WHAT WORKS - UNSCN...Krishna Rao, consultant for a larger study funded by the MI for the World Bank....

Part IProgram Guidance

Anemia Prevention

and Control:WHAT

WORKS

Anemia Preventionand Control:

WHAT WORKSPart I

Program Guidance

2 Anemia Prevention and Control:What WorksPart I : Program Guidance

The opinions expressed herein are those of the author(s) and do not necessarily reflectthe views of USAID.

The findings, interpretations, and conclusions expressed here are those of the author(s)and do not necessarily reflect the views of the Board of Executive Directors of the WorldBank or the governments they represent. The World Bank cannot guarantee the accura-cy of the data included in this work. The boundaries, colors, denominations, and otherinformation shown on any map in this work do not imply on the part of the World Bankany judgment of the legal status of any territory or the endorsement or acceptance ofsuch boundaries.

The views expressed in this publication are those of the author(s) and do not necessarilyreflect the views of UNICEF. Any map in this work does not reflect a position byUNICEF on the legal status of any country or territory or the delimitation of anyfrontiers.

This document does not necessarily represent the views or opinions of the PanAmerican Health Organization (PAHO).

The views expressed in this publication are those of the author(s) and do not necessarilyreflect the views of the Food and Agriculture Organization (FAO) of the United Nations.The designations employed and the presentation of material do not imply the expres-sion of any opinion whatsoever on the part of FAO concerning the legal status of anycountry, territory, city or area or of its authorities, or concerning the delimitation of itsfrontiers or boundaries. The designations “developed” and “developing” economies areintended for statistical convenience and do not necessarily express a judgement aboutthe stage reached by a particular country or area in the development process.

The views in this document do not necessarily reflect the views expressed or promotedby the Micronutrient Initiative.

The Monitoring, Evaluation, and Design Support (MEDS) project coordinated thedevelopment and production of this document. MEDS is funded by USAID undercontract no. HRN-I-02-99-0002-00, task order no. 02. LTG Associates, Inc., and TvT

Global Health and Development StrategiesTM, a division of Social & ScientificSystems, Inc., implement the project.

The Population, Health and Nutrition Information (PHNI) Project produced thisdocument. PHNI is funded by USAID under contract no. HRN-C-00-00-00004-00.The Project is managed by Jorge Scientific Corporation with The Futures Group

International and John Snow, Inc.

ISBN 0-9742991-0-3

June 2003

3

Contents

Part I: Program Guidance

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Abbreviations and Acronyms/Units of Measure . . . . . . . . . . . . . . . . . . 9

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Chapter I Anemia: “Lost Years of Healthy Life” . . . . . . . . . . . . . . . . 15

Chapter II Taking Action: Developing a Strategy for Anemia Prevention and Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Chapter III Providing Iron Supplements to Combat Anemia . . . . . . . 45

Chapter IV Improving Dietary Iron Intake to Combat Anemia . . . . . 59

Photo and Illustration Credits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

Part II: Tools and Resources

The contents of Anemia Prevention and Control: What Works,Part II: Tools and Resources are listed below. See the Part IIContents for page numbers.

Statistics/Technical Data Hemoglobin and Hematocrit Values Defining Anemia at Sea Level

Shifting the Hemoglobin Distribution: Hemoglobin Distribution inPalestinian vs American Children and Women

Anemia Prevalence Rates in Vulnerable Populations, Selected Countries

Anemia Prevalence by Rural/Urban Residence, Selected Countries

Substances That Inhibit and Enhance Absorption of Iron

Demands for Iron in Pregnancy

Proportion of Women Utilizing Antenatal Care (ANC) Services andReceiving/Taking Iron or Iron-Folic Acid (IFA) Supplements, SelectedCountries

Anemia Prevention and Control:What Works

Program DevelopmentRaising Awareness/Program Advocacy: Sample Fact Sheets

Selected Monitoring and Evaluation Indicators for Anemia Preventionand Control Programs

A Tool for Reviewing Micronutrient Programs

Qualitative Research Instrument on Perceptions of Anemia and Use ofIron Supplements – The Indramayu Project, Indonesia

Recommended Intermittent Presumptive Treatment (IPT) or TreatmentRegimens for Malaria, Hookworm, and Schistosomiasis

Iron Supplementation/Food FortificationIron Doses and Three-Month Hemoglobin Increase in Women

Iron and Folic Acid Doses for Universal Supplementation in VulnerableGroups

Iron and Folic Acid Doses for Treating Severe Anemia in VulnerableGroups

United States Dietary Reference Intakes for Anemia-RelatedMicronutrients (Other Than Iron and Folic Acid) for Vulnerable Groups

Counseling Pregnant Women and Mothers About Iron Supplements

Negotiating With Women to Follow Advice

Food Fortification: Seven Steps for Quality Control

Information Sources for Anemia Prevention and Control

References (to Parts I and II)


5

Preface

Anemia Prevention and Control:What Works has two purposes:

1. To bring to the attention of program andproject managers of health and relatedactivities the serious negative conse-quences of anemia for the health andphysical, mental, and economic produc-tivity of individuals and populations

2. To make managers aware of the variousapproaches to anemia prevention andcontrol they can take in policies andprograms in the health and health-relat-ed sectors

Anemia Prevention and Control: WhatWorks has two parts, Part I: ProgramGuidance and Part II: Tools andResources. Because anemia has multiplecauses, Program Guidance advocates acoordinated strategy that takes a numberof sector approaches to reducing anemia’sprevalence and effects. It provides guid-ance on important issues and componentsthat need attention in the design andimplementation of anemia prevention andcontrol strategies and programs. Tools andResources is a compilation of anemia-relat-ed data, survey instruments, programmaterials, and references that managerscan use to design and monitor programs.

In Program Guidance, this Preface is fol-lowed by Acknowledgments, Abbrevia-tions and Acronyms/Units of Measure,and an Introduction to anemia. Theremainder of Part I is organized as follows:

Chapter I, Anemia: “Lost Years of HealthyLife,” defines anemia; describes its impact,prevalence, and causes; and communicatesthe critical importance of taking actionagainst anemia.

Chapter II, Taking Action: Developing aStrategy for Anemia Prevention andControl, discusses good practices for strat-egy and program development and pres-ents sector-specific interventions in healthand related sectors for preventing andcontrolling anemia.

Chapters III and IV then cover the goodpractices associated with augmentingdietary iron by providing iron supple-ments and through food fortification, twoimportant interventions for addressingiron-deficiency anemia.

Each chapter includes a Country Exampledescribing anemia prevention and controlprogramming in a country that has incor-porated many of the elements discussed inthis document. In Chapters II, III, and IV,the country example follows a brief intro-duction to the section. A Good PracticesChecklist gives the steps to take in design-ing and implementing programs, and theGood Practices in Detail section thendescribes the specific actions involved withthese steps. The real-life experiences ofmany anemia prevention and control pro-grams are highlighted in shaded text boxesto illustrate how the information providedin Program Guidance can be put to use.Italicized references directing readers torelevant materials in Tools and Resourcesalso appear throughout the text.

Interagency Anemia Steering Group

Wilma B. FreirePan American Health Organization

Samuel G. KahnU.S. Agency for International

Development

Judith McGuireWorld Bank

Glenn L. PostU.S. Agency for International

Development

Acknowledgments

Anemia Prevention and Control: WhatWorks was written by Rae Galloway,whose time was generously funded by theU.S. Agency for InternationalDevelopment (USAID), the MicronutrientInitiative (MI), and the World Bank. Ms.Galloway received technical advice andsupport from the Interagency AnemiaSteering Group (IASG) composed ofWilma B. Freire, Pan American HealthOrganization (PAHO); Samuel G. Kahn,USAID; Judith McGuire, World Bank; andGlenn L. Post, USAID. The IASG definedthe objectives and audience of AnemiaPrevention and Control: What Works,identified reviewers, and gave essentialcomments at each step. Decisions aboutfinal content were made by the IASG.

Special thanks go to Milla McLachlan,nutrition adviser at the World Bank, forsupporting this project, and MiriamLabbok, who as chief of nutrition andmaternal/infant health at USAID’s Bureaufor Global Programs, Field Support andResearch, helped define objectives and,after moving to the United NationsChildren’s Fund (UNICEF), reviewedthe document.

Adjunct Steering GroupAdjunct organizations were partners inthis process and gave comments whenobjectives were defined and when review-ing the document. The adjunct organiza-tions included the MI, UNICEF, theCanadian International DevelopmentAgency (CIDA), the United Nations Foodand Agriculture Organization (FAO), theUnited Nations Standing Committee onNutrition (SCN), and the World HealthOrganization (WHO).

Country ContributorsThe Country Examples that appear in PartI: Program Guidance are based on casestudies of anemia prevention and controlprograms in Bolivia, Indonesia, Thailand,and Venezuela. These case studies wereessential to this document. The Bolivia

example was written by the author of thisdocument using a report prepared by con-sultant Maria Eugenia Lopez for the WorldBank and the MI. The Indonesia examplewas written by Endang Achadi and D.M.Utari, University of Indonesia; the Thai-land example by Pattanee Winichagoon,Mahidol University; and the Venezuelaexample by Maria Garcia-Casal, InstitutoVenezolana de Investigaciones Cientificas(IVIC). The Bolivian, Indonesian, and Thaistudies were made possible with fundingfrom the MI. The information on povertyand anemia prevalence was prepared byKrishna Rao, consultant for a larger studyfunded by the MI for the World Bank. Inaddition, Ritujit Chhabra at the WorldBank helped in checking prevalence datafor the document.

