et al. How can formative research inform the design of an iron-folic acid supplementation intervention starting in first trimester of pregnancy in Bangladesh? BMC Public Health. 2015;15(1):374. doi: 10.1186/s12889-015-1697-2. - DOI - PMC - PubMed
    1. ALIGN . Advancing Learning and Innovation on Gender Norms. 2018.
    1. Baumeister RF, Leary MR. The Need to Belong: Desire for Interpersonal Attachments as a Fundamental Human Motivation; 1995. p. 33. - PubMed
    1. Berger J, Dillon JC. Control of iron deficiency in developing countries. Sante. 2002;12(1):22–30. - PubMed

MeSH terms