Dr P V Kotecha

Child Anemia Feasibility Study: Approaches and Lessons LearntS R Nagar – Uttar Pradesh

Presentation at XIII Annual Conference of

Indian Association of Preventive & Social Medicine

UP & Uttarakhand Chapter Dehradun – Uttarakhand

31st October, 2010Prof Prakash V Kotecha

Country Representative,

A2Z, the USAID Micronutrient Project, New Delhi, India

Ex Professor and Head, PSM Dept, Medical College, Baroda, Gujarat

[email protected]/[email protected]

mailto:[email protected]/[email protected]

http://luke.asmallorange.com/~a2zorg/

Iron: The Scope of the ProblemThe World Health Organization (WHO) has categorized iron deficiency as one of the top ten most serious health problems in the modern world. Iron deficiency anemia (IDA):– Impairs the mental development of over 40% of the

developing world's infants and reduces their chances of attending or finishing primary school

– Decreases the health and energy of approximately 500 million women and leads to approximately 50,000 deaths in childbirth each year

– Is complex because it requires increased iron intake at critical stages of the life- cycle - before and during pregnancy and throughout early childhood

.

Source: http://www.micronutrient.org/english/view.asp?x=579

Iron: The Scope of the Problem

– Iron deficiency has assumed even greater importance as evidence accumulates linking iron deficiency with mental impairment.

– Various tests of cognitive and psychomotor skills associate lack of iron during infancy and early childhood with significant levels of disadvantage, affecting IQ scores by as much as 5 to 7 points.

– Millions of children might be unable to complete primary school due to the impeded cognitive development they sustained as newborns and young children who couldn't get enough iron and iodine.

Source: http://www.micronutrient.org/english/view.asp?x=579

• Reducing anemia will decrease maternal and perinatal mortality, improve cognitive development and schooling in children, and increase physical capacity and work productivity in adults.

• About 42 percent of pregnant women and 47 percent of preschool children worldwide are anemic.

• The most common cause of anemia is iron deficiency, which is associated with 115,000 maternal deaths and 591,000 perinatal deaths each year (Stolzfus et al., 2004).

Dr. Prakash V. Kotecha

4

Iron: The Scope of the Problem

5

Anemia in Children

74.279.2

73.8

85.1

0

20

40

60

80

100

India UP

NFHS II 1998-99 NFHS III 2005-06

Anemia failed to decrease…and at present highest ever


6

Current GOI Guidelines: April 2007Relevant to children

• Current GOI Guidelines: April 2007Relevant to children

• Children 6-60 months to be given IFA syrup• Dose is 20 mg iron and 100 microgram folic acid in one ml

per day• Total dose/days not mentioned (as per IMNCI)• For safety reason to be dispensed in bottles so designed

that only one ml can be dispensed at a time • DFS, Sprinkles, dispersible tablets, fortified rice and other

alternatives need to be explored as additional/alterative therapy

• Source: No Z.28020/50/2003-CH GOI 23rd April 2007



7

Current Program guideline for anemia control for young children

• Screening of all children for anemia• Those found clinically suffering from anemia appropriate

treatment be given • This has come with 10th five year plan objectives and

goals.• However actually what is followed at present is

screening by ANM and those found anemic are given IFA when available

• Calculation of IFA small tablets (and currently provided IFA syrup bottles) also based on this criteria, they are not sufficient in number if and when all eligible children will receive them.


8

Source: http://pariwarkalyan.up.nic.in/mch-intro.htm 17/09/2010

Policy on Anemia Control: 1991

• Acknowledges importance and consequences of anemia in mothers and children

• Recommends integrated approach (ICDS-PHC)• Stresses on diet first (with lists) and on counseling• Recommends 100 small IFA for ALL children/year• Recommends controlling worm and other infections• Screening and special attention to severe anemia

9


NFHS III (2005-06) India Data

Age in Months

10


Anemia by Age Group

11


12

Child Anemia Feasibility Study Why UP?

Source: DLHS III (2007-08) Much Larger Sample Size90,000+ HH UP

38

7

23

0

20

40

60

80

100

Have electricity Use piped drinkingwater

Live in a puccahouse

UP

What is this study about ?• Child anemia control requires a package of

services not just iron alone.• Is it FEASIBLE to provide this package of

services to children in rural UP?• Is it possible to implement the program within

the existing system?• Do front line workers have the capacity to grasp

and deliver what is necessary to control child anemia?