Review and CommentsComments were given by adjunct organi-zations, external reviewers, and USAID ondrafts of the document. The adjunctreviewers were Bruno de Benoist (WHO),Barbara MacDonald (CIDA), M. G.Venkatesh Mannar (MI), Ellen Muehlhoff(FAO), and Sonya Rabeneck (SCN).

External reviewers providing commentswere Lawrence Barat, World Bank/Centersfor Disease Control and Prevention (CDC)of the United States, on malaria; LenaDavidson, International NutritionalAnemia Consultative Group (INACG),technical/scientific aspects for the wholedocument; Patrick Friel, United NationsDevelopment Programme (UNDP), familyplanning; Victor Fulgoni, consultant, tech-nical/scientific aspects; Marito Garcia,World Bank, early childhood develop-ment; Marcia Griffiths, the Manoff Group,technical/scientific aspects; RichardHurrell, Swiss Federation Institute ofTechnology, technical/scientific aspects;Judiann McNulty, Cooperative forAssistance and Relief Everywhere, Inc.(CARE), operational issues; IbrahimParvanta, CDC, technical/scientificaspects; Peter Ranum, consultant, techni-cal/scientific aspects related to fortifica-tion; and Rebecca Stoltzfus, CornellUniversity, technical/scientific aspects.

7

USAID/Washington staff providing com-ments included Eunyong Chung, CarterDiggs, Mary Ettling, Miriam Labbok (nowwith UNICEF), Margaret Neuse, PatriciaStephenson, Joyce Turk, and EmilyWainwright. Victor Masbayi ofUSAID/Kenya and Kerry Pelzman ofUSAID/Russia also provided comments.

Staff from USAID-funded programs pro-viding comments included SuzanneHarris, the International Life SciencesInstitute (ILSI); staff from MicronutrientOperational Strategies and Technologies(MOST); and Sandra Remancus, Food andNutrition Technical Assistance (FANTA).

Coordination, Editing, andProductionThis document is the result of a multi-agency effort coordinated and facilitatedby staff of the Monitoring, Evaluation andDesign Support (MEDS) project with fund-ing from the USAID Bureau for GlobalHealth. The Population, Health andNutrition Information (PHNI) Project, alsofunded by the Bureau for Global Health,provided editorial and design staff andproduced the document. Karen Lombardi(MEDS) and Chris Wharton (PHNI) editedthe document. Muthoni Njage (MEDS)provided research and review assistance.Matthew Baek (PHNI) designed and for-matted the document. The Government ofthe Netherlands provided funding to theWorld Bank to cover some printing costs.


9

Abbreviations and Acronyms

ACC/SCN Administrative Committee on Coordination, Sub-Committee on Nutrition (United Nations)

AED Academy for Educational Development

AIDS acquired immunodeficiency syndrome

ANC antenatal care

BASICS Basic Support for Institutionalizing Child Survival (Project)

BF breastfeeding

CARE Cooperative for Assistance and Relief Everywhere

CDC Centers for Disease Control and Prevention (United States)

CF complementary foods

CIDA Canadian International Development Authority

DHS Demographic and Health Survey

ECD early childhood development

EDTA ethylene diamine tetra-acetate

FANTA Food and Nutrition Technical Assistance (Project)

FAO Food and Agriculture Organization (United Nations)

FGD focus group discussion

GTZ Deutsche Gesellschaft für Technische Zusammenarbeit (German Technical Cooperation)

Hb hemoglobin

hct hematocrit

HIV human immunodeficiency virus

IASG Interagency Anemia Steering Group

IDRC International Development Research Centre

IEC information, education, and communication

IFA iron-folic acid

ILSI International Life Sciences Institute

IMCI Integrated Management of Childhood Illness

INACG International Nutritional Anemia Consultative Group

IPT intermittent presumptive treatment (malaria)

IUD intrauterine device


IVIC Instituto Venezolana de Investigaciones Cientificas

LAM Lactional Amenorrhea Method

MEDS Monitoring, Evaluation and Design Support (Project)

MI Micronutrient Initiative

MOH ministry of health

MOST Micronutrient Operational Strategies and Technologies (Project)

NGO nongovernmental organization

NHHS National Household Survey (Indonesia)

NID national immunization day

OMNI Opportunities for Micronutrient Interventions (Project)

PAHO Pan American Health Organization

PATH Program for Appropriate Technology in Health

PHNI Population, Health and Nutrition Information (Project)

SCN Standing Committee on Nutrition (United Nations)

TBA traditional birth attendant

TIPS Trials of Improved Practices

TT tetanus toxoid

USAID United States Agency for International Development

UNICEF United Nations Children’s Fund

UNDP United Nations Development Programme

UNU United Nations University

VAD vitamin A deficiency

WHO World Health Organization

Units of Measure

dL deciliter

g gram

kg kilogram

L liter

mcg microgram

mg milligram

mL milliliter

Introduction

Anemia is defined as a low level of hemo-globin in the blood, as evidenced by areduced quality or quantity of red bloodcells. It has serious negative consequences,including increased mortality in womenand children, decreased capacity to learn,and decreased productivity in all individu-als. Its devastating effects on health andphysical and mental productivity affectquality of life and translate into significanteconomic losses for individuals and forcountries with high anemia prevalence.

Anemia is one of the world’s most wide-spread health problems. It affects morethan 2 billion people worldwide – one-third of the world’s population – and is asignificant public health problem through-out the developing world. In almost alldeveloping countries, between one-thirdand one-half of the female and child popu-lations are anemic. Prevalence among preg-nant women and children under 2 years ofage (the groups at highest risk) is typicallymore than 50 percent. In a 2002 report, theWorld Health Organization lists iron defi-ciency, a major cause of anemia, as one ofthe top 10 risk factors in developing coun-tries for “lost years of healthy life.”

Anemia has multiple causes. Its directcauses can be broadly categorized as poor,insufficient, or abnormal red blood cellproduction; excessive red blood celldestruction; and excessive red blood cellloss. Contributing causes include poornutrition related to dietary intake, dietaryquality, sanitation, and health behaviors;adverse environmental conditions; lack ofaccess to health services; and poverty. Therelative importance of these causes variesby region.

Iron deficiency causes 50 percent of allanemia worldwide. Supplementing dietaryiron with iron tablets, syrups, drops, orelixirs, and fortifying processed foods andcondiments with iron are the best offenseand defense against this cause of anemia.Where fortification has been evaluated in

specific populations, it has improved ironstatus and reduced anemia prevalence. Inmost developing countries, however, foodindustries are not well developed, and,where they are developed, most peoplecannot afford fortified foods. Supplement-ing dietary iron can meet the iron needs ofvulnerable groups who do not consumefortified foods. Iron supplementation alsohas the advantage of meeting the needs ofpregnant women and young children,whose high iron requirements cannot bemet only with fortified foods. In countrieswhere the feasibility of general dietaryimprovement is limited, iron supplementa-tion for vulnerable groups and food fortifi-cation are the most cost-effective means ofaddressing iron-deficiency anemia.

Because anemia has many causes in addi-tion to iron deficiency, many types of pro-grams in the health sector and other socialsectors have the potential to contribute toanemia prevention and control. An anemiacomponent can and should be part of pro-grams or activities in:

• Nutrition

• Infectious and parasitic diseases

• Antenatal care and safe motherhood

• Family planning and reproductivehealth

• Child health

• Schools

• HIV/AIDS prevention and treatment

• Food aid and security

• Environmental health

• Commercial sector: food and pharma-ceutical manufacturers, marketers, anddistributors

Sector-specific activities, when implement-ed concurrently as part of an anemia pre-vention and control strategy, can signifi-cantly reduce the prevalence of anemiaand its debilitating consequences in target-ed populations. In most cases, it is possibleto add anemia prevention or control activi-ties to already existing health or health-

11

related programs without large invest-ments of time or resources.

Raising awareness of anemia preventionand control, promoting behavior change inthe community, advocating for increasedfunding for national anemia programming,and training to build capacity amonghealth workers are activities that can beimplemented by any and all sectors andacross sectors. They are most effectivewhen approached in a coordinated, target-ed manner.

Health professionals, governments,donors, nongovernmental organizations,the commercial sector, and civil society allhave roles to play in achieving anemiaprevention and control. Effectively imple-menting interventions requires an inte-grated approach of financial, technical,and political commitment and support.Partnerships and collaboration amongthese various players should be built atthe national, provincial/state, district, andlocal levels from the outset of anemia pro-gramming. Input from and coordinationamong all potential parties is most criticalin the key initial phase of planning ananemia strategy.

