Understanding the Drivers of High Coverage and Low Utilization of Double Fortified Salt in Uttar Pradesh, India: Insights from a Mixed-Methods Study. (29th May 2020)

• Record Type: Journal Article
• Authors: Cyriac, Shruthi; Mbuya, Mduduzi; Haardörfer, Regine; Girard, Amy Webb; Ramakrishnan, Usha; Martorell, Reynaldo; Neufeld, Lynnette
• Is Part Of: Current developments in nutrition. Volume 4(2020)Supplement 2
• Page Start: 821
• Page End: 821
• Publication Date: 2020-05-29
• Subjects: Nutrition -- Periodicals; Nutritional Physiological Phenomena; Nutrition; Periodicals; Periodicals; Fulltext; Internet Resources; Periodicals; 612.3
• DOI: 10.1093/cdn/nzaa053_026
• Languages: English
• ISSNs: 2475-2991

Abstract

Abstract: Objectives: A pilot program delivering double fortified salt (DFS) with iron and iodine was launched in Uttar Pradesh, India, through the public distribution system (PDS), to address both nutrient deficiencies. We evaluated this DFS program in five districts to assess the fidelity of implementation and heterogeneity in coverage, examining influential factors to recommend actions for DFS scale-up. Methods: We conducted 23 in-depth interviews among women of reproductive age (WRA), to understand associated reasons for DFS use, partial use or non-use. We translated (from Hindi) and thematically coded the transcripts in MAXQDA using a priori codes, developed based on research objectives. We also administered a survey to WRA in 1202 PDS beneficiary households to collect data on DFS purchase & use and asset holding. Using wealth quintiles, we dichotomized households as high/low income and tested a theorized model describing how income influenced DFS adherence, using path analysis to understand direct and indirect effects. Results: The DFS program had good coverage; 89% survey respondents had heard of DFS, 80% had purchased it at least once. Yet, only 28% used DFS in all foods – DFS was considered to be of poor quality and several users noted changes in taste and food color, "our curry turns dark in color. Even our utensils become black and the taste is different". Only 20% were aware of DFS health benefits. Path analysis revealed higher odds of DFS use among low-income households (aOR 1.10; 95% CI: 1.06, 1.14), households with PDS access (aOR 1.28; 1.18, 1.38), and for households with WRA aware of DFS benefits (aOR 1.16; 1.11, 1.22). Odds of PDS access was higher among rural (aOR: 1.11; 1.08, 1.15) and food-insecure households (aOR: 1.08; 1.04, 1.12). Indirect path effects indicated higher odds of DFS use for both rural (aOR: 1.03; 1.02, 1.04) and food-insecure households (aOR: 1.02; 1.01, 1.03). Conclusions: DFS coverage was high but regular use low. Poor awareness about benefits and quality concerns about the product were key barriers to DFS use. Rural and low-income households were more likely to use DFS; however, micronutrient deficiencies are not restricted only to the rural poor. Efforts that address sensory issues with DFS, minimize implementation constraints and raise awareness about DFS benefits are needed to maximize potential for impact. Funding Sources: Bill & Melinda Gates Foundation.