The Effects of the RANI Project on 6-Month Physical Activity Among Women Living in Rural India: A Randomized-Controlled Trial.

Background: Anemia is associated with fatigue, low physical activity, and poor quality of life. The purpose of this study was to determine the effects of a field trial on 6-month change in anemia and physical activity among nonpregnant women living in rural India. Methods: The Reduction in Anemia through Normative Innovations (RANI) Project is a cluster randomized controlled trial of a social norms-based intervention to reduce anemia among women (15-49 years). Participants (n = 292) performed a modified Queen's College Step Test (QCST) and wore an ActivPAL accelerometer for 3 days. Hemoglobin concentrations (g/dL) were determined using a HemoCue 301 photometer. Linear regression tested the effects of the intervention on 6-month change in hemoglobin and physical activity, while adjusting for age, body mass index, education, parity, and predicted VO2max. Results: We observed no differences in hemoglobin (11.8 ± 1.2 vs.11.6 ± 1.4 g/dL) or overall physical activity (36.6 ± 2.1 vs. 35.3 ± 5.8 metabolic equivalent of task-hours/day) at 6 months between the treatment and control groups, respectively. In contrast, steps/day was significantly higher in the treatment, compared with the control group (ß = 1353.83; 95% confidence interval: 372.46, 2335.31), independent of other covariables. Conclusions: The potential to modify walking and other health-seeking behaviors using a social norms approach is worthy of further investigation among women living in rural India.Clinical Trial Registry - India: CTRI/2018/10/016186.

Interpersonal Communication Strategies to Increase Iron-Folic Acid Supplement Consumption: Reduction in Anemia Through Normative Innovations (RANI) Project.

More than half of women of reproductive age in India are anemic. This study investigates the role of interpersonal communication in increasing the consumption of iron-folic acid supplements. Interventions that increase interpersonal communication may influence and empower individuals and the larger community in promoting behavior change. This investigation uses data from a cluster randomized intervention to understand the pathways by which interpersonal communication mediates the consumption of iron-folic acid supplements. Longitudinal data from control and intervention arms in rural Odisha, India, were collected at baseline (N = 3,691) and 20 months later at end-line (N = 3,394). Structural equation models highlighted the positive role of interpersonal communication in mediating iron-folic acid supplement use. This study illustrates that even during social distancing due to COVID-19, strategic interpersonal communication can improve iron-folic acid supplement use. Our results elucidate two key interpersonal communication pathways at play, namely the ritualistic and instrumental pathways in improving health behavior change in the community.

How does a social norms-based intervention affect behaviour change? Interim findings from a cluster randomised controlled trial in Odisha, India.

BACKGROUND: Behaviour change interventions targeting social norms are burgeoning, but researchers have little guidance on what they look like, and which components affect behaviour change. The Reduction in Anaemia through Normative Innovations (RANI) project designed an intervention to increase iron folic acid (IFA) consumption in Odisha, India. OBJECTIVE: This paper examines the effect of the intervention at midline to understand which components of the RANI intervention affect uptake. METHODS: Using a cluster randomised controlled design, we collected baseline data and midline data 6 months later from women of reproductive age in the control and treatment arms (n=3800) in Angul, Odisha, India. Using nested models, we analysed data from three different intervention components, monthly community-based testing for anaemia, participatory group education sessions, and videos, to determine the extent to which exposure to each of these components accounted for the overall intervention effect on haemoglobin and self-reported IFA use. RESULTS: Overall, residing in a treatment as opposed to control village had little effect on midline haemoglobin, but increased the odds of taking supplements by 17 times. Exposure to each of the intervention components had a dose-response relationship with self-reported IFA use. These components, separately and together, accounted for most of the overall effect of treatment assignment on IFA use. CONCLUSIONS: All intervention components increased iron supplement use to differing degrees of magnitude. It appears that a social norms-based approach can result in improving IFA uptake, though improvements in haemoglobin counts were not yet discernible.

Multilevel theorizing in health communication: Integrating the Risk Perception Attitude (RPA) framework and the Theory of Normative Social Behavior (TNSB).

Research testing the risk perception attitudes (RPA) framework has demonstrated that efficacy can moderate the effect of risk perceptions on behavior. This effect of efficacy has also been seen at the social-level through tests of the theory of normative social behavior (TNSB). We tested if efficacy could bridge normative factors at a social-level and risk perception at an individual-level. Data for this study come from the Reduction in Anemia through Normative Innovations (RANI) project's baseline survey in Odisha, India. We used hierarchical regressions to analyze interactions between predictors at various levels and efficacy to predict behavioral intention. Efficacy beliefs moderated the effect of injunctive norms (ß = 0.07, p < 0.01), collective norms (ß = 0.06, p < 0.01), and risk perception (ß = 0.04, p < 0.01) on intentions. This study provides preliminary evidence for a multilevel theoretical framework.

