Child Anemia Feasibility Study: Approaches and Lessons Learnt S R Nagar – Uttar Pradesh Presentation at XIII Annual Confer...
Iron: The Scope of the Problem <ul><li>The World Health Organization (WHO) has categorized iron deficiency as one of the t...
Iron: The Scope of the Problem <ul><ul><li>Iron deficiency has assumed even greater importance as evidence accumulates lin...
<ul><li>Reducing anemia will decrease maternal and perinatal mortality, improve cognitive development and schooling in chi...
Anemia in Children Anemia failed to decrease…and at present highest ever Dr. Prakash V. Kotecha
Current GOI Guidelines: April 2007 Relevant to children <ul><li>Current GOI Guidelines: April 2007 Relevant to children </...
Current Program guideline for anemia control for young children <ul><li>Screening of all children for anemia </li></ul><ul...
Dr. Prakash V. Kotecha Source: http://pariwarkalyan.up.nic.in/mch-intro.htm 17/09/2010
Policy on Anemia Control: 1991 <ul><li>Acknowledges importance and consequences of anemia in mothers and children </li></u...
NFHS III (2005-06) India Data Age in Months Dr. Prakash V. Kotecha
Anemia by Age Group Dr. Prakash V. Kotecha
Child Anemia Feasibility Study  Why UP? Source: DLHS III (2007-08) Much Larger Sample Size 90,000+ HH UP
What is this study about ? <ul><li>Child anemia control requires a  package of services  not just iron alone. </li></ul><u...
Study area Dr. Prakash V. Kotecha
Study area Dr. Prakash V. Kotecha District State S. R. Nagar,  UP Block Gyanpur Total population 2,65,678 No. of Sub-cente...
Child Anemia Feasibility Study: Steps <ul><li>Formative Research </li></ul><ul><li>Based on the findings and recommendatio...
Comprehensive Package of Interventions <ul><li>Improving nutritional status by addressing complementary feeding practices ...
Scenario at the Start of the Feasibility Study in Gyanpur Block Dr. Prakash V. Kotecha
Anemia Prevalence at the starting of the Feasibility Study (6-23 m) Dr. Prakash V. Kotecha Source: NFHS III & A2Z study 20...
Helminthes Study Children in UP N=472 (Gyanpur Block) Source: Awasthi et al, 2008 Dr. Prakash V. Kotecha
IFA Consumption at the starting time 2008 Baseline study Dr. Prakash V. Kotecha Source: A2Z study 2007-08
Capacity Building of Frontline Providers <ul><li>ALL ANM (33), AWW (209), ASHA (203) Supervisors of ICDS (6) and LHV (Supe...
Capacity Building of Frontline Providers <ul><li>Follow up with AWW/ANM for distribution and tracking the supply of IFA sy...
Anemia Status of Health workers N=288
Dr. Prakash V. Kotecha
Dr. Prakash V. Kotecha IEC Material in form of calendar
 
 
 
 
 
 
 
 
 
 
IFA Syrup Supply Tracking all the way… <ul><li>Assumption was to give IFA in the month of May and follow up children for 9...
Program Period <ul><li>Started Training for the program Feb 2008. IFA syrup was supplied in May 2008 and repeat supply was...
On going Monitoring LQAS  Dr. Prakash V. Kotecha     FOCUS LQAS I (Sept. 08) LQAS II (Feb. 09) LQAS III (Aug. 09) Advice o...
RESULTS OF THE END LINE STUDY Dr. Prakash V. Kotecha
End Line Study Children Dr. Prakash V. Kotecha District Block Number of mothers of children aged 6-23 months (total sector...
Religion & Caste of children studied Dr. Prakash V. Kotecha Characteristics Project Block (Gyanpur) Comparison Block (Hand...
Standard of living  & Literacy Dr. Prakash V. Kotecha Standard of living Percent Households Project Block (Gyanpur) Compar...
ANC Coverage of Mothers Dr. Prakash V. Kotecha
IFA Received by Mothers of children  6-23 months during their pregnancy Dr. Prakash V. Kotecha
IFA Consumption by Mothers Dr. Prakash V. Kotecha
Anemia among children IFA Consumption by Mothers Dr. Prakash V. Kotecha
IFA Syrup Received by Children 6-23 months Dr. Prakash V. Kotecha
IFA Syrup Knowledge among mothers of children who received syrup Dr. Prakash V. Kotecha
IFA Syrup Consumption & Side effect <ul><li>92.6 % of children who received iron consumed it. 94% of these children were a...
IFA Syrup Consumption in last 7 days Dr. Prakash V. Kotecha
Deworming Medicine Received by the Children Dr. Prakash V. Kotecha 87% children & 73% of mothers consumed the medicine
Benefits explained by ASHA Dr. Prakash V. Kotecha “ Child becomes weak and pale due to lack of blood in the body. It is ad...
Complementary Feeding Dr. Prakash V. Kotecha
Hygiene Practices observed Dr. Prakash V. Kotecha
Hemoglobin Study  <ul><li>31 cluster sampled PPS and then 10 children from each cluster was planned with expected design e...
Anemia Prevalence Difference 13% Reduction of Anemia 2% Reduction of Anemia 84% Increase in non anemic children
Level of Malnutrition Dr. Prakash V. Kotecha
Achievements <ul><li>Complete Package delivery is  feasible  to be delivered  within the system </li></ul><ul><li>It is po...
Dr. Prakash V. Kotecha
Challenges <ul><li>Coverage for every child remains a challenge </li></ul><ul><li>IFA supply and logistics and monitoring ...
Age profile of mothers Dr. Prakash V. Kotecha
Upcoming SlideShare
Loading in …5
×

