Unpacking the relationship between social norms and behavior: how social norms and gender norms affect women’s use of iron folic acid supplements in rural India
Open AccessWhile the Indian government provides free iron supplements to women of reproductive age, demand is low and endemic levels of anemia persist. Yet research is sparse on how to increase demand and why demand is low, particularly among women who are not pregnant. In three papers, this dissertation uses data from the RANI project, Reduction in Anemia through Normative Innovations, a cluster randomized controlled trial that is being implemented in Odisha, India. Paper #1 uses the formative research qualitative data and papers #2 and #3 use baseline data. Paper #1 qualitatively examines the multilevel barriers to iron supplement use and identifies areas to intervene. We found that participants knew that iron supplements prevent anemia but greatly underestimated anemia prevalence in their community. Participants also believed that taking too many supplements during pregnancy would “make your baby big” causing a painful birth and a costly cesarean section. They reported that only pregnant women and adolescents are taking iron supplements, ignoring non-pregnant women altogether. Unequal gender norms are also an upstream barrier to women thinking about their own wellbeing. Frontline health workers distribute iron supplements to pregnant women only and do not follow up on adherence. Iron supplement demand interventions need to be tailored to a woman’s reproductive life course stage (adolescents, pregnancy, and non-pregnant women) because social norms and available services differ between the subpopulations.In paper #2, we used a mixed-methods approach to develop and validate a novel gender norms scale. We tested two hypotheses and then evaluated psychometric properties using confirmatory factor analysis and structural equation modeling. The analysis resulted in two sub scales with high internal validity, “descriptive gender norms” and “injunctive gender norms.” We examined differences among sub groups and found that younger, more educated women reported more equitable gender norms than their counterparts. This scale improves on existing measures by incorporating concepts within social norms theory and moving beyond individual attitudes by assessing women’s perceptions of community-level gender norms.In paper #3, we describe the current state of iron supplement use and examine associations with intentions to take iron supplements among women who are not pregnant. We found that most women in our sample were anemic but less than 5% of women knew they were anemic. Despite national guidelines, less than 3% of women in our sample were currently taking iron supplements. However, average intentions to take iron supplements were rather high and intentions and iron supplement use were significantly correlated. Several factors were associated with intentions to take iron supplements including younger age, currently breastfeeding, accurate knowledge about anemia, self-efficacy, beliefs around the benefits of iron supplements, injunctive norms around iron supplements, and collective norms around iron supplement intentions. Addressing factors at different levels of the socio-ecological model may increase intentions to take iron supplements but more resources should focus on reducing the prevalence of anemia among women who are not pregnant. Overall, findings from this dissertation show that to truly increase iron supplement use thereby decreasing anemia, interventions need to take a multi-level approach that is tailored to the different stages of a woman’s reproductive life course. We found that gender norms were an upstream barrier to use, that unequal gender norms were prevalent, and that women who were not pregnant were largely ignored (despite making up the largest sub group of people with anemia). While pregnant women’s health is important given the inter-generational nature of anemia, women’s health alone should not be ignored.
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Sedlander_gwu_0075A_15023.pdf | 2020-05-15 | Open Access |
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