If fear of infertility restricts contraception use, what do we know about this fear? An examination in rural Ethiopia.

BACKGROUND: Ethiopia has made great progress toward reducing unmet need for family planning and increasing contraception use over the last decade. However, almost one-quarter of women still have an unmet need. The primary reason for non-use is "method-related health concerns" and, within this broad category, the belief that using contraception will cause infertility is common. This belief extends beyond Ethiopia to low-, middle-, and high-income countries across the world. The objective of this paper is to examine associations with the belief that contraception use causes infertility and to subsequently suggest potential strategies to address this misperception. METHODS: We collected data from women of reproductive age (between 15 and 49 years old) in 115 rural districts of Ethiopia (n = 706). Our main outcome variable was the belief that contraception causes infertility. We analyzed data, both individual-level factors and interpersonal factors, using nested logistic regression models. RESULTS: Almost half of women in our sample (48.2%) believed that contraceptive use causes infertility. In the final model that included factors from both levels, self-efficacy to use contraception (AOR = 0.81, p < 0.05), visiting a health center and speaking to a provider about family planning in the last 12 months (AOR = 0.78, p < 0.05), and husband support of contraception (AOR = 0.77, p < 0.01) were associated with a reduction in the odds of believing that contraception causes infertility. The belief that infertility will result in abandonment from one's husband (AOR = 3.06, p < 0.001) was associated with an increase in the odds of holding the belief that contraception causes infertility. A home visit in the last 12 months from a health worker who discussed family planning was not associated with the belief that contraceptive use causes infertility. CONCLUSIONS: Given that this belief is both salient and positively associated with other fears such as abandonment from one's husband, it is critical for family planning programs to address it. Communication campaigns or interventions that address this misperception among couples may diminish this belief, thereby increasing contraception use and reducing unmet need in rural Ethiopia.

Qualitative research in sub-Saharan Africa has shown that women's belief that contraception use causes infertility is a barrier to contraception use. In this paper, we examine different factors related to this belief and suggest strategies to address this misperception. We surveyed 706 married women from 115 rural districts of Ethiopia. We found that women who believed that infertility would result in abandonment from one's husband had three times higher odds of believing that contraception causes infertility. We also found that some factors associated with a decreased odds in holding this belief included self-efficacy to use contraception, visiting a health center and speaking to a provider about family planning, and husband support of family contraception. A home visit from a health extension worker who discussed family planning was not associated with holding this belief. Our findings suggest some ways to address this misconception. Clearly, women's own self-efficacy, or believing that they can use family planning, is an important piece to any intervention. Given that husbands' support of contraception is associated with reduced odds of holding the belief that contraception causes infertility, including them in intervention efforts is also a logical step. Finally, a home visit from a health extension worker was not associated with reduced odds of holding this belief. Including information that contraception does not cause infertility and discussing the real causes of infertility as part of their education strategy may help debunk this myth and thereby reduce unmet need in rural Ethiopia.

Improving iron folic acid consumption through interpersonal communication: Findings from the Reduction in Anemia through Normative Innovations (RANI) project.

OBJECTIVE: More than half of Indian women of reproductive age are anemic. Regular iron folic acid uptake can prevent and treat anemia. This study investigated the effect of interpersonal communication on improving IFA use among women of reproductive age. METHODS: The Reduction in Anemia through Normative Innovations (RANI) Project is a cluster randomized trial that collected longitudinal data from control (n = 1896) and intervention (n = 1898) communities in Odisha, India at Time 1 and six months later at Time 2. Structural equation models assessed the effect of the intervention on iron folic acid use via multiple interpersonal communication pathways. RESULTS: Compared to the control arm, iron folic acid use significantly increased in the intervention arm. Both, general health interpersonal communication and anemia-specific interpersonal communication were augmented in the intervention communities. The impact of the intervention on iron folic acid use was mediated through anemia-specific interpersonal communication. CONCLUSION: The RANI Project increased interpersonal communication among participants, resulting in increased iron folic acid use for anemia reduction. PRACTICE IMPLICATIONS: Strategic use of targeted interpersonal communication to promote behavior change appears to be a viable strategy to increase iron folic acid use to reduce anemia.

