Making programs worth their salt: Assessing the potential of the Double Fortified Salt Program in addressing iron deficiency anemia in Uttar Pradesh, India Open Access

Cyriac, Shruthi (Spring 2021)

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Double fortified salt (DFS) – salt fortified with iron and iodine – has proven efficacy in addressing iron deficiency anemia under controlled settings. However, there is limited evidence of DFS effectiveness in large-scale settings, and few studies examine the implementation process of DFS programs. In 2017, the Indian state of Uttar Pradesh (UP) implemented its flagship DFS program. This dissertation focuses on a process evaluation of the UP DFS program, with the objective of examining the implementation of the program and its potential for impact.

Guided by the UP DFS program impact pathway (PIP), we adopted a mixed-methods design for the process evaluation. We conducted a household survey (n=1202) to examine DFS coverage and utilization. In addition, we conducted in-depth interviews with DFS consumers (n=23) and key program staff (n=25) to assess the fidelity of implementation (FOI) in the DFS program. Finally, we conducted a predictive modeling exercise using baseline data on individual iron intakes and DFS coverage estimates to document potential program impact at different levels of utilization.

The household survey determined whether the program is moving in the expected direction, and identified the drivers of DFS utilization. The program documented low FOI and its implementation deviated from design, as per the PIP. This helped understand where and how to course-correct, and subsequently convey remedial measures to program staff. The predictive modeling exercise provided the ability to estimate, under certain assumptions, the change in outcomes consequent to the implementation of the UP DFS program. This model could help policy makers optimize and adopt context-specific interventions that can address iron deficiency anemia.           

Our process and findings provided important learnings for conducting and using implementation research to design and evaluate nutrition interventions at scale. Examining the DFS program in a real-world context and identifying inefficiencies in program delivery helped assess the adequacy of the program. At this early stage of the UP program, the potential for measurable benefits was constrained by low rates of DFS utilization. Findings from this process evaluation informed the design of an adaptive impact evaluation and provided generalizable insights for ensuring that the potential for impact is realized. 

Table of Contents

Table of Contents

Abstract iv

Acknowledgements. vi

List of Tables. x

List of Figures. xi

Abbreviations. xii

CHAPTER 1: Introduction. 1

1.1. Double Fortified Salt (DFS) 3

1.2. DFS program in Uttar Pradesh. 5

1.3. Beyond Impact: A Case for Implementation Research in Food Fortification. 7

1.4. Dissertation Aims. 9

Chapter 1: References. 11

CHAPTER 2: High coverage and low utilization of the Double Fortified Salt Program in Uttar Pradesh, India: Implications for program implementation and evaluation. 14

2.1. Abstract 15

2.2. Introduction. 17

2.2.1. Uttar Pradesh (UP) DFS program.. 18

2.2.2. Evaluation of the UP DFS Program.. 19

2.3. Methods. 19

2.3.1. Sampling Strategy. 19

2.3.2. Variable measurement 20

2.3.3.. Hypothesized pathways. 22

2.3.4. Analyses. 23

2.3.5. Ethical Considerations. 24

2.4. Results. 25

2.5. Discussion. 27

2.6. Acknowledgements. 31

Chapter 2: References. 32

CHAPTER 3: Making programs worth their salt: Assessing the context, fidelity, and outcomes of implementation of the Double Fortified Salt Program in Uttar Pradesh, India. 44

3.1. Abstract 45

3.2. Introduction. 47

3.2.1. Key messages. 49

3.3. Methods. 49

3.3.1. Study sites and sampling. 50

3.3.2. Data collection and analysis. 51

3.3.3. Analytic Framework. 52

3.4. Results. 53

3.4.1. Domain 1: Objects of Implementation (Product, Price and Promotion) 53

3.4.2. Domain 2: Implementing Organization and Staff 55

3.4.3. Domain 3: Implementation context and enabling environment 57

3.4.4. Domain 4: Target of Implementation (Individuals, Households, Community) 58

3.5. Discussion. 61

3.6. Conclusion. 63

Chapter 3: References. 65

CHAPTER 4: Modeling the potential impact of the Double Fortified Salt Program on iron intake levels of non-pregnant women of reproductive age in Uttar Pradesh, India. 78

