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

To assess whether improvements in social norms related to iron and folic acid consumption are associated with increased iron and folic acid consumption.

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).

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).

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.