Descriptive, Injunctive, and Collective Norms: An Expansion of the Theory of Normative Social Behavior (TNSB).

We propose and test several hypotheses derived from the expanded theory of normative social behavior (TNSB) that also includes collective norms (with descriptive and injunctive norms). Data come from a quasi-experiment intervention to promote safer driving among adolescents in Serbia. The intervention was administered among high school students, most of whom were on the verge of receiving their driver's licenses. Longitudinal data were collected from treatment and control schools at baseline (N = 1,449) and four months later at end line (N = 1,072). Descriptive norms at baseline predicted six-month changes in safer-driving intentions among women (ß = .010 p < .05) but not among men. Main-effects of injunctive and collective norms were not significant. However, a significant interaction between descriptive norms and collective norms emerged among men (though not among women) and injunctive norms interacted with both collective norms and descriptive norms among women (but not among men). Initial evidence adds credence to the idea of enhancing the TNSB by adding both injunctive and collective (together with descriptive) norms as drivers of behaviors.

Iron and folic acid consumption and changing social norms: cluster randomized field trial, Odisha, India.

OBJECTIVE: To assess whether improvements in social norms related to iron and folic acid consumption are associated with increased iron and folic acid consumption. METHODS: In a cluster randomized trial in Odisha, India, we implemented an intervention to improve descriptive norms (people's perceptions about how many other people take iron and folic acid), injunctive norms (social pressures people feel to take iron and folic acid) and collective norms (actual levels of iron and folic acid consumption). We assessed changes in these norms and self-reported iron and folic acid consumption in control and intervention arms after 6 months (September 2019-February 2020). We collected data from control (n = 2048) and intervention (n = 2060) arms at baseline and follow-up (n = 1966 and n = 1987, respectively). FINDINGS: At follow-up, mean scores in self-reported iron and folic acid consumption in the control arm had decreased from 0.39 to 0.31 (21% decrease; not significant). In the intervention arm, mean scores increased from 0.39 to 1.62 (315% increase; P < 0.001). The difference between the two arms was statistically significant (P < 0.001). Each of the three norms also improved at significantly higher rates in the intervention than in the control arm (P < 0.001 for each norm). Changes in descriptive and collective norms (but not injunctive norms) were associated with changes in self-reported iron and folic acid consumption (P < 0.001 for both norms). CONCLUSION: Our results show that social norms can be improved and that these improvements are associated with positive behavioural changes. A social norms-based approach may help promote iron and folic acid consumption in India.

mHealth for Anemia Reduction: Protocol for an Entertainment Education-Based Dual Intervention.

BACKGROUND: More than half of the women of reproductive age (aged 15-49 years) are anemic in India. The uptake of and adherence to iron folic acid (IFA) supplements remain low despite sustained efforts to increase their use. With India's burgeoning digital environment, mobile phones offer a potential medium for increasing their uptake, especially when combined with interactive voice messages that deliver entertaining stories infused with norms-based educational messages. OBJECTIVE: This study aims to investigate whether a norms-based entertainment education mobile health intervention can increase self-efficacy for IFA adherence among women of reproductive age in Odisha, India. METHODS: Mobile reduction in anemia through normative innovations (mRANI) is a randomized 2-arm study that includes assessments before and after the intervention. All study participants will be recruited from the intervention arm of the parent reduction in anemia through normative innovations trial only. Although the usual practice is to randomize participants either to a treatment arm or a usual care control arm, we will assign the mRANI control group to another entertainment education-based treatment group that is designed to improve bystander intervention to reduce violence against women. Data collection for the mRANI study is embedded in the parent trial and will include baseline and end line assessments. The primary outcomes are self-efficacy for IFA adherence and violence against women-related bystander intervention. The inclusion criteria for the mRANI study are participation in the parent trial and phone ownership. Women (approximately n=400) who meet the mRANI inclusion criteria will be randomly assigned to the IFA arm or the bystander arm. Ordinary least squares regression with robust SEs will be conducted to assess between-group comparisons at the end line. A mediation analysis will be conducted to examine whether social norms and interactivity mediate the relationship between intervention exposure and primary outcomes in both arms. Real-time monitoring data will offer insights into intervention receptivity and audience engagement. RESULTS: Data collection for the mRANI study is integrated within the parent trial. Household surveys were conducted between February and March of 2021. Responses on the mRANI study's primary and secondary outcomes were collected from 381 participants. The data analysis is expected to be completed by October 2021. CONCLUSIONS: This study will provide evidence on whether a mobile health norms-based entertainment education intervention can increase self-efficacy for IFA adherence and violence against women-related bystander intervention. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/26252.