Knowing what has worked for others canfacilitate the efforts of new programs totake action. Part I: Program Guidance ofAnemia Prevention and Control: WhatWorks thus presents good program prac-tices for anemia prevention and control,with examples of good practices fromaround the world. Part II: Tools andResources shares materials such as qualita-tive research instruments and methodolo-gies, background data, norms and proto-cols, and references to also inform andsupport such efforts.


13Chapter I Anemia:“Lost Years of Healthy Life”

Anem

ia:“Lost Years of H

ealthy Life”COUNTRY EXAMPLE

ASSESSING THE EFFECTIVENESS OF ANEMIAPREVENTION AND CONTROL IN BOLIVIA

In Bolivia, which has had a policy to give iron supplements to pregnant women since 1986,the 1997 Demographic and Health Survey (DHS) found that 27 percent of women of repro-ductive age were anemic. The survey data were not disaggregated between pregnant andnonpregnant women, but it is likely that anemia prevalence in pregnant women was higher.One study of antenatal care (ANC) clients, for example, found that 50 percent were anemic.Undoubtedly, anemia prevalence remains high because ANC coverage is low – only 50 per-cent of women have contact with health services during pregnancy. As a result, only 35 per-cent of pregnant women routinely receive iron-folic acid (IFA) supplements.

Anemia is also a problem in other population groups. In response to the 67 percent anemiaprevalence the 1997 DHS found among children under age 3, the government has extendedIFA supplementation to children under age 2. In addition, to help build the iron stores of theentire population, Bolivia now requires all wheat flour to be fortified with iron and othermicronutrients.

In 2000, a qualitative assessment of Bolivia’s public and private health systems (conducted aspart of a larger World Bank study on nutrition) identified the strengths and constraints ofIFA supplementation programs. Representative municipalities were chosen from the threegeographic zones (highland plateau, valley, and plains) according to a human developmentindex based on socioeconomic variables such as life expectancy at birth, educational level,and income, and on the presence of public and private health systems.

Observations of services and interviews with health staff, women, and mothers of young chil-dren showed that awareness of policies, norms, and protocols in support of IFA supplementa-tion was low. The low priority given to iron and other micronutrients was reflected in suchstatements as “The Expanded Program on Immunization demands a lot of effort and causeslack of attention to the micronutrient component” and “During the technical council meet-ings, micronutrients have never been an important topic or item for discussion.” The assess-ment also indicated a need to put micronutrients on the agenda of health care institutions.

In addition, most of the focus of IFA supplementation activities was on curative treatment ofanemia rather than anemia prevention. Anemia control for young children was almost non-existent, despite the policy supporting IFA supplementation for children under 2. The IFAsupplementation program for pregnant women was more active, but coverage was stilllower than expected for a 15-year-old program. Reasons for this low coverage included:

• Copies of norms and protocols on anemia prevention and treatment not available in allhealth facilities

• Lack of standardization of norms and protocols

• Lack of training in how to use norms and protocols

• Failure to seek advice from knowledgeable, experienced personnel in the lower levelsof the health system when developing norms and protocols

• Supply shortages preventing health workers and IFA users from complying withprogram norms


While supplies of IFA supplements were adequate at the national level, only 9 percent of thenational supply was distributed between January and October 1999. As a result, only 21percent of pregnant women received all of the recommended 90 supplements, and only 30percent received 60. These findings are indicative of either (or both) an ineffective distribu-tion and logistics system or a lack of demand for the supplements due to poor utilization ofANC services or poor supplement quality. In subtropical districts, problems with the qualityof the IFA supplements were severe. One health worker noted that the supplements “turnto powder because of the humidity and women refuse to take them.”

Women rarely received consistent messages on when to take IFA supplements and how tomanage side effects. Health worker training on anemia control and counseling was limited. Ina few areas, some health staff received in-depth training on IFA supplementation throughspecial programs such as the MotherCare and Opportunities in Micronutrient Interventions(OMNI) projects (funded by the U.S.Agency for International Development and implement-ed by John Snow, Inc.) and Integrated Management of Childhood Illness (IMCI) activities. Inmost cases, health workers felt they had forgotten most of what they had learned, indicatinga lack of follow-up supervision to reinforce messages. The MotherCare/OMNI projectsdeveloped counseling cards and other behavior change materials for use throughout thecountry, but their dissemination and use stopped after the projects ended.

The World Bank study made the following recommendations to improve service quality:

• Ensure adequate supplies of IFA supplements for pregnant women and young children

• Make norms and protocols available to health workers who are giving supplements topregnant women and children

• Train health workers to ensure that they 1) understand the importance of anemia, 2) fol-low norms and protocols, 3) improve their communication and interpersonal skills withwomen and mothers attending health services or receiving counseling, and 4) are able toconvey effective messages to women

• Supervise health workers and programs adequately to ensure continuous qualityimprovement in services

• Scale up the success of smaller programs that have developed effective training andbehavior change materials

• Utilize all channels in the health system (including community workers and public healthprograms such as immunization campaigns, growth-monitoring contacts, and pre- andpostnatal care) to deliver iron to ensure that the most vulnerable groups receive suppliesof IFA supplements or syrups

Chapter IAnemia: “Lost Years

of Healthy Life”1

What Is Anemia2 ?Anemia is defined as a low level of hemoglobinin the blood, as evidenced by a reduced qualityor quantity of red blood cells.

Hemoglobin is the substance in red bloodcells that carries oxygen to the cells of thebody. The body’s cells need oxygen tofunction and enable a person to performall physical and mental activities. Whenhemoglobin levels are low, as in a personwho has anemia, less oxygen reaches thecells to support the body’s activities. Theheart and lungs also must work harder tocompensate for the blood’s low capacity tocarry oxygen.

Internationally accepted hemoglobin val-ues for defining anemia in different popu-lation groups are shown in table 1.1.

Anemia is subclassified into mild, moder-ate, and severe levels as hemoglobin val-ues decline. It can also be measured interms of the hematocrit content of packedblood cell volume.

What Is the Impact of Anemia?Anemia makes it more difficult for men andwomen to earn incomes, carry out daily tasks,and care for their families. It makes womenweaker during pregnancy and delivery, reduc-ing their chances of having healthy babies andsurviving blood loss during and after child-birth. Anemic infants and children grow moreslowly than non-anemic infants and children.They are apathetic and anorexic, do not haveenough energy to play, and have trouble learn-ing. A 2002 World Health Organization reportlists iron deficiency, a major cause of anemia,as one of the top 10 risk factors in developingcountries for “lost years of healthy life.”

Adult productivity. In adults, one of thefirst signs of anemia is fatigue, whichoccurs when there is not enough oxygen inthe body to support physical activity.Work productivity and earned income suf-fer accordingly. Preventing and treating allcauses of anemia improves work output. A

literature review from 1973 to 1981 foundthat a 10 percent increase in hemoglobinlevels was associated with a 10 to 20 per-cent increase in work output. Adults withanemia are also less likely to engage insocial activities and nurture and care fortheir infants and children.

Maternal health. Anemia reduces awoman’s ability to survive bleeding dur-ing and after childbirth. Women with


Anem


ealthy Life”

1 The 2002 World Health Report of the World HealthOrganization uses this concept to measure the impactof a number of health problems, including anemia.2 The terms “anemia” and “iron-deficiency anemia” areoften used interchangeably. In this document, “anemia”means anemia from any cause, unless specified as“iron-deficiency anemia” – anemia caused only by irondeficiency.

Table 1.1Hemoglobin Values Defining Anemia

For Population Groups

Age or Sex GroupHemoglobin

Value Defining Anemia (g/dL)

Children 6-59 mos.

Children 5-11 yrs.

Children 12-14 yrs.

Nonpregnant women > 15 yrs.

Pregnant women

Men > 15 yrs.

< 11.0

< 11.5

< 12.0

< 12.0

< 11.0

< 13.0

Source: WHO/UNICEF/UNU (2001); values used inDHS.

Tools and Resources has an expanded versionof table 1.1 with hemoglobin values for mild,moderate, and severe anemia, and hematocritvalues for different age and sex groups.

In Bangladesh, India, and Pakistan, anemia-related losses in economic productivity amountto an estimated $4.5 billion annually.

severe anemia are particularly at risk andhave a 3.5 times greater chance of dyingfrom obstetric complications during orafter pregnancy than women who do nothave anemia. Anemia-related fatigue alsomakes the effort of labor more difficult,thus prolonging delivery.

Conservative estimates suggest anemia isthe direct cause of 3 to 7 percent of mater-nal deaths worldwide. Other estimatessuggest it is the direct or indirect cause of20 to 40 percent of maternal deaths.

Although it is currently accepted that onlysevere anemia causes maternal mortality, ithas been estimated that moderate anemiaincreases a woman’s chance of dying 1.35times, making it a risk for maternal mortal-ity. Many more women have mild to mod-erate anemia than severe anemia. Thisunderscores the importance of preventingand treating all forms of anemia, as the

number ofdeathsassociatedwith mildto moder-ate ane-mia ispotential-ly greaterthan the

number associated with severe anemia.This is consistent with patterns seen withvitamin A and energy deficiencies, which,because of the greater numbers of peopleaffected, also cause more deaths in theirmild to moderate forms than in theirsevere forms.