Dr P V Kotecha

1,687 views

Published on

Published in: Education
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
1,687
On SlideShare
0
From Embeds
0
Number of Embeds
3
Actions
Shares
0
Downloads
14
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

Dr P V Kotecha

  1. 1. Child Anemia Feasibility Study: Approaches and Lessons Learnt S R Nagar – Uttar Pradesh Presentation at XIII Annual Conference of Indian Association of Preventive & Social Medicine UP & Uttarakhand Chapter Dehradun – Uttarakhand 31st October, 2010 Prof Prakash V Kotecha Country Representative, A2Z, the USAID Micronutrient Project, New Delhi, India Ex Professor and Head, PSM Dept, Medical College, Baroda, Gujarat pkotecha@aed.org/pvkotecha@gmail.com
  2. 2. Iron: The Scope of the Problem <ul><li>The World Health Organization (WHO) has categorized iron deficiency as one of the top ten most serious health problems in the modern world. Iron deficiency anemia (IDA): </li></ul><ul><ul><li>Impairs the mental development of over 40% of the developing world's infants and reduces their chances of attending or finishing primary school </li></ul></ul><ul><ul><li>Decreases the health and energy of approximately 500 million women and leads to approximately 50,000 deaths in childbirth each year </li></ul></ul><ul><ul><li>Is complex because it requires increased iron intake at critical stages of the life- cycle - before and during pregnancy and throughout early childhood </li></ul></ul><ul><ul><li>. </li></ul></ul>Source: http://www.micronutrient.org/english/view.asp?x=579
  3. 3. Iron: The Scope of the Problem <ul><ul><li>Iron deficiency has assumed even greater importance as evidence accumulates linking iron deficiency with mental impairment. </li></ul></ul><ul><ul><li>Various tests of cognitive and psychomotor skills associate lack of iron during infancy and early childhood with significant levels of disadvantage, affecting IQ scores by as much as 5 to 7 points. </li></ul></ul><ul><ul><li>Millions of children might be unable to complete primary school due to the impeded cognitive development they sustained as newborns and young children who couldn't get enough iron and iodine. </li></ul></ul>Source: http://www.micronutrient.org/english/view.asp?x=579
  4. 4. <ul><li>Reducing anemia will decrease maternal and perinatal mortality, improve cognitive development and schooling in children, and increase physical capacity and work productivity in adults. </li></ul><ul><li>About 42 percent of pregnant women and 47 percent of preschool children worldwide are anemic. </li></ul><ul><li>The most common cause of anemia is iron deficiency, which is associated with 115,000 maternal deaths and 591,000 perinatal deaths each year (Stolzfus et al., 2004). </li></ul>Iron: The Scope of the Problem Dr. Prakash V. Kotecha
  5. 5. Anemia in Children Anemia failed to decrease…and at present highest ever Dr. Prakash V. Kotecha
  6. 6. Current GOI Guidelines: April 2007 Relevant to children <ul><li>Current GOI Guidelines: April 2007 Relevant to children </li></ul><ul><li>Children 6-60 months to be given IFA syrup </li></ul><ul><li>Dose is 20 mg iron and 100 microgram folic acid in one ml per day </li></ul><ul><li>Total dose/days not mentioned (as per IMNCI) </li></ul><ul><li>For safety reason to be dispensed in bottles so designed that only one ml can be dispensed at a time </li></ul><ul><li>DFS, Sprinkles, dispersible tablets, fortified rice and other alternatives need to be explored as additional/alterative therapy </li></ul><ul><li>Source: No Z.28020/50/2003-CH GOI 23 rd April 2007 </li></ul>Dr. Prakash V. Kotecha