Determinants of work capacity (predicted VO2max) in non-pregnant women of reproductive age living in rural India.

BACKGROUND: The negative impact of anemia on work capacity has been studied extensively in male and female workers; however, the simultaneous contributions of confounding variables such as physical activity, as well as other behavioral and sociodemographic characteristics have not been considered. The purpose of this study was to examine cross-sectionally the multivariable correlates of work capacity in non-pregnant women (n = 330) living in rural India. METHODS: The Reduction in Anemia through Normative Innovations (RANI) Project is a norms-based, clustered randomized controlled trial to reduce anemia among women (15-49 years) living in Odisha, India between 2018 and 2021. For the larger trial, 89 clusters of villages were randomized into treatment and control groups on a 1:1 basis. Women (2055/group) living in 15 selected clusters (40-41 villages) were then randomly selected for data collection. The sampling design also randomly-generated a subset (n = 375) of non-pregnant participants who performed a modified Queen's College Step Test (QCST) and who wore an activity monitor for 3 days. Predicted work capacity (VO2max) was determined using the QCST. Levels (h/day) of daily reclining, sitting, standing, walking (steps/day), and energy expenditure (MET∙h/day) were determined using an ActivPAL accelerometer. Hemoglobin concentrations (g/dL) were determined using a HemoCue photometer. Predetermined hierarchical (non-multilevel) regression models tested the independent associations between the primary study variables of interest (physical activity, hemoglobin concentrations) and predicted VO2max, while adjusting for age, body mass index (BMI: kg/m2), education, parity, and dietary diversity score. RESULTS: Approximately 61% of the participants had anemia (Hb < 12 g/dL). Age2 (ß = - 0.01; 95% CI: - 0.01, 0.00), BMI (ß = - 0.19; 95% CI:-0.28, - 0.09), educational attainment (ß = - 1.35; 95% CI: - 2.34, - 0.36), and MET∙h/day (ß = 0.19; 95% CI: 0.00, 0.38) were significant and independent determinants of work capacity. Hemoglobin concentration was marginally associated with work capacity in the presence of the other covariables (ß = 0.22; 95% CI:-0.02, 0.47). CONCLUSIONS: Our data indicate that factors other than anemia are important correlates of work capacity and should be considered when promoting the health and economic capacity of rural Indian women. TRIAL REGISTRATION: Clinical Trial Registry- India (CTRI) http://ctri.nic.in/Clinicaltrials/pmaindet2.php?trialid=26285&EncHid=&userName=CTRI/2018/10/016186 on 29 October 2018.

Is fatigue a cue to obtain iron supplements in Odisha, India? A mixed methods investigation.

OBJECTIVES: This study aims to understand if fatigue, the main symptom of anaemia, is a health concern that cues women and their referent groups to obtain iron folic acid supplements. DESIGN: This is a mixed methods study that consisted of a cross-sectional perceptual mapping and card sorting activity along with 16 focus group discussions with women of reproductive age, mothers-in-law and men. Participants of the perceptual mapping and card sorting activity were asked to compare images of anaemia-related items and concepts. Participants in the focus group discussions were asked about their daily life, aspirations and concerns among women and perceptions of anaemia and iron supplementation in the community. The quantitative data were analysed through multidimensional scaling and analyses of variance in SPSS. The qualitative data were analysed through applied thematic analysis using NVivo. SETTING: Bhubaneswar, Odisha, India. PARTICIPANTS: Women of reproductive age (n=30), mothers-in-law (n=30) and married men (n=30) were randomly selected to participate in the perceptual mapping and card sorting exercise. A separate sample of each group was randomly selected for the focus group discussions (n=148). PRIMARY AND SECONDARY OUTCOME MEASURES: We collected perceptions of dissimilarity between anaemia-related items, including fatigue and medical items; the extent to which these items were perceived as important to health or likable; and qualitative information about gender norms. RESULTS: Cognitive maps and card sorting revealed that fatigue was conceptualised distinctly from items related to medical treatment and that perceptions around fatigue's importance to health were low. Women from the focus groups reported that fatigue is a regular part of their daily life. CONCLUSION: Our results indicate that fatigue is currently not an adequate cue to seek treatment, perhaps due to the normalisation of fatigue as a part of women's daily life.

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

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.

The reduction in anemia through normative innovations (RANI) project: study protocol for a cluster randomized controlled trial in Odisha, India.