Young child development and learn-ing. Anemia is associated with prematurebirths, intrauterine growth retardation,and low birthweight in infants. In turn,premature, underdeveloped, and under-weight infants have decreased chances ofsurvival. If they survive, they may have(both as infants and later as children)physical and mental developmental prob-lems, including learning deficits, eatingdisorders such as anorexia, and poorgrowth. Full-term infants of anemic moth-ers have reduced iron stores and are at risk

of becoming iron-deficient and anemicduring exclusive breastfeeding in the firstsix months of life. Iron-deficiency anemia,particularly in children under 2 years ofage, can result in irreversible learningproblems even if the iron deficiency andresulting anemia are corrected. In malaria-endemic areas, many children are anemicbecause of a combination of iron deficiencyand untreated episodes of malaria. Thehemoglobin levels of these children candrop to life-threatening levels. Iron defi-ciency also affects iodine uptake, increas-ing the risk of iodine deficiency disordersthat can have devastating effects on fetalbrain development and a child’s IQ.Anemic children of all ages are apathetic,which affects social development.

Adolescent development. Because theyare undergoing rapid growth, adolescentshave high requirements for iron and areparticularly vulnerable to anemia causedby multiple nutritional deficiencies andhelminth infections. Both boys and girls areat risk, although prevalence peaks at differ-ent ages for each because the growth spurtsof boys and girls occur at different ages.


In Tools and Resources, “Shiftingthe Hemoglobin Distribution”shows the distribution of mild,moderate, and severe anemia in apopulation and describes itsimplications for programdevelopment.

Children and adolescents have high ironrequirements because of rapid growth.

Iron requirements for boys decrease afterthey stop growing, while those for girlsremain high throughout the reproductiveyears because of menstrual blood loss, theiron demands of the developing fetus, andblood loss during delivery.

How Prevalent Is Anemia?There are more than 2 billion people in theworld with anemia – one third of the world’spopulation. Anemia prevalence is highest indeveloping countries. Worldwide, pregnantwomen and children, particularly children lessthan 2 years old, are the most vulnerable. Inmany countries, anemia prevalence is highestin rural areas.

When national anemia prevalence surveysdisaggregate anemia prevalence by ageand sex, they generally show that the high-est rates occur in pregnant women andyoung children under 2 years of age.National surveys may also include data forother groups, such as all reproductive-age

women,childrenunder age5, school-age chil-dren, ado-lescents,

laborers with heavy workloads, farmlaborers, and the elderly.

At the national level, anemia is considereda severe public health problem when ane-mia prevalence is equal to or greater than

40 percent. By the measures given in fig-ure 1.1, anemia is a severe public healthproblem in nearly all developing countries.Anemia prevalence rates in industrializedcountries are typically in the normal tomild range.

Tables 1.2 and 1.3 show estimates of ane-mia prevalence for developing and indus-trialized countries and different worldregions. For all age groups, the risk ofdeveloping anemia is two to seven timesgreater indevelopingcountries thanin industrial-ized coun-tries. Anemiaprevalence is usually higher in rural areasthan urban areas.

Anemia prevalence is highest in WHO’sSouth East Asia,3 Eastern Mediterranean,


Anem


ealthy Life”

The table “Anemia PrevalenceRates in Vulnerable Populations,Selected Countries” appears inTools and Resources.

Figure 1.1

Public Health Significance of Anemia

Anemia Public Health Prevalence Significance

> 40% Severe20-39% Moderate5-19% Mild0-4.9% Normal

Source: WHO/UNICEF/UNU (2001).

Table 1.2Prevalence of Anemia by Risk Group, Developing and Industrialized Countries, 1998*

0-4 yrs. (%) 5-14 yrs. (%) Nonpregnant Women (%)Pregnant

Women (%) Others (%)

Developing Countries 42** 53 43 55

Men: 35Elderly: 51

IndustrializedCountries 17 8 11 19

Men: 5Elderly: 12

* Estimates using hospital populations or data over 10 years old. ** National data from countries within each region suggest that prevalence rates for children < 2 yrs. are higherthan the rates shown here for children 0-4 yrs. Source: SCN (2000).

Tools and Resources containsthe table “Anemia Prevalenceby Rural/Urban Residence,Selected Countries.”

3 WHO’s South East Asia region includes South Asia.

and Africa regions, with the highest ratesfound among pregnant women and chil-dren. Increases in anemia prevalenceoccurred during the 1990s in EasternEurope, the Caucasus, and Central AsianRepublics. Prevalence is lower in WesternEurope and in WHO’s Western Pacific andAmericas regions. Nonetheless, anemiaprevalence among pregnant women andchildren in these areas persists at moderateto severe levels, according to international-ly accepted standards. This reflects the dif-ficulty of meeting the iron needs of thesevulnerable groups even in areas wherediets are relatively high in iron. Lowerrates in some countries, however, indi-cate that targeted programs can addressthis problem.

What Are the Causes of Anemia?

There are different causes of anemia worldwide.Their relative importance varies by region.

In order of importance, the major causes ofanemia are iron deficiency; other nutrition-al deficiencies; malaria; helminth infections(particularly hookworm but also schistoso-miasis); chronic infections includingHIV/AIDS and tuberculosis; causes relatedto reproduction and contraception; andgenetic conditions such as thalassemia andsickle cell. These causes can be dividedinto direct causes and contributing causes.Table 1.4 lists these direct and contribut-ing causes and the components of each.

The relative importance of anemia’s causesvaries geographically. Table 1.5 shows theimportance of the major causes by region.In developing countries, there is seldomjust one cause of anemia, while in industri-alized countries anemia may be causedprimarily by poor dietary intake of severalnutrients.

Direct Causes: Poor, Insufficient, orAbnormal Red Blood Cell Production

Iron deficiency. Iron deficiency causes 50percent of anemia worldwide, making itthe single largest cause of anemia. Whileiron deficiency causes anemia by reducingred blood cell production, iron deficiencyitself may be exacerbated by excessive redblood cell loss (from menstruation, forexample).

Iron is an essential component of hemoglo-bin, which is needed to make red bloodcells. The body obtains iron from dietaryiron, recycled red blood cells, or stored iron.Both quantity and quality of diet con-tribute to iron sufficiency. Substances indifferentfoodshaveeitherinhibit-ing or enhancing effects on iron absorp-tion. If there is not enough iron in the dietor if it is not well absorbed, the body can-not meet its requirement for iron, causing


Table 1.3 Anemia Prevalence, Children 0-5 Years and

Pregnant Women, 1998

WHORegion

Children0-5 yrs. (%)

PregnantWomen (%)

Africa 44 51

Americas 20 35

E. Mediterranean 48 55

Europe 25 25

South East Asia* 65 75

Western Pacific 24 43

* includes South AsiaSource: SCN (2000).

In India, an estimated 131 million women ofreproductive age (52 percent of this popula-tion) and 85 million children under age 4 (74percent) are anemic. Combining these esti-mates with those for schoolchildren and ado-lescents, there are at least 360 million anemicindividuals in India.

In Cambodia, 57.8 percent of reproductive-age women are anemic. This rate increases to66 percent among pregnant women. Anemiaprevalence is 63 percent among children under5 but nearly 82 percent among 6- to 23-month-olds.

In Egypt, 29.7 percent of adolescents 11 to 19years of age are anemic.

Tools and Resources contains thetable “Substances That Inhibit andEnhance Absorption of Iron.”

a decline in red blood cell production andhemoglobin levels. If dietary iron is notincreased or some other source of iron(such as supplements) is not available,anemia occurs.

Red blood cell production increases as theiron requirements of individuals increase.Iron requirements are high during periodsof rapid growth, which occur in the fetus,children less than 2 years old, preschooland school-age children, and adolescents.Individuals who experience excessiveblood loss also have high iron require-

ments. Pregnant women are particularlysusceptible to anemia, as the growth of thefetus and other physiological changes dur-ing pregnancy increase the need for iron.In bothindustrialanddevelop-ing coun-tries, stan-dard diets do not provide the amount ofiron needed during pregnancy, so ironsupplementation is necessary. Healthy


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ealthy Life”Table 1.4 Causes of AnemiaDirect Causes Components (in order of importance)Poor, insufficient, orabnormal red blood cellproduction

Poor dietary intake and/or absorption of ironPoor dietary intake and/or absorption of vitamins (A, B-12, folicacid, and possibly B-6, C, and riboflavin) and copperIncreased needs for nutrients due to growth or disease (diarrhea)HIV/AIDSOther infectious diseases (tuberculosis, malaria)Genetic blood diseases (sickle cell disease or trait, thalassemia)

Excessive red blood celldestruction

Malaria

Excessive red blood cellloss

Helminth (worm) infections (hookworm, schistosomiasis)Bacterial or viral infections (peptic ulcers, gastritis, diarrhea)Reproduction (excessive blood loss during menstruation, delivery,and postpartum period; too many pregnancies; shortened postpar-tum amenorrhea)Contraceptive methods (intrauterine devices)

Contributing Causes ComponentsKnowledge and behavior Poor knowledge among health workers about anemia, iron supple-

mentation, and other anemia prevention and control interventionsPoor knowledge among vulnerable groups about the importance ofanemia and anemia prevention and control interventionsCultural taboos or biases (e.g., women eating after others)Practices that restrict food intake, including poor infant breastfeed-ing practices and inadequate introduction of complementary foodsPoor compliance with recommended behaviors (iron supplementation;malaria, tuberculosis, and other medication regimens; use of familyplanning; use of sanitation facilities; HIV prevention behaviors)

Environmental Contamination by heavy metals (lead)

Lack of access to services Low use of antenatal and other services providing iron supplements Lack of trained birth attendants to manage bleeding during deliveryLack of access to sanitation services that mitigate helminth infestationLack of access to bednets to prevent malaria transmission

Poverty Lack of income to buy foods with adequate amounts of absorbableiron or to obtain iron supplements, malaria treatment, insecticide-treated bednets, shoes to prevent helminth infection, and other pre-ventive commodities or services

Source: Adapted from Gillespie and Johnston (1998).

