Qualitative inquiry can improve the description and explanation of complex, real-world phenomena related to attitude and behavior change. Quantitative research alone is often insufficient to understand these complicated processes59,60. Our research team proposes to examinewhy IFA supplement use is low despite recommendations from the government and existing programs promoting its uptake andwhich existing social norms promote or hamper uptake. Additionally, surveys and quantitative methods have been the primary tool to test theories on social norms and to understand the prevalence of existing norms in communities61,62. Some theorists have suggested that more qualitative research would be useful in illuminating the process of social norm change in different situations63. We respond to that call.

Data collection modalities

We will collect qualitative data via in-depth interviews, focus groups, Participatory Ethnographic Evaluation and Research (PEER) interviews, and structured observations.

In-depth interviews and focus groups. We will conduct in-depth interviews with key informants including Self-help group (SHG) leaders, health providers, teachers and health officials. We will conduct focus groups with women of reproductive age (including pregnant women), spouses, mothers, and mothers-in-law. Prior to focus group interviews participants will complete a demographic questionnaire including questions about caste. We plan to conduct approximately sixteen focus groups and twenty-four key informant interviews but the final sample size will be determined based on theoretical saturation64.Table 1 shows the expected number of interviews and focus groups.

Table 1. Participants Session

type #

Sessions #

Participants Self-help group leaders IDI 4 1 Government/ministry representatives IDI 4 1 Antenatal service providers IDI 4 1 Secondary school teachers IDI 4 1 Traditional Healers IDI 4 1 Anganwadi/ASHA workers IDI 4 1 Adolescents of reproductive age (15 – 19) years old FGD 4 6–10 Women of reproductive age (20 – 35) years old FGD 4 6–10 Married men (18 – 42) years old FGD 4 6–10 Mothers-in-law FGD 4 6–10

Observational Data. Observation can allow the researcher to draw inferences about a phenomenon that they cannot obtain from direct conversation via interviews or focus groups. We will collect observational data from four venues: antenatal care (ANC) clinics, medicine stores/pharmacies, self-help groups, and outdoor food markets. Data collectors will take notes on a standard observation form (SeeSupplementary File 3) at one of each of the following four venues in each of the four villages (16 observations total):

Medicine store/pharmacy observations will note how well IFA tablets are stocked, where they are stocked within the store, the extent to which they are purchased, their price, and their packaging.

ANC clinic observations will note whether there are existing communications (e.g. health education posters) about anemia and/or IFA supplementation. They will also record notes on the environment including (cleanliness, crowding, wait-time, etc.). Additionally, they will observe the pharmacy within the ANC clinic and note how many IFA tablets are available, cost, packaging and stocking/stock outs. We will not inform clinic staff about the observation prior to arrival to ensure that we observe the facility in its authentic state.

Data collectors will observe SHGs and take notes about the nature of their interactions with women in the community. They will take note of how well they function, what they discuss; the kind of activities that they undertake and any challenges that they face.

Data collectors will observe outdoor food markets, as diet is an important factor to consider while studying iron-deficiency anemia. We will take photos of all food items in the market; list them out and inquire about the cost of each item.

Perceptual Mapping. We will conduct perceptual mapping exercises to obtain a visual model that depicts how women and their influencers (their spouses/partners, their mothers-in-law, and others in their social network) think about IFA supplements, anemia, and other related factors, including physical and mental fatigue, and diet (seeSupplementary File 4). Perceptual mapping is a technique used to elicit a mental picture held in common by members of a group. Perceptual mapping helps us understand how people construe various objects, both in terms of what meaning they give to them and how they construe the objects in relation to one another65,66. Perceptual mapping is done in three steps – attribute elicitation, scoring, and mapping.

Step 1: Attribute Elicitation. The purpose of this step is to extract the meaningful attributes with which people construe specific objects. For example, if people are asked to list a significant attribute pertaining to “IFA tablets,” some may point to “awful taste” as the primary attribute. For others, IFA tables may represent the idea of “medication for a better tomorrow” or “healthy” as the primary attribute. Knowing these key attributes will help us craft meaningful messages during the intervention phase. For example, we may be tempted to develop messages about IFA uptake on the assumption that it represents “no anemia” in the minds of participants. It may well be, however, that the primary attribute pertaining to taking IFA supplements for certain women may center around issues of forgetfulness or something whose impact is not easily visible. If this is the case, then our messages about IFA supplementation would be far less effective than those that tackle the issue from the perspective of linking it with more immediate positive outcomes.

For attribute elicitation, we will provide two images (on two cards), one being a reference object, of particular objects and ask people to tell us how similar or different the two are from each other (on any dimension that the participant uses). Subsequently, the reference object will be kept the same, but another second object will be shown and the same comparison will be solicited. This process will be done for all permutations of all object pairs. We anticipate having 12 objects, for a total of 55 comparisons. The objects we have currently include: IFA pill; clinic; medicine store/pharmacy; SHG; traditional healer; physicians; fatigue; prenatal care; green vegetables; meat; money; and nausea/diarrhea.

Step 2: Scoring. A handful of attributes are thus identified for each primary behavior of interest. Respondents are then asked to rate the importance of each attribute for each behavior or object.

Step 3: Mapping. Step 2 results in ap (number of attributes) xq (number of behaviors or objects) matrix that is then used to model the relative distances between behaviors or objects on ap-dimensional plane, thus showing the relative distances among behaviors or objects. Two behaviors or objects close to each other on a particular attribute signify their conceptual proximity. This mapping provides an understanding about how the primary behaviors or objects of interest are understood by the audience; it also specifies the relative distances among objects.

Three perceptual mapping exercises will be conducted: one among women of reproductive age (including pregnant women), one among men (who constitute the support group for the women), and one among mothers/mothers-in-law and sisters or sisters-in-law. Approximately 30 individuals per group will participate in the mapping exercise, for a total of 90 individuals.

Rapid PEER. We will also conduct Rapid Participatory Ethnographic Evaluation and Research interviews (Rapid PEER), which will enable us to gain local insights into the beliefs and behaviors of beneficiaries, in the full context of their lived experience. This unique ‘insider perspective’ will ensure intervention is truly designed with the user in mind. We will train ‘ordinary’ members of the target group, in this case pregnant women and women of reproductive age, their spouses, and their mothers/mothers-in-law, after which they will serve as Peer Interviewers67,68.

To execute the Rapid PEER, we will train Peer Interviewers to carry out in-depth conversational interviews designed to obtain targeted information from others in their own social group. We will decide on five key questions that form the structure of the conversational interview process. The Peer Interviewers themselves will suggest how to form the questions from formal Odia language into a more conversational format. Non-literate Peer Interviewers will draw pictures to represent each of the five questions. We will ask the same questions at each site to at least two interviewees from the PEER interviewers social group. The informal wording and pictures to remember and ask the question may vary to suit the preference of the Peer Interviewers.

Data collection will be carried out over a one-day period, wherein the PEER interviewers will hold conversations with two same-sex friends who fit the inclusion criteria (pregnant women, women in the reproductive age group, their spouses or mothers/mothers-in-law, all living in the community, 15 years of age or older who speak Odia). Within 24 hours, researchers will debrief the PEER interviewers to obtain detailed in-depth information from each PEER interviewer on what they discussed during the interview. During the debriefing process, the research team will probe PEER interviewers for broader contextual information regarding the responses during the interview. A final workshop with PEER interviewers will explore their experiences of assisting with the formative research.

The Rapid PEER process will take 4 days at each site (two villages total):