BACKGROUND: More than half of women in India are anemic. Anemia can result in fatigue, poor work productivity, higher risk of pre-term delivery, and maternal mortality. The Indian government has promoted the use of iron-folic acid supplements (IFA) for the prevention and treatment of anemia for the past five decades, but uptake remains low and anemia prevalence high. Current programs target individual-level barriers among pregnant women and adolescents, but a more comprehensive approach that targets multiple levels among all women of reproductive age is needed to increase uptake of IFA and iron-rich foods. METHODS: The Reduction in Anemia through Normative Innovations (RANI) project is a norms-based intervention to reduce anemia among women of reproductive age. We will evaluate the intervention through a clustered randomized controlled trial in Odisha, India. We will collect data at three time points (baseline, midline, and end line). For the study, we selected 89 clusters of villages, which we randomized into treatment and control on a 1:1 basis. The treatment arm will receive the RANI project components while the control arm will receive usual care. Fifteen clusters (40-41 villages) were selected and 4000 women (2000 in each arm) living in the selected clusters will be randomly selected to take part in data collection. Women in both study arms will have their hemoglobin concentrations measured. They will also complete in-person surveys about their knowledge, attitudes, perceptions of iron folic acid supplements, and nutritional intake. We will also select a smaller cohort of 300 non-pregnant women (150 in each arm) from this cohort for additional physical activity and cognitive testing. We will conduct both within- and between-group comparisons (treatment and control) at baseline, midline and end line using t-tests. We will also conduct structural equation modeling to examine how much each factor accounts for IFA use and hemoglobin levels. DISCUSSION: This RCT will enable us to examine whether a social norms-based intervention can increase uptake of iron folic acid supplements and iron rich foods to reduce anemia. TRIAL REGISTRATION: This trial was registered with Clinical Trial Registry- India (CTRI) (CTRI/2018/10/016186) on 29 October 2018.

Driven to succeed: Improving adolescents' driving behaviors through a personal narrative-based psychosocial intervention in Serbia.

Globally, more adolescents die from road traffic fatalities than from any other cause, and males are significantly more vulnerable than females. Driver education interventions directed at males are less likely to succeed than those directed at females, and stronger optimistic bias and overconfidence bias have been implicated as likely reasons. We report results from a quasi-experiment conducted in Serbia, targeting male and female adolescents. Stratified by size, forty schools were randomly assigned to either a personal-narrative intervention or a no-intervention control arm. Data were collected before the intervention (N = 1449) and again six months later (N = 1072). Risk perceptions improved for both males and females, and injunctive norms improved for females. Improvements in overconfidence bias and descriptive norms were predictive of improvements in high-risk driving behaviors. A significant interaction between improvements in injunctive norms and the intervention revealed that males whose injunctive norms improved were significantly more likely to be affected by the intervention, compared to the other groups. Implications for interventions are discussed.

The RANI Project: A socio-normative intervention to reduce anemia in Odisha, India: A formative research protocol.

Background: More than half of women of reproductive age in India are anemic. Anemia is associated with increased risk of preterm delivery, higher maternal mortality and contributes to fatigue, which affects women's work productivity. The World Health Organization (WHO) recommends daily oral iron and folic acid (IFA) supplements during pregnancy and weekly supplements for women of reproductive age. Government programs and global donors have distributed and promoted IFA supplements in India for over four decades. However, initial intake and compliance remain inadequate. Objectives: This protocol describes the formative research phase of a larger study, called the Reduction in Anemia through Normative Innovations (RANI) Project, which will test, through a randomized controlled trial, the hypothesis that a social norms-based behavioral intervention in Odisha, India will improve uptake of IFA supplements and reduce anemia among reproductive age women as compared to usual care. The focus of this paper is on the formative research required to develop a sound intervention. We will examine socio-normative barriers to and facilitators of IFA supplement uptake. Methods and analysis: Based on the Theory of Normative Social Behavior, we will adopt a mixed-method, multilevel approach. We will collect data using focus groups, in-depth interviews, observations, Rapid Participatory Ethnographic Evaluation and Research (PEER) techniques, and perceptual mapping methods. Our sample includes reproductive age women (pregnant and not pregnant), their husbands, their mothers/in law and key stakeholders. Before collecting the data, and after analyzing the results, we will hold convenings in India to engage key stakeholders in collaborative design. Following the intervention design, we will test components of the intervention, gather user feedback and fine-tune as necessary. Impact: This study will contribute to the social norms and behavioral intervention research and inform policymakers about the value of adopting a socio-normative approach.