In Tools and Resources, the table“Demands for Iron in Pregnancy”outlines the iron losses and gainsin pregnant women.

infants of healthy mothers receive suffi-cient iron from their stored iron as well asa small but absorbable amount of ironfrom breast milk. Complementary foods tosupply iron need to be introduced at sixmonths, when iron stores are exhausted.Children between 6 and 24 months of ageneed iron supplements because most stan-dard diets do not supply enough iron (seebox The Special Iron Needs of ChildrenUnder Age 2).

Not all individuals with iron deficiencydevelop anemia and not all people withanemia are iron-deficient, as demonstratedin figure 1.2. Anemia is the most seriousmanifestation of iron deficiency, and inplaces where iron deficiency is the maincause of anemia, many more people areiron-deficient than anemic. In areas wheremore people have anemia due to othercauses, iron deficiency may still be a signif-icant cause of anemia.

Deficiencies in other nutrients. Anemia isalso caused by poor dietary intake and

poor absorption of other key nutrientsneeded for red blood cell production. Inconjunction with iron deficiency, deficien-cies of folic acid and vitamins A and B-12cause nutritional anemia. Deficiencies ofvitamins B-6 and C, riboflavin, and copperare also associated with anemia, but thereis little evidence that these deficienciescontribute significantly to anemia in devel-oping countries. Deficiencies in othernutrients can cause other devastating prob-lems. For example, if a woman is deficientin folic acid around the time of conception,the deficiency can cause neural tube andother developmental defects in the fetus.

Undernutrition itself can cause poor redblood cell production (as well as retardedgrowth, immunodeficiencies, and learningdeficits independent of iron-deficiencyanemia), and addressing undernutrition invulnerable groups is essential to correctinganemia in a sustainable way. The quantityof micronutrients consumed, particularlyiron, depends both on the type andamount of food consumed. Knowledge of


Table 1.5 The Importance of Anemia’s Major Causes by Region

IronDeficiency

Malaria Sickle Cell Thalassemia HIV/AIDS

Hookworm HighFertility

Sub-SaharanAfrica

+++ +++ ++ + ++ ++ +++

North Africa +++ + + ++ + + ++

Americas +++ + + + + + +

Central Asia/Caucasus

+++ ++ ++ ++ + + ++

EasternMediterranean

+++ ++ ++ ++ + + ++

Europe(Industrial)

+ — + + + — —

South EastAsia*

+++ ++ + + + + ++

WesternPacific**

+++ + + + + ++ +

* includes South Asia **includes ChinaKey: +++ very important as a cause; ++ of medium importance; + of mild importance or important on aregional basis; --- not significant or not of public health significanceSource: Warren et al. (1993); Fairbanks (1999); various DHS.

the kinds and amounts of food that shouldbe eaten may be inadequate and thus affectmicronutrient consumption. Inequities infood distribution within families and chron-ic or recurrent health conditions may alsoprevent the food and micronutrient needsof vulnerable groups from being met.

HIV/AIDS. People who have HIV infec-tion and are anemic are at greater risk ofdying than those without anemia. Theirrisk of dying increases as their hemoglobindecreases, and they have high require-ments for iron and other micronutrients.Their risks of anemia may increase becauseof poor diet and inadequate nutritionalcare affecting their red blood cell produc-tion. People living with HIV/AIDS areoften anorexic and may have mouth soresthat cause eating problems, resulting inreduced food intake. Iron deficiency andthe presence of other infections can furtherreduce appetite and exacerbate anemia.HIV infection itself suppresses red bloodcell production. When HIV infection devel-ops into AIDS, anemia may become severeas iron is sequestered in the liver and mus-cle. Certain types of AIDS treatmentsreduce this iron build-up and alter thebody’s iron balance. If iron deficiency

already exists, further negative effects onimmune function may result.

Other infectious diseases. Other infec-tious diseases make anemia more severeby increasing metabolism, thus increasingiron and other micronutrient requirements.Measles, for example, can increase the riskof vitamin A deficiency, which in turn canincrease the risk of anemia. There is anassociation between malnutrition, anemia,and tuberculosis. Chronic diarrheal diseasein children causes malabsorption andundernutrition, affecting red blood cellproduction. Some of the anemia in chronicdiseases is due to inflammation or swellingof tissues and not related to poor nutrition-al status.

Genetic conditions. Genetically linkedblood diseases and hemoglobin abnormali-ties such as sickle cell and thalassemiacause abnormal hemoglobin production.People with sickle cell disease or sickle celltrait have genetically altered hemoglobinthat offers some protection against malariabut increases risks of anemia. About 1 to 2percent of infants in Africa are born withsickle cell disease and are at high risk ofsevere anemia and death. People with


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ealthy Life”The Special Iron Needs of Children Under Age 2

Until 6 months of age, normal-weight, full-term infants who are born to healthy mothers andare exclusively breastfed receive enough iron from their own stored iron and from breast milk.Their stored iron is exhausted in about six months.Additional iron is then required becausethe iron content of unfortified conventional complementary foods is insufficient to meet thehigh iron requirements of growing 6- to 24-month-old infants and children. Infants and childrenwho do not obtain adequate iron will suffer cognitive impairment that will affect their ability tolearn and to perform income-earning tasks later in life. Iron supplements provided after 24months of age may not correct this cognitive impairment.

Low-birthweight infants, premature infants, and infants of mothers with anemia need additionaliron starting at about 2 months of age to build iron stores and meet the requirements of theirrapid growth. Non-exclusively breastfed infants also may need small amounts of additional ironto compensate for the iron they do not receive through breast milk.The iron requirements ofchildren with severe malnutrition and anemia need special attention.

National iron-deficiency anemia programs for young children exist only in a few countries, butnew products for supplementing or fortifying diets may lead to promising interventions inmore areas. Products under study and development include multimicronutrient sprinkles,spreads, and other forms of micronutrients to add to food.Work on these and other productsneeds to increase and accelerate to facilitate new and expanded programs in countries whereiron deficiency is still a major cause of anemia in children less than 2 years old.

sickle cell trait (which occurs in 30 percentof Africa’s population) do not have severeanemia but have a slight reduction in func-tional hemoglobin. Thalassemia (bothalpha and beta) is concentrated in Africa,Asia, the Middle East, and the Mediter-ranean region. It can be life-threatening inchildren but does not represent a signifi-cant public health problem worldwide.Identifying individuals with thalassemia isprobably not cost-effective in most devel-oping countries because the number ofpeople affected is relatively small and testsare expensive.

Direct Causes: Excessive Red BloodCell DestructionMalaria. Malaria parasites destroy redblood cells and suppress red blood cellproduction. All persons living in or visit-ing areas with endemic malaria transmis-sion are at risk of anemia from malaria. Inareas of intense malaria transmission,malaria infection – usually accompanied

by iron deficiency – causes life-threateningsevere anemia in children under 2 years ofage and in women in their first and secondpregnancies.

Direct Causes: Excessive Red BloodCell LossHelminth (worm) infections. In develop-ing countries, excessive red blood cell lossand resulting iron-deficiency anemia arecaused by worm or helminth infections.Two types of hookworm, three types ofschistosomes, and whipworm all causeblood loss. Among these infections, hook-worms are the most common cause of ane-mia and schistosomes the second mostcommon. Hookworms are contractedwhen parasites enter the skin, generallythrough the feet as people walk barefooton feces-contaminated soil. They consume


In Nepal, anemia prevalence in women hasbeen associated with intensity of malaria andhookworm infections.

Figure 1.2. Relationship Between Iron Deficiency, Iron-Deficiency Anemia, and Anemia ina Population. More people are affected by iron deficiency than have iron-deficiency anemia. Whileanemia can be caused by factors other than iron deficiency, most people with anemia in developingcountries are also iron-deficient.

the blood of their host and cause signifi-cant blood loss. Endemic hookworms are asignificant cause of anemia in childrenafter the ages of 2 or 3 years.

Bacterial and viral infections. Infectionsthat cause peptic ulcers and gastritis (specif-ically Helicobacter pylori) are common indeveloping countries. They cause anemiaby increasing blood loss but also by reduc-ing stomach acid, resulting in poor absorp-tion of iron. Diarrhea caused by particularbacterial infections may also cause anemia,especially if the diarrhea is chronic andcharacterized by bloody stools.