4.1. Abstract 79

4.2. Introduction. 81

4.3. Materials and Methods. 82

4.3.1. Study design and sampling. 83

4.3.2. Biomarkers. 83

4.3.3. Dietary intakes at baseline. 84

4.3.4. Validity of dietary data. 85

4.3.5. DFS utilization at midline. 86

4.3.6. Simulating post-fortification iron intakes. 88

4.4. Ethics. 89

4.5. Results. 89

4.6. Discussion. 91

4.7. Acknowledgements. 95

Chapter 4: References. 96


5.1. Key findings. 106

5.1.1. What influenced DFS utilization in Uttar Pradesh?. 106

5.1.2. How did DFS program implementation affect coverage and utilization?. 107

5.1.3. Why is understanding program coverage and utilization important?. 108

5.2. Strengths and innovations. 109

5.3. Limitations. 110

5.4. Generalizability. 112

5.5. Implications of our findings. 112

5.6. Conclusions. 115

Chapter 5: References. 117

List of Tables

Table 2.1: Descriptive analysis of household and individual characteristics, stratified by location of residence. 36

Table 2.2: Drivers of complete DFS adherence: Adjusted path model showing standardized cooefficients of direct and indirect pathways thorough which lower wealth households adhere to DFS use in all foods. 37

Supplementary Table 2.1: Awareness levels about DFS contents. 38

Supplementary Table 2.2: Wealth quintile creation for separate (panel A) and combined (panel B) sample populations. 38

Supplementary Table 2.3: Food Security by rural and urban areas. 39

Supplementary Table 2.4: District-level DFS adherence rates (complete or any adherence) in rural areas. 39

Table 3.1: Thematic analysis of Domains 1-3, using the adapted analytic framework of Implementation Science in Nutrition. 68

Table 3.2.1: Descriptive characteristics of DFS end-users, by typology. 71

Table 3.2.2: Thematic Analyses of Domain 4 - Target of Implementation (Individuals/Households/Communities) 72

Table 4.1: Descriptive Analysis of Individual- and Household-level socio-demographic characteristics, stratified by type of survey (Baseline vs. Midline) 99

Table 4.2: Prevalence of Anemia, Iron Deficiency and Iron Deficiency Anemia in Women of Reproductive Age, baseline sample with biomarker data, stratified by availability of diet data. 100

Table 4.3: Estimates of risk of dietary iron inadequacy and risk of excess iron intake among non-pregnant women of reproductive age in Uttar Pradesh, at pre- and post- fortification scenarios. 101

Supplemental Table 4.1: Logistic regression coefficients of predictors of effective DFS coverage, midline household survey. 102

Supplemental Table 4.2: Validity of dietary data using Goldberg cut-offs, Physical Activity Level = 1.3. 102

List of Figures

Figure 1.1: DFS intervention districts in Uttar Pradesh, India. 5

Figure 1.2: Timeline of DFS program and evaluation. 6

Figure 2.1: Double Fortified Salt (DFS) Program - Coverage Cascade. 40

Figure 2.2: Hypothesized path model indicating measured variables, pathways and the direction of effect 41

Figure 2.3: Rural path model showing standardized direct effects. 42

Supplementary Figure 2.1: Path Model for the overall sample. 43

Figure 3.1: Theory based Program Impact Pathway: DFS program in Uttar Pradesh, India. 76

Figure 3.2: The adapted analytic framework of Implementation Science in Nutrition. 77

Figure 4.1: Pre- and post-fortification iron intakes for baseline intervention and control districts. 103

Figure 4.2: Hypothetical scenarios of improved DFS program coverage and effect on baseline iron intake levels. 104

Figure 4.3: All scenarios with full dietary sample and subsample (plausible reporters only) 105

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