  7. 7. Current Program guideline for anemia control for young children <ul><li>Screening of all children for anemia </li></ul><ul><li>Those found clinically suffering from anemia appropriate treatment be given </li></ul><ul><li>This has come with 10 th five year plan objectives and goals. </li></ul><ul><li>However actually what is followed at present is screening by ANM and those found anemic are given IFA when available </li></ul><ul><li>Calculation of IFA small tablets (and currently provided IFA syrup bottles) also based on this criteria, they are not sufficient in number if and when all eligible children will receive them. </li></ul>Dr. Prakash V. Kotecha
  8. 8. Dr. Prakash V. Kotecha Source: http://pariwarkalyan.up.nic.in/mch-intro.htm 17/09/2010
  9. 9. Policy on Anemia Control: 1991 <ul><li>Acknowledges importance and consequences of anemia in mothers and children </li></ul><ul><li>Recommends integrated approach (ICDS-PHC) </li></ul><ul><li>Stresses on diet first (with lists) and on counseling </li></ul><ul><li>Recommends 100 small IFA for ALL children/year </li></ul><ul><li>Recommends controlling worm and other infections </li></ul><ul><li>Screening and special attention to severe anemia </li></ul>Dr. Prakash V. Kotecha
  10. 10. NFHS III (2005-06) India Data Age in Months Dr. Prakash V. Kotecha
  11. 11. Anemia by Age Group Dr. Prakash V. Kotecha
  12. 12. Child Anemia Feasibility Study Why UP? Source: DLHS III (2007-08) Much Larger Sample Size 90,000+ HH UP
  13. 13. What is this study about ? <ul><li>Child anemia control requires a package of services not just iron alone. </li></ul><ul><li>Is it FEASIBLE to provide this package of services to children in rural UP? </li></ul><ul><li>Is it possible to implement the program within the existing system? </li></ul><ul><li>Do front line workers have the capacity to grasp and deliver what is necessary to control child anemia? </li></ul>Dr. Prakash V. Kotecha
  14. 14. Study area Dr. Prakash V. Kotecha
  15. 15. Study area Dr. Prakash V. Kotecha District State S. R. Nagar, UP Block Gyanpur Total population 2,65,678 No. of Sub-centers 32 No. of ANM 29 No. of AWC 187 Children 6-23 14000 Control block Handia, Allahabad district
  16. 16. Child Anemia Feasibility Study: Steps <ul><li>Formative Research </li></ul><ul><li>Based on the findings and recommendation of TAG </li></ul><ul><ul><li>Comprehensive package of services for intervention </li></ul></ul><ul><ul><li>Attempted through the system within system guidelines </li></ul></ul><ul><li>Training and Capacity building of AWW/ANM/ASHA and others providing services </li></ul><ul><li>Enhanced Monitoring and evaluation </li></ul><ul><ul><li>Anemia Prevalence </li></ul></ul><ul><ul><li>Worm prevalence </li></ul></ul><ul><ul><li>IFA syrup stock and distribution </li></ul></ul><ul><ul><li>Morbidity data for study and control area to check for morbidity in study area with reference to iron supplementation if any </li></ul></ul><ul><li>Follow up with AWW/ANM for distribution and tracking the supply of IFA syrup </li></ul><ul><li>Post training support (mentoring) by ICDS sector meeting and joint block meeting facilitation by field staff </li></ul><ul><li>Ensuring anemia control and worm control in mothers </li></ul>
  17. 17. Comprehensive Package of Interventions <ul><li>Improving nutritional status by addressing complementary feeding practices appropriate to the age and ensuring energy rich dense food adequate in quality and quantity. </li></ul><ul><li>Increasing iron intake of the target population through </li></ul><ul><ul><li>Iron supplementation in form of syrup one ml twice a week (GOI policy) using dropper only (discontinue when sick) </li></ul></ul><ul><ul><li>Improving breast feeding practices </li></ul></ul><ul><li>Control of infections </li></ul><ul><ul><li>Hookworm by deworming and improved hygiene practice </li></ul></ul><ul><ul><li>Malaria (EDPT) </li></ul></ul><ul><li>Increasing iron stores at birth by improving the iron status of pregnant women with better ANC and IFA </li></ul>Dr. Prakash V. Kotecha