Reproduction and contraception: men-struation, childbirth, breastfeeding prac-tices, contraceptive practices. Womenwho have excessive blood loss duringmenstruation and childbirth haveincreased risks of developing anemia.

Also, hav-ing manycloselyspacedpregnan-cies cancause“maternaldepletion”syndrome,

in which a number of nutritional deficien-cies lead to anemia. Introducing food andwater in an infant’s diet before the infanthas completed six months of exclusivebreastfeeding may increase the mother’sanemia risk because the period of lactation-al amenorrhea (which reduces menstrualblood loss) is shortened. Intrauterinedevices can increase blood loss, as opposedto oral and injectable contraceptives (suchas Depo-Provera), which reduce menstrualblood loss.

Contributing CausesPoor knowledge and behaviors. Lack ofknowledge contributes to high anemiaprevalence worldwide. Poorly trainedhealth workers may not know or believeanemia is important and thus may fail topromote preventive behaviors. People atrisk of anemia may not know it is animportant contributor to poor health andmay not be aware of preventive behaviorssuch as good nutrition and dietary prac-tices, good infant feeding practices, sanita-tion-related practices, and sleeping underbednets for malaria protection. Culturalbiases and taboos (such as those prohibit-ing certain foods or requiring women toeat after others have finished) also con-tribute to anemia risk, as does noncompli-ance with modern family planning meth-ods, IFA supplements, and malaria orhookworm medications.

Environmental causes. Anemia caused bylead poisoning, which interferes withhemoglobin production, is a problem incrowded urban areas where lead paint isstill used or where automobiles still useleaded gasoline. Lead competes with ironduring absorption, so poor dietary intakeof iron exacerbates lead poisoning byallowing more lead absorption than wouldoccur in an iron-replete individual.

Lack of access to health services and poorsanitation. Poor access to health servicesand poor sanitation conditions and prac-tices also contribute to higher anemia rates.Antenatal care services are an appropriatevenue for delivering anemia interventions.However,access tothese serv-ices is lowin manycountries,with manywomenhaving fewvisits orbeginning them late in pregnancy.Additionally, in many countries, womendo not have trained attendants duringdelivery to manage severe bleeding if it


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ealthy Life”

Demographic and Health Surveys in Armenia,Egypt, Kazakhstan, Kyrgyz Republic,Turkmenistan, and Uzbekistan have reportedanemia rates among intrauterine device (IUD)users 1.6 to 14.5 percentage points higher thanrates among women not using IUDs.

The table “Anemia PrevalenceRates in Vulnerable Populations,Selected Countries” in Tools andResources shows anemia ratesamong pregnant women,intrauterine device users, andother women of reproductive age.

Tools and Resources contains thetable “Proportion of WomenUtilizing Antenatal Care (ANC)Services and Receiving/TakingIron or Iron-Folic Acid (IFA)Supplements, SelectedCountries.”

occurs. In many areas, lack of sanitation orpoor sanitary practices, such as walkingwithout shoes through feces-contaminatedsoil, contribute to anemia by increasing therisk of helminth infection.

Poverty. The poor are at greater risk ofanemia due to lack of income and otherresources that prevents them from con-suming a diet with adequate, well-absorbed iron. Iron is a highly income-elastic micronutrient. As family incomesrise, families tend to purchase more meat,which contains a type of iron that is betterabsorbed than the iron in most plantproducts.

In addition, lack of income may preventthe poor from utilizing health services.Anemia risks are increased by the inabilityto pay for maternal and child health servic-es, iron supplements, malaria and de-worming medications, bednets, and otherprotective interventions.


In Andra Pradesh, India, anemia rates arehighest among the lowest income group.Although iron supplementation is high, 14 per-cent of the poor do not receive iron in preg-nancy, compared to 8 percent in the highestincome group.This contributes to higher ane-mia prevalence among the poor.

Chapter IITaking Action:Developing a

Strategy for AnemiaPrevention and Control

Most anemia prevention and control pro-grams have focused only on reducing theanemia caused by iron and folic acid defi-ciencies. However, because anemia has anumber of different causes (see Chapter I,Anemia: “Lost Years of Healthy Life”), it isbest addressed by adding anemia preven-tion and control activities to existing pro-grams in public health and other sectors,and, where needed, by introducing newprograms.

This chapter recommends that to initiateanemia prevention and control, a strategyor long-term plan should be developed.This strategy or plan should cover:

• Surveying the anemia problem

• Assessing related programs

• Suggesting improvements to currentprograms or introducing new programs

• Designing monitoring and evaluationactivities

As part of the planning process, partnersshould be identified and brought in toassist in strategy development. Howeverthe process begins – in the efforts of oneindividual, as an initiative of private citi-zens, or as a new public sector activity – itshould become a collaborative ventureinvolving all potential stakeholders,including governments and governmentagencies, donors, civil society, nongovern-mental organizations, health professionals,and the commercial sector. Building thesepartnerships is critical in the initial plan-ning phase.

Existing data about which populationgroups are anemic, where these groupsare concentrated geographically, and thespecific causes of anemia provide the basis

for developing an anemia prevention andcontrol strategy. In most cases, it is possi-ble to add anemia prevention or controlactivities to already existing health orhealth-related programs without largeinvestments of time or resources. Potentialprogram partners in anemia preventionand control include the following healthand health-related sectors:

• Nutrition




• Child health

• Schools




• Commercial sector: food and pharma-ceutical manufacturers, marketers, anddistributors

Specific activities to prevent and controliron deficiency, which is a major cause of

25Chapter II Taking Action: Developing a Strategy

Taking A

ction:D

eveloping a Strategy

A child in Cambodia receives vitamin A, ironsupplements, and de-worming medication.

anemia, should be part of the strategy.Chapter III, Providing Iron Supplementsto Combat Anemia, and Chapter IV,Improving Dietary Iron Intake to CombatAnemia, provide guidance for supplement-ing dietary iron and increasing the amountof iron in the diet through food fortifica-tion, the major interventions for address-ing iron-deficiency anemia.

The anemia prevention and control strate-gy should include indicators for monitor-ing and evaluating anemia prevention andcontrol activities. These indicators and aplan for collecting relevant data should bedeveloped in the strategy planning stage.

Effectively implementing interventions ofany kind requires an integrated approachwith financial, political, and technical com-mitment and support. The key to theimmediate success and long-term sustain-ability of an anemia prevention and con-trol strategy is the support of governmentat all levels – national, provincial/state,and local – and, where needed, interna-tional organizations.

The Country Example that followsdescribes how Indonesia worked toimprove its anemia prevention and controlprogram by targeting antenatal care clientsand by introducing an integrated approachof activities across a number of sectors andprograms.

The Good Practices Checklist shows thesteps for developing an anemia preventionand control strategy. The steps are present-ed in a suggested order of implementation.The Good Practices in Detail sectiondescribes specific actions that managers,concerned policy makers, and othersshould take in following these steps todevelop a strategy. It emphasizes theimportance of taking an integratedapproach to anemia programming and ofbuilding partnerships at all levels toaccomplish anemia prevention and controlobjectives. It also suggests “sector-specificinterventions” that can be added to healthand other programs to help prevent andcontrol anemia.

Part II of this document, Tools andResources, provides research instrumentsand methodologies, background data,norms and protocols, and references thatprovide additional information to helpprogram and project managers design,implement, and monitor interventions.



Taking A

ction:D

eveloping a StrategyCOUNTRY EXAMPLE

EXPANDING ANEMIA PREVENTIONAND CONTROL IN INDONESIA

Anemia prevalence is high in a number of groups throughout Indonesia. After initiatingefforts to reduce anemia in pregnant women in 1985, Indonesia has since expanded its ane-mia prevention and control strategies and is addressing anemia prevalence in other vulnera-ble groups through a number of measures.

As the table below indicates, the 1995 National Household Survey (NHHS) found preva-lence highest among adolescent girls, followed by pregnant women, school-age children, chil-dren less than 5 years old, and all women of reproductive age.

National survey data show that anemia prevalence in pregnant women decreased from 73.7percent in 1985 to 50.9 percent in 1995, a 31 percent decline. This suggests that progresshad indeed occurred by the mid-1990s. As seen in the figure below, anemia prevalence inpreschool children (0 to 5 years of age) also decreased from 55.5 to 40.5 percent between1992 and 1995.

The change in anemia prevalence in pregnant women accompanied increased attention toanemia prevention and control in antenatal care (ANC) services. Several good practiceswere identified as responsible for the improvements in this program:

Anemia Prevalence in Vulnerable Populations in Indonesia

Vulnerable Group % Anemic

Pregnant women 50.9

All women of reproductive age (15-44 yrs.) 39.5

Young children (0-5) 40.5

School-age children (5-11) 47.2

Adolescent girls (10-14) 57.3

Source: 1995 NHHS.

