In the United States, around ten million Americans are iron deficient, and around five million have iron deficiency anemia, according to the National Library of Medicine. In India, however, the number is much larger — 50% of adolescent girls are anemic.
Hagere Yilma, a clinical assistant professor at Boston University’s Sargent College of Health and Rehabilitation Sciences, said social norms in India contribute to iron deficiency.
“There is this common cultural and gender norms practice where women are eating last in their families,” Yilma said. “What’s left over is not usually the most nutritious or the most iron rich.”
Yilma said iron deficiency anemia is characterized by a low oxygen-carrying capacity for blood cells or, in simple terms, that a person is not getting enough iron in their diet, which could cause them to feel weak and fatigued.
The RANI project, short for Reduction in Anemia through Normative Innovation, was wrapped in 2021 and designed to lower that number of anemic women in India. Yilma said she worked on the RANI project with a team at The George Washington University.
“What we were seeing was there were gender and social norms as well as other sorts of psychological and environmental factors that are determining whether or not somebody’s doing this very easy behavior of taking a pill or eating enough iron-rich foods,” Yilma said.
Yilma said the iron supplement pill is something she’d call a “really cool medical innovation” because it lessened the impacts of food insecurity.
“Trying to eradicate poverty is a big task, but you could take these supplements when you can’t afford or have access to iron-rich foods,” Yilma said.
Despite a global promotion by the World Health Organization, Yilma said many people are not taking iron supplements, including pregnant women who are “very much at risk for anemia.”
Yilma said one of the many reasons why iron deficiency is so high in many parts of India is because many women are vegetarian, which limits the amount of iron they’re taking in.
In part due to these cultural norms that make women’s daily lives “characterized by so much work from the moment they wake up to the moment they go to sleep,” Yilma said many women don’t even know they’re iron deficient.
To create change, the RANI project had to develop a “multi-component intervention” in the form of monthly community meetings.
Women learned about what causes anemia, and at the end of each session, women volunteered to get their hemoglobin tested to check their anemia levels. The levels were then color coded.
“You could see, just by looking at the colors, how much anemia was in your community,” Yilma said.
And, she said, the project was a success — including among women of marginalized caste groups.
“That’s really hard to do and that doesn’t always happen because these marginalized caste groups don’t usually have the same access to healthcare or social support because of prejudice and discrimination in our social and structural systems,” Yilma said.
Even though discriminating against caste is illegal, she said it still occurs.
“Some people are born into higher caste groups where they might have a little bit more privilege in society, maybe people revere them a little bit more,” Yilma said. “And some people are born into lower caste groups where they’re marginalized.”
Now at BU, Yilma, joined by undergraduate students, continues to analyze the project in two different ways.
Maisie Bradley, a senior in SAR, is working independently and with Yilma to understand the psychological and social factors that are impacting whether or not women decide to take the iron folic acid supplements.
“It’s really kind of fun and really academically interesting to try to figure out what are the real-life causes for the things that we’re seeing in the data,” Bradley said.
Yi-Hsi Huang, a sophomore in SAR, is also working with Yilma. Huang analyzes data, focusing on the Risk Perception Attitude framework.
The RPA framework has two components. The risk perception component measures a person’s awareness of their own health risks, while the efficacy component measures how much an individual perceives the prevention measures as effective.
“In our case, that would be on whether the individual believes that taking iron supplements would be an accessible and effective solution,” Huang said.
This means that Huang compares iron supplement intake before and after the intervention to see whether or not there is a correlation.
“For a lot of parts of the world, we take it for granted that, as long as you’re eating enough iron, it’s not something you have to worry about,” Yilma said. “But in many parts of the world, people are faced with food insecurity. So getting enough iron is harder to do than you would think.”