Adolescent Nutrition_Roche

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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

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Women today - 3.5 billion!
600 M 10-24 years living in LMIC countries
UNFPA, 2014

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Women today - anaemia
Stevens, et al, 2013

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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)

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Age of first pregnancy
UNICEF 2014
• Adolescent pregnancy: 17-20 M
• 95% occur in low- and middle-income countries

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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/10665/44649/1/9
789241502023_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

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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

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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)

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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

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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

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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

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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)

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Workplace Setting: Engaging employers,
supervisors and leaders
• Distribution setting for IFA
supplements
• Distribution channel for
messages to support
adherence and provide
awareness on anemia

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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

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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

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Product & Promotion Appeal for Adolescents

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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

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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

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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

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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

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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

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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 EndlinePercentage
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

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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

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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

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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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