Prevalence of Anemia (%) in Pregnant Women and Preschool Children, 1985-1995


• High commitment from the Indonesian government to control anemia

• Monitoring systems for anemia and iron-folic acid (IFA) supplement use

• Improved packaging to protect IFA supplements from humidity and make them moreattractive to consumers

• A change to a red, film-coated supplement that did not have the fishy taste of the previ-ous supplements

• Messages about when and how to take IFA supplements to mitigate side effects

• Increased supply and availability of IFA supplements at each level of the health system,including distribution by community health workers (village midwives and traditional birthattendants) and private sector sales by drug vendors and small shops

• Availability of program guidelines and protocols on how many IFA supplements to give

These improvements have increased the number of pregnant women receiving and taking IFAsupplements. Demographic Health Surveys in 1994 and 1997 indicated a 36 percent declinein pregnant women receiving no IFA supplements (from 26.4 to 16.9 percent) and a 69 per-cent increase in pregnant women receiving 90 or more IFA supplements (from 14.4 to 24.4percent). There were not commensurate increases in the number of women receiving ANCfrom a trained provider or in the number of women receiving four or more ANC visits. Theincrease in coverage for IFA supplements thus was not due to an increase in ANC use but tospecific actions taken to improve IFA supplement distribution.

Indonesia has also developed protocols for giving iron supplements to children ages 6 to 60months, but these recommendations have not been extensively implemented. Nonetheless,anemia prevalence also declined for this group between 1992 and 1995. This decline mayhave been due to improvements in overall nutritional status or in maternal iron status,resulting in better iron stores in newborn infants.

In addition, the Directorate of Nutrition in Indonesia’s Ministry of Health has collaboratedwith a number of other ministries to address anemia and introduce IFA supplementation tovarious population groups. Collaborating ministries include the Ministry of Religious Affairs towork with engaged or newly married women and children attending Islamic schools; theMinistry of Education to reach other school-age children; the Ministry of Manpower to intro-duce IFA in workplaces; and the Ministry of Industry and Trade to introduce iron-fortifiedflour.The Government has worked with parastatal and private sector pharmaceutical compa-nies to sell IFA supplements in retail shops throughout the country. While the commitmentof these various sectors needs strengthening, as do behavior change communications,Indonesia has made important steps in improving anemia prevention and control provided byANC services and in expanding activities beyond those targeted at pregnant women.

(Note: These steps are presented in a suggestedorder of implementation.)

KNOW THE PROBLEM: SITUATIONANALYSIS

❑ Determine anemia prevalence; identifypriority target groups, areas of greatestanemia prevalence, and anemia causes

❑ Determine what people know aboutanemia and their experience with ane-mia prevention and control programs

RAISE AWARENESS AND DEVELOPPARTNERSHIPS

❑ Raise awareness across sectors: advocateand educate to prevent and controlanemia

❑ Build partnerships in the health, agricul-ture, food, and pharmaceutical sectorsamong government ministries andagencies, nongovernmental organiza-tions (NGOs), donors, industry, andcommerce

DEVELOP INTERVENTIONS ANDIMPLEMENTATION PLANS

❑ Identify priorities, responsibilities, andtimeframes

❑ Identify specific objectives

❑ Identify potential collaborating groups(universities, government agencies,NGOs, civic groups, commercialentities)

❑ Review existing programs and deter-mine and develop anemia preventionand control activities

❑ Determine and secure staffing, funding,and other resources for implementingactivities

❑ Develop a monitoring andevaluation plan

SECTOR-SPECIFIC INTERVENTIONSTO PREVENT AND CONTROLANEMIA

The following health and related sectorscan implement anemia prevention andcontrol interventions:

• Nutrition




• Child health

• Schools




• Commercial sector: food and pharma-ceutical manufacturers, marketers,and distributors


Taking A

ction:D

eveloping a StrategyTaking Action: Developing a Strategy for Anemia

Prevention and ControlGood Practices Checklist


Taking A

ction:D


Know the Problem:Situation Analysis

❑ Determine anemia prevalence;identify priority target groups,areas of greatest anemia preva-lence, and anemia causes

National anemia surveys provide convinc-ing evidence of the need for anemia pre-vention and control and help programdevelopers and project managers advocatefor programs.

In the lastfive years,nationalanemiasurveysfrom all

parts of the developing world have con-firmed the findings of smaller surveys thatanemia rates are high in reproductive-agewomen and children under 2 years of agein all regions. National studies are neededfor all developing countries. If resourcesare available, data on anemia in preschooland school-age children, adolescents,heavy laborers, farm workers, and the eld-erly should also be collected. Baseline sur-veys on existing interventions may be nec-essary to collect quantitative informationon, for example, the number of people invulnerable groups receiving and correctlyusing iron or iron-folic acid (IFA) supple-ments, anthelmintics, and antimalariadrugs; the number of people sleepingunder insecticide-treated bednets; thenumber of women using intrauterinedevices (IUDs) and oral contraceptives(with and without iron); the number ofhealth workers and workers in other fieldstrained in anemia control; and nationalsupply and distribution figures for supple-

ments andother com-modities.If nationalor otherbroad sur-veys aretoo expen-sive or notfeasible for other reasons, anemia preva-lence can be estimated using hemoglobinvalues collected from smaller populationsduring other health surveys.

Figure 2.1 shows groups affected by ane-mia and the suggested priority for address-ing them. Pregnant women and childrenunder age 2 are the highest priority groupsbecause they have the highest require-ments for iron and are most vulnerable toparasitic infections. Lactating women are

of higher priority than other women ofreproductive age because of blood loss atdelivery and during the postpartum peri-od. Newly or soon-to-be married womenare of high priority because many are ado-lescents who are still growing. Most ofthese women will become pregnant soonafter marriage, and many will have anemiawhen they become pregnant.

The 1998/99 Family Health Survey in Indiacollected data on both anemia prevalence andiron supplementation coverage.

Tools and Resources containsthe table “Anemia PrevalenceRates in Vulnerable Populations,Selected Countries.”

Tools and Resources contains“Selected Monitoring andEvaluation Indicators for AnemiaPrevention and ControlPrograms,” which lists indicatorsthat can help formulate surveyquestions.

Taking Action: Developing a Strategy for AnemiaPrevention and Control

Good Practices in Detail

Figure 2.1

Prioritizing Target Groupsfor Anemia Control

(From Highest to Lowest Priority)

Pregnant women; children 0-2 yrs.

Lactating women; engaged or newly married women

Women of reproductive age; adolescents;children 2-10 yrs.; physical laborers

Elderly

Men


Anemia prevention and control programsshould address anemia where it is geo-graphically concentrated. Prevalence sur-veys can help disaggregate anemia preva-lence by province, district, rural and urbansettings, and altitude. Disaggregation ofdata from national to lower levels requiresgreater sample sizes, however, and will bemore costly.

In most countries, the major causes of ane-mia are known. They include iron deficien-cy; other nutritional deficiencies; malaria;helminth infections (particularly hook-worm but also schistosomiasis); chronicinfections, including HIV/AIDS; causesrelated to fertility, reproduction, and con-traception; and genetic conditions such asthalassemia and sickle cell. The relativeimportance of the different causes of ane-mia varies by world region (see table 1.5 inChapter I, Anemia: “Lost Years of HealthyLife”); it may also vary by regions withincountries. Iron deficiency is always a con-tributing cause of anemia in developingcountries. In most areas of Africa, othernutritional deficiencies, malaria, and hook-worm are regionally significant. Thesecauses are usually known from evidence ofworm infestation or knowledge of dietaryintake in the general population or vulnera-ble groups. Reviews of health-related pro-grams can supplement information aboutanemia’s causes in particular areas or set-

tings. Studies to determine the relativeimportance of iron deficiency and othercauses of anemia are expensive, however,and should be limited to population sub-samples. In some individual cases, clinicalassessment may be necessary to confirm aspecific cause of anemia.

An analysis of a population group’sdietary intake can help ascertain the extentor importance of iron deficiency or othernutritional causes of anemia in the group.Dietary intake often varies widely by geog-raphy and season, an important factor indetermining prevalence.

It may also be important to analyze intakeof other micronutrients and determine ifthere are serious deficiencies that warranttheir addition to foods or supplements.Other micronutrients associated with ane-mia and other health problems includefolic acid, riboflavin, vitamins A and B-12,thiamin, and zinc. Adding these to ironsupplements and fortified foods should beconsidered, especially if inexpensivemicronutrient mixtures containing themare available. Folic acid is particularlyimportant for preventing neural tubedefects, which are prevalent in developingcountries with 370,000 cases reported glob-ally every year.

❑ Determine what people knowabout anemia and their experiencewith anemia prevention and con-trol programs

Formative research – both qualitative andquantitative – is an important step indeveloping an anemia strategy. It can clari-fy what people know about anemia andwhat behaviors they are able and willingto change to prevent and control it. It canhelp determine how consumers, healthworkers, policymakers, and program andproject managers perceive anemia.Formative research can also help evaluateexisting programs and aid in the develop-ment of products such as iron tablets,other forms of iron supplements, and forti-fied foods. Research findings can helpidentify appropriate interventions with

Bangladesh targeted newly married women,providing them with iron tablets andcounseling to improve their iron status.