  18. 18. Scenario at the Start of the Feasibility Study in Gyanpur Block Dr. Prakash V. Kotecha
  19. 19. Anemia Prevalence at the starting of the Feasibility Study (6-23 m) Dr. Prakash V. Kotecha Source: NFHS III & A2Z study 2007-08
  20. 20. Helminthes Study Children in UP N=472 (Gyanpur Block) Source: Awasthi et al, 2008 Dr. Prakash V. Kotecha
  21. 21. IFA Consumption at the starting time 2008 Baseline study Dr. Prakash V. Kotecha Source: A2Z study 2007-08
  22. 22. Capacity Building of Frontline Providers <ul><li>ALL ANM (33), AWW (209), ASHA (203) Supervisors of ICDS (6) and LHV (Supervisors of ANM) (6) total 493 </li></ul><ul><li>3 day, highly interactive training that covered (March 08 to Sept 08 total 22 trainings) </li></ul><ul><ul><li>tracking pregnant women, </li></ul></ul><ul><ul><li>early and complete registration, IFA for every pregnant mother with counseling for consumption and reasons to continue consumption </li></ul></ul><ul><ul><li>identify target children, </li></ul></ul><ul><ul><li>Counseling for IFA syrup, (how, when, where and why, how to preserve, what precaution to take, where to store), for IYCF (energy dense adequate quality and quantity to be fed timely and responsively) </li></ul></ul><ul><ul><li>Deworming when and how to dose (1yr onwards six monthly) </li></ul></ul><ul><ul><li>How to prevent malaria and protect form malaria and advocacy for early diagnosis and prompt treatment for fever/malaria </li></ul></ul>Dr. Prakash V. Kotecha
  23. 23. Capacity Building of Frontline Providers <ul><li>Follow up with AWW/ANM for distribution and tracking the supply of IFA syrup </li></ul><ul><ul><li>From District to Block </li></ul></ul><ul><ul><li>From Block to sub-health center and AWC </li></ul></ul><ul><ul><li>From AWC to beneficiary </li></ul></ul><ul><li>Post training support (mentoring) by ICDS sector meeting and joint block meeting facilitation by field staff </li></ul><ul><li>IEC Material (for HW and beneficiary)and Training to use them </li></ul>Dr. Prakash V. Kotecha
  24. 24. Anemia Status of Health workers N=288
  25. 25. Dr. Prakash V. Kotecha
  26. 26. Dr. Prakash V. Kotecha IEC Material in form of calendar
  27. 37. IFA Syrup Supply Tracking all the way… <ul><li>Assumption was to give IFA in the month of May and follow up children for 9-12 months for their regular consumption </li></ul><ul><li>Continuous monitoring only can improve the situation and detect issues </li></ul>Dr. Prakash V. Kotecha
  28. 38. Program Period <ul><li>Started Training for the program Feb 2008. IFA syrup was supplied in May 2008 and repeat supply was required after one year. 15000 IFA syrup bottles were supplied each time </li></ul><ul><li>A2Z Program Support continued till Dec 2009. End line study was conducted in January 2010. </li></ul>Dr. Prakash V. Kotecha
  29. 39. On going Monitoring LQAS Dr. Prakash V. Kotecha     FOCUS LQAS I (Sept. 08) LQAS II (Feb. 09) LQAS III (Aug. 09) Advice on Anemia 46 34 75 IFA syrup Received 66 45 73 Benefits Explained 44 33 65   IFA consumed in last 7 days 59 15 50   Complementary Feeding Advice   28 51   Complementary Feeding Practice   14 11   Anemia Prevalence 95 87 86
  30. 40. RESULTS OF THE END LINE STUDY Dr. Prakash V. Kotecha
  31. 41. End Line Study Children Dr. Prakash V. Kotecha District Block Number of mothers of children aged 6-23 months (total sectors) Sant Ravi Das Nagar Gyanpur 304 Allahabad Handia 331 Total 635
  32. 42. Religion & Caste of children studied Dr. Prakash V. Kotecha Characteristics Project Block (Gyanpur) Comparison Block (Handia) Religion Endline Baseline Endline Baseline Hindu 93.4 93.8 93.4 94.2 Muslim 6.3 6.2 6.3 5.8 Scheduled caste 24.3 30.8 24.3 22.6 Scheduled tribe 2.6 0.0 2.6 1.3 Other backward caste 44.7 41.6 44.7 55.5 Total N 304 305 331 310