13

Gyanpur

14

Study area


Handia

15

Study areaDistrict

State

S. R. Nagar,

UP

Block Gyanpur

Total population 2,65,678

No. of Sub-centers 32

No. of ANM 29

No. of AWC 187

Children 6-23 14000

Control block Handia, Allahabad districtDr. Prakash V. Kotecha

16

Child Anemia Feasibility Study: Steps• Formative Research• Based on the findings and recommendation of TAG

– Comprehensive package of services for intervention – Attempted through the system within system guidelines

• Training and Capacity building of AWW/ANM/ASHA and others providing services

• Enhanced Monitoring and evaluation– Anemia Prevalence– Worm prevalence– IFA syrup stock and distribution– Morbidity data for study and control area to check for morbidity in study area with

reference to iron supplementation if any

• Follow up with AWW/ANM for distribution and tracking the supply of IFA syrup

• Post training support (mentoring) by ICDS sector meeting and joint block meeting facilitation by field staff

• Ensuring anemia control and worm control in mothers

17

Comprehensive Package of Interventions• Improving nutritional status by addressing complementary

feeding practices appropriate to the age and ensuring energy rich dense food adequate in quality and quantity.

• Increasing iron intake of the target population through – Iron supplementation in form of syrup one ml twice a week

(GOI policy) using dropper only (discontinue when sick)– Improving breast feeding practices

• Control of infections – Hookworm by deworming and improved hygiene practice – Malaria (EDPT)

• Increasing iron stores at birth by improving the iron status of pregnant women with better ANC and IFA


Scenario at the Start of the Feasibility Study in Gyanpur Block


18

19

Dr. Prakash V. KotechaSource: NFHS III & A2Z study 2007-08

Anemia Prevalence at the starting of the Feasibility Study (6-23 m)

20

54.4

14.2 11

74.6

0102030405060708090

100

Ascariasis TrichurisTrichirura

Hook worm Any Infection

Helminthes Study Children in UP

N=472 (Gyanpur Block)

Source: Awasthi et al, 2008Dr. Prakash V. Kotecha

21

IFA Consumption at the starting time 2008 Baseline study

2 40

20

40

60

80

100

Intervention Block Non Intervention Block

Uttar Pradesh

Consumed Iron

Dr. Prakash V. KotechaSource: A2Z study 2007-08

22

Capacity Building of Frontline Providers• ALL ANM (33), AWW (209), ASHA (203) Supervisors of

ICDS (6) and LHV (Supervisors of ANM) (6) total 493• 3 day, highly interactive training that covered (March 08 to

Sept 08 total 22 trainings)– tracking pregnant women, – early and complete registration, IFA for every pregnant mother with

counseling for consumption and reasons to continue consumption– identify target children, – Counseling for IFA syrup, (how, when, where and why, how to

preserve, what precaution to take, where to store), for IYCF (energy dense adequate quality and quantity to be fed timely and responsively)

– Deworming when and how to dose (1yr onwards six monthly)– How to prevent malaria and protect form malaria and advocacy for

early diagnosis and prompt treatment for fever/malaria


23

Capacity Building of Frontline Providers• Follow up with AWW/ANM for distribution and tracking

the supply of IFA syrup– From District to Block– From Block to sub-health center and AWC– From AWC to beneficiary

• Post training support (mentoring) by ICDS sector meeting and joint block meeting facilitation by field staff

• IEC Material (for HW and beneficiary)and Training to use them


24

Anemia Status of Health workers

68.20% 65.70%

56.10%50.00%

61.10%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

ANM ASHA AWW SUPERVISOR Total

N=288


25


26IEC

Material in form

of calendar

IFA Syrup Supply Tracking all the way…

• Assumption was to give IFA in the month of May and follow up children for 9-12 months for their regular consumption

• Continuous monitoring only can improve the situation and detect issues


37

100

21.6

80

20.6

6.9

67.4

32.6

17.5 19

81

69

0

10

20

30

40

50

60

70

80

90

100

May

June Ju

ly

Augus

t

Supply and Distribution of IFA syrup staus from May to August 2008 in Gyanpur

Stock at Block Supply to ANM Distribution to ben.