In Peru, adolescent girls are a priority group.They receive iron and are targeted forimproving dietary iron through schools andcommunities.

In India, pregnant women are a primary targetgroup for anemia prevention and control.Children ages 1 to 5 years, IUD users, adoles-cent girls, women in post-abortion care, andpreterm/low-birthweight infants are alsotargeted.

Thailand targeted anemia prevention and con-trol activities to factory workers, schoolchild-ren, and adolescents.


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appropriate monitoring and evaluationindicators. They can also suggest themesand messages for advocacy, counseling,and social marketing, as well as ways toimprove training, education, and products.For example, qualitative research helpedestablish that women taking iron supple-ments preferred small sugar-coated redtablets over large fishy- or chalky-tastingbrown ones. A single study can determineoverall perceptions of anemia as well asattitudes about iron tablets, antimalariaand anthelmintic drugs, bednets, and forti-fied foods. Qualitative research can alsotest products such as iron tablets and forti-fied foods once they have been developed.

The first step is to develop a researchinstrument that is primarily qualitative innature. Communication specialists and

marketingexpertshave theskills andexperienceto gatherthe qualita-tive dataneeded forinformedplanning. Nutritionists should be involvedin qualitative data collection to ensure thatthe right nutrition questions are beingasked.

Formative research should also review:

• Programs that are already having a pos-itive impact on anemia

• The potential of these programs to havea greater impact

• The potential impact of programs notyet involved in anemia

These include programs in nutrition, infec-tious and parasitic diseases, antenatal careand safe motherhood, family planning andreproductive health, child health, schools,HIV/AIDS prevention and treatment, envi-ronmental health, and food aid, as well asactivities in the commercial food and phar-maceutical sectors. Findings about thepotential roles and contributions of theseprograms should be presented to and dis-cussed with program and project managers,policymakers, donors, consumer groups,and commercial representatives to obtaintheir input and find common grounds andgoals for program activities.

Some Qualitative Research Findings About Anemia

Qualitative research among women in several countries suggests that they often recognize the signsof anemia but do not know or understand its consequences. In most cases, women are not aware ofmedical terms such as “anemia” but have local terms like “lack of blood” for anemia’s signs of pallorand fatigue.Where women are familiar with iron-folic acid (IFA) supplements, they report that theylike taking them, at least initially, and side effects are not a problem.They have concerns, however,about taking supplements for a long time – they fear, for example, that long-term use causes womento have large babies.They seldom receive counseling to counter such misperceptions and encouragecontinued use of supplements. Research also shows that because prevention is not a well-under-stood concept in most countries, women might stop taking IFA supplements once they feel stronger.(See Chapter III, Providing Iron Supplements to Combat Anemia.)

Qualitative research includesasking consumers about their

health-related beliefs and practices.

Tools and Resources contains “ATool for ReviewingMicronutrient Programs” and“Qualitative ResearchInstrument on Perceptions ofAnemia and Use of IronSupplements – The IndramayuProject, Indonesia.”


Raise Awarenessand DevelopPartnerships

❑ Raise awareness across sectors:advocate and educate to preventand control anemia

In many cases, program managers, healthprofessionals, policymakers, the public atlarge, and groups vulnerable to anemia arenot aware that anemia is a significantproblem. There are many interventionsthat can be implemented by any and allprograms in the health sector and othersocial sectors to raise awareness in thesegroups. These include interventionsdesigned to encourage behavior or policychanges and introduce and sustain pro-gram improvements. Advocacy may betargeted at policymakers and the public (orboth) to raise their awareness of anemia; athealth professionals to encourage them totake action against anemia; and at the pub-lic to promote behavior change. Information, education, and communication (IEC)activities, such as training in counselingand capacity building for communication,may also be targeted to these groups toimprove existing programs.

To accomplish these cross-sector objec-tives, programs can:

• Recruit a well-known person with highname recognition as an anemia “cham-pion” or spokesperson who will advo-cate for anemia prevention and controlin different sectors and raise politicaland public support for anemia preven-tion and control programs

• Take advantage of national health cam-paigns such as “national immunizationdays” and “micronutrient days” to raiseawareness about anemia

• Engage the media – radio, newspapers,television – to disseminate anemia pre-vention and control messages

• Develop and use fact sheets (which canbe tailored for use in different sectors)

to educate target groups about anemia’sprevalence, its causes and effects, andprevention and control interventions

• Secure the support of respected reli-gious leaders and involve them inadvocacy activities

In Indonesia, community meetings wereheld with men and community leaders totalk about anemia and distribute leaflets onthe importance of women taking iron sup-plements. Respected religious leaders pro-moted the value of iron tablets and enlistedfamily support. Reaching out to communitiesthrough the media was also effective. Donorassistance supported nutritionist training.

In Chile, a national anemia champion pro-moted anemia prevention and control. Also,scientists were trained in anemia preventionand control both in Chile and the UnitedStates to increase technical capacity, espe-cially at the implementation level.

In China, the government translated inter-national documents on the consequences ofanemia to build support for anemia control.

In Egypt, the government publicized scien-tific research about the safety of dietaryiron to combat public perceptions that itwas dangerous.

In Thailand, a public relations campaignemphasized private sector contributions tosocial sector programs.

In Mali, Mozambique, and Indonesia, sup-plements have been distributed on nationalmicronutrient days and through community-based outlets.

In Niger, IFA supplements have been dis-tributed on national immunization days.

In Malawi, health worker training empha-sized the role of iron supplements in com-bating anemia in pregnant women.

In India, improvements were made in in-service training on anemia prevention andcontrol for health workers.

In Peru, teachers were trained in anemiaprevention and control.


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eveloping a Strategy• Convince government officials and rep-

resentatives from the commercial foodand pharmaceutical sectors of the impor-tance of anemia prevention and control

• Build capacity and provide training forhealth workers in technical knowledge,communication for behavior change,counseling skills, program design andimplementation, program management(including supervision), and monitoringand evaluation

• Provide pre- and in-service training forpersonnel from food, sanitation, educa-tion, and other sectors to incorporateanemia prevention and control in theiractivities

❑ Build partnerships in the health,agriculture, food, and pharmaceuti-cal sectors among government min-istries and agencies, nongovern-mental organizations (NGOs),donors, industry, and commerce

Addressing anemia through and across anumber of sectors requires close coopera-tion and coordination among governmentagencies, NGOs, donors, and commercialsector entities. A national intersectoralcommittee can help achieve and coordinatean integrated approach with counterpartsat the regional, provincial/state, district,and community levels. Participating sec-tors and groups should include ministriesof health, education, women’s affairs,youth, trade, industry, agriculture, andplanning; donor agencies; the food andpharmaceutical industries; consumers; andtechnical experts in science, research, andmarketing. Such a committee should haveits own budget and staff. Committee mem-bers should agree there is an anemia prob-lem and agree upon a common goal towhich each organization can contribute.

Develop Interventions andImplementation Plans

❑ Identify priorities, responsibilities,and time frames

Working toward their common goal, thepartners need to decide what anemia pre-vention and control activites are impor-tant, who is responsible for them, andwhen they will be carried out. These deci-sions should be based on the nature of thenational anemia problem and a review ofexisting programs. When making thesedecisions, the partners should clearly artic-ulate priorities and goals, delegate respon-sibilities to appropriate sectors, and estab-lish time frames for initiating actions.

❑ Identify specific objectives

Specific objectives or results may includeincreased awareness of anemia as a publichealth problem, improvement of existinganemia programs, introduction of new pro-grams to prevent and control anemia, andreduction of anemia prevalence. Objectivesshould be time-bound and measurable toallow for monitoring and evaluation.

Tools and Resources contains the sam-ple fact sheets “How Can EarlyChildhood Development (ECD)Programs Beat Iron Deficiency?”, “TheImpact of Preventing and Treating IronDeficiency Anemia”, and “Risk of IronOverload From Iron-Fortified Foods.”

In Chile, politically adept nutrition plannerswere able to bring government, industry, andthe research community together on a nationalcommittee to work for anemia prevention andcontrol.The committee raised community andconsumer support for nutrition and anemiaprevention and control programs.

In Thailand, medical professionals convincedcommercial sector partners about the impor-tance of iron fortification and supplementation.

In Tanzania, a favorable sociopolitical environ-ment and the government’s commitment tosocial action with community involvement con-tributed to a successful national strategy toimprove nutrition programming. Specialistsfrom the national nutrition coordinating body,the Tanzania Food and Nutrition Centre, helpedthe government with anemia programming.


❑ Identify potential collaboratinggroups (universities, governmentagencies, NGOs, civic groups, com-mercial entities)

Organizations with interests and capabili-ties in anemia prevention and control arepotential resources and collaborators. Inaddition to the health ministry, other min-istries such as agriculture, education, andindustry can contribute. Some NGOs willbe able to link anemia to their organiza-tional goals and missions – women’s andhuman rights organizations, for example,might consider protection from anemia abasic right and thus support and assistanemia prevention and control. For techni-cal assistance, food industry specialists,re

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WHAT WORKS - UNSCN...Krishna Rao, consultant for a larger study funded by the MI for the World Bank....

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