Evaluating a delivery model to ensure feasible and effective reduction of childhood anaemia

By Lindsey Peugh, Research Associate – ICTPH

The period between 6 and 24 months of age is a critical stage during which nutritional deficiencies can cause deleterious and irreversible effects on a child’s growth and cognitive development. Iron deficiency is considered to be the most common micronutrient deficiency in the world and anaemia is the most frequent clinical classification of this deficiency. Infants with iron deficiency anaemia score lower on tests of motor and mental development and are at-risk for long-term developmental disadvantages compared with non-anemic infants. The Indian National Health and Family Survey-3 (NFHS) conducted in 2005-2006, found that anemia among children less than three years of age is extremely widespread. Results from Tamil Nadu show that 72.7 percent of children aged 6-35 months of age are anaemic and the prevalence has actually increased from the NFHS-2 at which time 69.1 percent of this age group was anaemic.

Typically, in low-income regions the iron density of food is largely is composed of non-heme iron from grains, fruits, and vegetables, which is poorly absorbed. Depending on the region, diets in India usually contain an adequate amount of iron but the absorption of iron is inadequate. When foods do not provide the recommended intake of micronutrients, research recommends micronutrient supplementation as a strategy to combat micronutrient deficiencies in children under five. In non-malarial regions, iron supplementation for children of this age group can be used as an effective strategy to reduce iron deficiency anaemia and should be coupled with long-term strategies as well. The goal of iron supplementation is to restore normal levels of iron storage and hemoglobin levels.

In India, national programs have attempted to tackle anaemia among the population. For instance, the National Nutritional Anaemia Prophylaxis Programme recommends routine iron supplementation and folic acid for children aged 6-60 months regardless of anaemia status. However, due to practical difficulties, the system has failed to deliver as expected. Likewise, iron drops are available through the Integrated Child Development System yet research and observations has shown that utilization is low. Iron drops are often difficult to use, cause uncomfortable side effects, and have an unpleasant taste lending to their unfavorable use. On the other hand, microencapsulated Sprinkles for home fortification has been a well-received and effective method to raise blood hemoglobin and reduce anaemia prevalence among children.

Despite the evidence of its effectiveness, research on specific delivery models of Sprinkles is limited, especially in the Indian context. In order to ensure the feasible and effective delivery of a proven strategy to improve nutrition is achieved, research is needed to evaluate the effectiveness of a delivery model and identify potential bottlenecks and barriers in the delivery pathway. Our nutrition program will focus on this end with the goal of evaluating the feasibility of combining the delivery of Sprinkles from the RMHC with social marketing and education messages delivered through the network of SughaVazhvu nurses and guides. Children in the 6-24 month age group will be identified through our PLSP and SVGs will visit these households to provide social marketing and educational messages on nutrition, particularly anaemia, to consenting caregivers. At the RMHC, children can have their nutritional status assessed (e.g. hemoglobin level, anthropometric measurements, etc.) and nurses will provide additional educational messages on available strategies to reduce anaemia. Caregivers will be able to decide whether or not they want to purchase Sprinkles or another iron supplement at the RMHC, or elsewhere. SVGs will then conduct fortnightly follow-up visits to assess the compliance of caregivers who purchased Sprinkles and will also assess any side effects experienced by the child and the caregiver perceptions of the product and delivery system. Also important is the insight from caregivers who do not purchase or use Sprinkles. Information at each step of the intervention will be collected through structured questionnaires and will be analyzed to identify ways in which the delivery system can be improved. Key to this intervention is the delivery of consistent, quality messages to caregivers to increase awareness and encourage healthy behaviors to improve child nutrition as well as the reduction of barriers which prevent the healthy behaviors in the first place.

For detailed information on each step of the Sprinkles intervention, download the intervention manual here.

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6 Comments on "Evaluating a delivery model to ensure feasible and effective reduction of childhood anaemia"

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Professor Caroline fall
13 years 7 months ago
Dear Nachiket and Lindsey, Thank you for allowing me to read your proposal. This looks a really useful study, and the methodology is extremely good. I have a few comments: The social marketing messages could be better, I think – they are currently full of words that would probably be pretty meaningless to most poor rural mothers (“nutrient”, “nutrition”, “development” and “anaemia”). Shouldn’t the messages get across what nutrition means, why particular nutrients are needed and a simpler description of what happens if the nutrients are not obtained? You mention a limitation being that you will not be able to… Read more »
Lindsey Peugh
Lindsey Peugh
13 years 7 months ago
Dear Prof Fall, Thank you for your very useful comments. After conducting focus groups on mother’s perceptions and practices related to child nutrition this week, I agree with you that our social marketing messages need tweaking. In these groups, we found exactly what you mentioned – that many mothers are unaware of “anemia” and that family and community members greatly influence a mother’s ideas of “nutritious” food for children. These factors will definitely be taken into account as we further develop our messaging and include more educational components along with them. Also, to address your suggestion regarding compliance and side… Read more »
David Osrin
13 years 7 months ago

Dear Nachiket

Thanks for inviting me to have a look at the proposal. It’s an interesting study and the proposal itself has been worked through thoroughly. At some point in the future it would be interesting to look at growth and development in the children in the area.

I have a colleague, Melody Tondeur, who is an expert on sprinkles and the work on them across the world. You might like to contact her and tell her about the study. I can give you her email on request.

Deepika Nayar Chaudhery
Deepika Nayar Chaudhery
13 years 6 months ago
Dear Dr Mor and Lindsey, Thankyou for inviting me to comment. I find the proposed methodology in the right direction factoring all possible aspects for ensuring effective delivery and use. I have the following points for your consideration: •Embedding “sprinkles” related messages within “appropriate IYCF/ complementary feeding” package of messages. •Weekly or more frequent visits during the early implementation phase. •Working out mechanisms /messages to ensure full utilization of a sprinkles sachet in a day by the child and also avoiding sharing with other siblings. As you have laid out in your plan continuous analysis of barriers and facilitating factors… Read more »
Anuska Kalita
Anuska Kalita
13 years 4 months ago
Dear Nachiket and Lindsey, The attached study protocol reads very well. I had a few thoughts – 1. Regarding the deworming tablets and their interaction with the sprinkles (mentioned in the limitations section of your paper) – is it possible for the health workers to maintain a cohort register (or some other form of record) to identify which children have been administered one or both interventions. Even though not a pre-determined control-intervention design for differential treatment, it may provide insight as to how the two interventions interacted and which combination resulted in the maximum impact on the primary outcomes. 2.… Read more »
Nutrition education programmes
11 years 10 months ago

Really good stats given here about nutrition deficiencies in children. HNFI (Heinz Nutrition foundation of India) conducts Continued Nutrition Education Programmes. A special panel of Scientific Council Members contributes to this forum to spread nutritional knowledge, attitudes and practices of nutrition to the field level workers in the Department of Health and Nutrition.

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