  33. 43. Standard of living & Literacy Dr. Prakash V. Kotecha Standard of living Percent Households Project Block (Gyanpur) Comparison Block (Handia) Low 80.6 25.7 Medium 14.8 33.5 High 4.6 40.8 Illiteracy Illiterate 54.3 37.8 Total N 304 331
  34. 44. ANC Coverage of Mothers Dr. Prakash V. Kotecha
  35. 45. IFA Received by Mothers of children 6-23 months during their pregnancy Dr. Prakash V. Kotecha
  36. 46. IFA Consumption by Mothers Dr. Prakash V. Kotecha
  37. 47. Anemia among children IFA Consumption by Mothers Dr. Prakash V. Kotecha
  38. 48. IFA Syrup Received by Children 6-23 months Dr. Prakash V. Kotecha
  39. 49. IFA Syrup Knowledge among mothers of children who received syrup Dr. Prakash V. Kotecha
  40. 50. IFA Syrup Consumption & Side effect <ul><li>92.6 % of children who received iron consumed it. 94% of these children were administered doses by the mother </li></ul><ul><li>Only 13% had consumed more than 50 doses ; while 35% consumed less than 10 doses and 36% consumed between 10 and 50 doses ! </li></ul><ul><li>Only 21% of children’s mother complained about side effects; 4/5 th of these were black color stool and 1/5 th had nausea as side effects. </li></ul>Dr. Prakash V. Kotecha
  41. 51. IFA Syrup Consumption in last 7 days Dr. Prakash V. Kotecha
  42. 52. Deworming Medicine Received by the Children Dr. Prakash V. Kotecha 87% children & 73% of mothers consumed the medicine
  43. 53. Benefits explained by ASHA Dr. Prakash V. Kotecha “ Child becomes weak and pale due to lack of blood in the body. It is advisable to take iron rich diet and other iron preparation to prevent anemia. Iron increases blood and help fight infection.”
  44. 54. Complementary Feeding Dr. Prakash V. Kotecha
  45. 55. Hygiene Practices observed Dr. Prakash V. Kotecha
  46. 56. Hemoglobin Study <ul><li>31 cluster sampled PPS and then 10 children from each cluster was planned with expected design effect of 2. </li></ul><ul><li>HemoCue Machine (301) was used for measuring hemoglobin level. </li></ul><ul><li>Children were pricked either at the toe or heel using lancet needle provided by Hemocue </li></ul><ul><li>All precuations were taken for aseptic and antiseptic measures and children were pricked after consent from the parents </li></ul>Dr. Prakash V. Kotecha
  47. 57. Anemia Prevalence Difference 13% Reduction of Anemia 2% Reduction of Anemia 84% Increase in non anemic children
  48. 58. Level of Malnutrition Dr. Prakash V. Kotecha
  49. 59. Achievements <ul><li>Complete Package delivery is feasible to be delivered within the system </li></ul><ul><li>It is possible to build the capacity of front line workers to deliver IFA syrup and provide counseling within the system </li></ul><ul><li>Through the system, we can reach to children for IFA syrup to young age group that is not part of vaccination. ICDS also usually does not cover this age group at the center. </li></ul><ul><li>IFA to mothers is also attended to and improved when importance is emphasized </li></ul><ul><li>Complementary feeding is discussed </li></ul><ul><li>Deworming medicine to children is being advised. </li></ul>Dr. Prakash V. Kotecha
  50. 60. Dr. Prakash V. Kotecha
  51. 61. Challenges <ul><li>Coverage for every child remains a challenge </li></ul><ul><li>IFA supply and logistics and monitoring </li></ul><ul><li>Compliance for IFA syrup </li></ul><ul><li>Reduction of anemia to a larger proportion </li></ul><ul><li>Deworming medicine </li></ul><ul><li>Complimentary food advice and practice </li></ul><ul><li>Health Workers themselves are anemia… </li></ul>Dr. Prakash V. Kotecha
  52. 62. Age profile of mothers Dr. Prakash V. Kotecha

×