Program Period

• Started Training for the program Feb 2008. IFA syrup was supplied in May 2008 and repeat supply was required after one year. 15000 IFA syrup bottles were supplied each time

• A2Z Program Support continued till Dec 2009. End line study was conducted in January 2010.


38

On going Monitoring LQAS

39

FOCUS

LQAS I (Sept. 08)

LQAS II (Feb. 09)

LQAS III (Aug. 09)

Advice on Anemia 46 34 75

IFA syrup Received 66 45 73

Benefits Explained 44 33 65

IFA consumed in last 7 days 59 15 50

Complementary Feeding Advice 28 51

Complementary Feeding Practice 14 11

Anemia Prevalence 95 87 86


RESULTS OF THE END LINE STUDY


40

End Line Study Children


41

District BlockNumber of mothers of

children aged 6-23 months (total sectors)

Sant Ravi Das Nagar Gyanpur 304

Allahabad Handia 331

Total 635

Religion & Caste of children studied


42

CharacteristicsProject Block

(Gyanpur)Comparison Block

(Handia)Religion Endline Baseline Endline Baseline

Hindu 93.4 93.8 93.4 94.2Muslim 6.3 6.2 6.3 5.8

Scheduled caste 24.3 30.8 24.3 22.6

Scheduled tribe 2.6 0.0 2.6 1.3

Other backward caste 44.7 41.6 44.7 55.5

Total N304 305 331 310

Standard of living & Literacy


43

Standard of living

Percent Households

Project Block (Gyanpur)

Comparison Block (Handia)

Low80.6 25.7

Medium14.8 33.5

High 4.6 40.8

Illiteracy

Illiterate54.3 37.8

Total N 304 331

ANC Coverage of Mothers


44

IFA Received by Mothers of children 6-23 months during their pregnancy

2 4

79

61

0

20

40

60

80

100

Gyanpur Handia

Baseline

Endline


45

IFA Consumption by Mothers


46

Anemia among children IFA Consumption by Mothers


47

IFA Syrup Received by Children 6-23 months


48

IFA Syrup Knowledge among mothers of children who received syrup


49

IFA Syrup Consumption & Side effect

• 92.6 % of children who received iron consumed it. 94% of these children were administered doses by the mother

• Only 13% had consumed more than 50 doses; while 35% consumed less than 10 doses and 36% consumed between 10 and 50 doses !

• Only 21% of children’s mother complained about side effects; 4/5th of these were black color stool and 1/5th had nausea as side effects.


50

IFA Syrup Consumption in last 7 days


51

Deworming Medicine Received by the Children


52

11.8

2

9.9

1.50

7

14

Gyanpur Handia

Children Mothers

87% children & 73% of mothers consumed the

medicine

Benefits explained by ASHA


53

“Child becomes weak and pale due to lack of blood in the body. It is advisable to take iron rich diet and other iron preparation

to prevent anemia. Iron increases blood and help fight

infection.”

Complementary Feeding


54

Hygiene Practices observed


55

Hemoglobin Study • 31 cluster sampled PPS and then 10 children

from each cluster was planned with expected design effect of 2.

• HemoCue Machine (301) was used for measuring hemoglobin level.

• Children were pricked either at the toe or heel using lancet needle provided by Hemocue

• All precuations were taken for aseptic and antiseptic measures and children were pricked after consent from the parents


56

Anemia Prevalence Difference13% Reduction of

Anemia2% Reduction of

Anemia

84% Increase in non anemic children

Level of Malnutrition

39.8

34.435.3

33.5

30

35

40

45

Gyanpur Handia

Baseline

Endline


58

Achievements• Complete Package delivery is feasible to be delivered

within the system

• It is possible to build the capacity of front line workers to deliver IFA syrup and provide counseling within the system

• Through the system, we can reach to children for IFA syrup to young age group that is not part of vaccination. ICDS also usually does not cover this age group at the center.

• IFA to mothers is also attended to and improved when importance is emphasized

• Complementary feeding is discussed

• Deworming medicine to children is being advised.

59



60

Challenges

• Coverage for every child remains a challenge• IFA supply and logistics and monitoring• Compliance for IFA syrup• Reduction of anemia to a larger proportion• Deworming medicine• Complimentary food advice and practice• Health Workers themselves are anemia…

61


Age profile of mothers


62

Dr P V Kotecha

Education

Transcript of Dr P V Kotecha