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Weekly Iron Folic Acid Supplementation to reduce Adolescent Anemia: From Policy to

Programs

Marion Roche, Micronutrient Initiative CORE Group Spring 2015, Global Health Practitioners

Conference, Alexandria, April 14th


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WHA nutrition targets 2025



Women today - 3.5 billion!

600 M 10-24 years living in LMIC countries UNFPA, 2014



Women today - anaemia

Stevens, et al, 2013



Anemia in Adolescent Girls & Women

• 21 countries assessed by UNICEF, > 1 in 3 girls are anaemic a • 4 of 8 African countries reviewed >40% anemia in 12-14 years of age • In India 55.8% of adolescents aged 15–19 years are reported to be

anaemic • Ages 15–19 have the greatest total energy requirement compared to

any age group (~2,420 kcal/day)b • Higher needs for micronutrients: Iron, vitamin D, calcium & Zinc • Low dietary availability of iron • Parasitic infections add to iron deficiency burden

(aUNICEF, 2012, bWoodruff and Duffield, 2000)



Age of first pregnancy

UNICEF 2014

• Adolescent pregnancy: 17-20 M • 95% occur in low- and middle-income countries



Lost Potential from Anemia in Adolescent Girls & Women

1. School performance

2. Loss productivity

3. Reproductive performance


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Intermittent Iron and Folic Acid Supplementation

http://apps.who.int/iris/bitstream/10665/44649/1/9789241502023_eng.pdf

WHO Recommendation Intermittent iron and folic acid supplementation is recommended as a public health intervention in menstruating women living in settings where anaemia is highly prevalent, to improve their haemoglobin concentrations and iron status and reduce the risk of anaemia • Complement with deworming


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Intermittent Iron and Folic Acid Supplementation

http://apps.who.int/iris/bitstream/10665/44649/1/9789241502023_eng.pdf



Review of Existing Examples of Weekly IFA Supplementation

• Past supplementation programmes not implemented effectively in preventing and controlling iron deficiency & anaemia

• WHO global consultation on weekly iron and folic acid supplementation for preventing anemia in women of reproductive age (2007) recommended review of programs:

• ► critical elements of weekly iron and folic acid supplementation programmes were identified



WHO Review in 2007: Ten successful pilot projects in 6 countries were identified

• Population size targeted varied from large to small:

– 4 in India (several million school age girls) – 2 in Vietnam (30,000 to 250,000 WRA in communities) – 1 in Cambodia (30,000 WRA in factories, communities &

schools) – 1 in the Philippines (30,000 WRA in communities and schools) – 1 in Lao PDR (1,500 schoolgirls and WRA in villages) – 1 in Egypt (6 million school girls and boys)



Project approaches • Two distinct program approaches were used and are

recommended:

1) free WIFS supply for socio-economically disadvantaged groups 2) social marketing of WIFS to WRA who can purchase low cost IFA supplements

• Potential Impact:

– reduction of - 9% to - 57% in prevalence of anaemia, during 6 to 16 months of supplementation



Opportunities

• Delivery platforms for IFA supplements: – schools – health sector – Workplace settings – women’s & community organizations – Peer to peer outreach Delivery channels for messages: -peers, teachers, radio, SMS and text messages, TV, local

markets/billboards, faith based leaders



School Programs: Role of the Teacher

• Distribute IFA supplements • Monitor/ Record consumption of IFA supplementation • Encourage Consumption & Counsel on Strategies to avoid Side

effects • Nutrition education as part of school curriculum

Photos from WHO program Gujurat, India



Community Level Outreach

• Outreach to adolescents with other community groups & women’s organizations

• Faith based and community leaders reaching those who are married as adolescents

One in three girls in developing countries are married before the age of 18 and a startling one in nine before the age of 15 (UNFPA, 2012)



Workplace Setting: Engaging employers, supervisors and leaders • Distribution setting for IFA

supplements • Distribution channel for

messages to support adherence and provide awareness on anemia



Health System: Frontline health workers

• Adolescents unlikely to seek treatment of anemia from health facility unprompted

• Delivery of IFA supplements and promotion by frontline health workers



Peer to peer outreach

• School girls reaching out of school girls • Core groups of 15-20 school girls • Each school girl reach 1-3 out of school girls • Need support and engagement from parents

and community and husbands • Can provide IFA supplements and monitor

consumption • Peers trained to provide counseling



Product & Promotion Appeal for Adolescents



Weekly iron-folic acid supplementation for adolescent girls in Chhattisgarh, India

School Girls • Teachers distributed IFA • Teachers encouraged and

monitored consumption of IFA • Training of Teachers • Behaviour Change

Interventions

Out of School Girls • Delivery of IFA supplements

through Integrated Child Development Centres

• Messages Delivered by Peers



Challenges: 1. Irregular procurement and distribution mechanism and need to

streamline procurement and distribution systems

2. Reporting systems need to be improved. 3. Improve convergence between Education , Health facility and ICDS at

block level.

4. Importance of Influencing and Engaging teachers

5. Continued innovations needed to reach out of school girls

Lessons for Scale Up Phase



DEMONSTRATION PHASE (2010-2012)

SCALE-UP PHASE (2013 ONWARDS)

Number of Schools

424 23,000

School-going adolescents reached

66,709 3.56 million

Number of Community based Centres

6,832 43,763

Out-of-School adolescents reached

29,008 250,000

Project Reach



57.1

47.9

72.3

34.2 30.1

24.8

0

10

20

30

40

50

60

70

80

Received IFA (80 % of recommended dose)

Consumed IFA (80 % of recommended dose)

Consumed at least 1 dose of Deworming

School going Out of school

Demonstration Phase: Proportion of Adolescent Girls consuming IFA and Deworming at endline

p<0.01 for differences in the three indicators between the groups



65

75

25 20

0

10

20

30

40

50

60

70

80

School Going Out of School

Full dose of Weekly IFA One Albendazole Tablet

Scale-Up Phase: Proportion of Adolescents consuming IFA and Albendazole during Scale-Up

Data from State – Jan to Mar 2014



85.2 88.9

71

82

0

20

40

60

80

100

Anemia among school going AGs

Anemia among out of school AGs

Baseline %Endline %

Anemia - Baseline vs Endline

Perc

enta

ge

Unpublished data; Baseline N = 961 (SG: 482, OS: 479); Endline N = 1869 (SG: 455, OS: 1414 p<0.01 for differences in anaemia between baseline and endline in both groups



Take Home Messages for Implementing Effective Weekly IFA for Adolescents

1. Advocate for this intervention and ensure supplements available as effective anemia reduction strategy for adolescents themselves and as young WRA (future moms)

2. Engage policy makers in programs and raise awareness on anemia in adolescents

3. Distinct Delivery Channels – Schools, Community, Workplace

4. Develop Appealing and Packaging 5. Provide free supplements for low SES adolescents



Take Home Messages for Implementing Effective Weekly IFA for Adolescents

6. Assess market demand for purchasing supplements by

market segments 7. Create partnerships for supply management (health,

schools, workplaces, private pharmacies) 8. Monitor and encourage consumption -Peer support by

school girls for out of school girls 9. Improve communication and appealing messaging is

critical 10.Select fixed day for consumption



THANK YOU

Dr Tommaso Cavalli-Sforza- Photo credits and WHO program examples Manpreet Chadha and Pravin Khobragade of MI India for sharing Chhattisgarh Dr. Luz Maria de Regil, Director MI Research and Evaluation Unit

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