Incidence of Side-effects After Weekly Iron and Folic Acid Consumption Among School-going Indian Adolescents

Objective: To estimate incidence of side effects after weekly iron and folic acidsupplementation (WIFS) in Delhi and Haryana. Methods: In this cross-sectional school-based study, data were collected from 4,183 adolescents on WIFS consumption and sideeffects experienced first time of receipt of WIFS (week 1), and in last two consecutive weeks(week 2,3). Week 3 was 48 hours preceding the survey. Results: WIFS consumption in week1, 2 and 3 was 85%, 63% and 52%, respectively. Side effects reported were highest in firstweek (25%) and reduced to 7% (week 2) and 5% (week 3). Side effects most reported wereabdominal pain (80%) and nausea (10%). Adolescents (45%) who faced a side-effect in week1 did not consume WIFS in subsequent week. Conclusion: Incidence of side effects was low,but it affected compliance. Positive reinforcement to students who face side effects requiresstrengthening by teachers.

Towards an Anemia-Free West Bengal: Convergent Policies and Collective Action.

Objectives: West Bengal - India's most densely populated state - is home to 8.3 million adolescent girls. Surveys indicate that 62 percent of adolescent girls were anemic, despite several sectoral programmes in place. To address this situation, the Government of West Bengal launched in 2012 Anemia Free West Bengal strategy convening all stakeholders, integrating flagship programmes and introducing new schemes as needed. Methods: Six sectoral Departments that were implementing programmes focusing on adolescent girls were brought together under the leadership of State Chief Minister to convergently deliver interventions that includes: 1) Food supplements fortified with nine essential micronutrients; 2) weekly iron and folic acid supplementation; 3) Biannual deworming; 4) A new conditional cash transfer scheme to promote secondary education and prevent child marriage; 5) A state-wide mass and mid-media communication campaign; and 6) Partnerships for social mobilization at community and household level. Programme convergence included formation of a state planning and monitoring committee, joint training of staff, pooling of resources as feasible, common reporting using standardized tools using dis-aggregation of reporting data by social group. Results: By mid-2013, all monthly inter-sectoral progress review meetings had been held as planned, three of the six departments had pooled budgets to support the strategy, and about 2 million adolescent girls were already receiving iron and folic acid supplementation weekly, deworming bi-annually, fortified food supplements, and/or cash transfers. Conclusions: The better practices from W. Bengal experience are critical know-hows on building political commitment and programme convergence on programming for adolescent girls through a common vision.

Girls' Collectives Address Adolescents' Anemia and Social Norms in Socially-excluded Tea Estates in India: A Public-private Partnership in Assam.

Objectives: To generate evidence on engaging girls' collectives to address anemia and social norms in self-contained, privately-managed tea plantations in India. Methods: In 2006, UNICEF India partnered with a federation of tea companies in Assam's Dibrugarh district, and Twinning Corporate Social Responsibility to establish 158 girls' collectives across 117 of 273 tea gardens. These collectives meet weekly to discuss and address social issues such as child marriage, child labor, school dropout, and life skills. In 2012, supervised weekly iron folic acid (IFA) supplementation, biannual deworming and nutrition education were weaved in these peer interactions and implemented in 15 tea estates through 45 girls' collectives comprising 7097 adolescent girls, with the objective to address anemia. Visual aids, recipe demonstrations, and home gardening were used to make sessions interesting. Government positioned adequate supplies at tea estate hospitals/outposts. Two peer monitors per tea estate supervised the activities of the collectives. The follow up of this cohort included a baseline (2011) and an end line (2013) survey. Results: Compliance with weekly IFA supplementation (4 tablets per month) increased from 25% (2012) to 82% (2013). Home gardens were introduced in 1,002 homes and 55 community patches. Provisional end line data shows a 1.25 g/dl improvement in mean hemoglobin levels (9.77 to 11.2 g/dl). There is also evidence of increased girls' re-enrollment in high school and a reduction in the proportion of child marriages. Conclusions: Lessons from this public-private partnership can be adapted to similar programming environments that aim at reaching out to adolescent girls with anemia control interventions.

India's Adolescent Anemia Control Programme: Ten Make-or-break Elements for Sustaining Success.

Objectives: In India, 56% of adolescent girls are anemic. In response to this situation and building on 13 years of evidence-generation using a knowledge-centred framework (evidence, innovation, evaluation and replication), India's adolescent girls anemia control programme was universalized in 2013 covering 130 million adolescents. Implemented jointly by Ministries - Health, Education and Women and Child Development, services delivered by the programme include: 1) weekly iron and folic acid supplementation; 2) bi-annual deworming; and 3) nutrition counselling. UNICEF is technically supporting the government in roll out of the programme in 14 Indian states that house 88 percent of total adolescent girls in India. Methods: Using information emanating from programme reports analyses, structured interviews with state programme implementors and a national consultation, this presentation highlights ten make-or-break elements to address the most important challenges encountered in the universal rollout of the programme. Results: Ten make-or-break elements are: 1) political will along with well-defined inter-ministerial convergence and accountability mechanisms; 2) solving procurement challenges and continued supply monitoring; 3) instituting emergency response mechanisms (teams, helplines, standardized tools) for managing undesirable events; 4) sustained media engagement; 5) ensuring technical human resource support to state governments where capacity is sub-optimal; 6) devising a supplementation strategy during school vacations; 7) monitoring and evaluating the programme implementation independently through civil society/academia; 8) associating celebrities, parliamentarians and religious/peer leaders to mass communication campaigns; 9) ensuring functional review mechanisms; and 10) specific strategies to reach the unreached. Conclusions: All the ten make-or-break elements are critical for ensuring success of an universal adolescent anemia control programme.

Scaling up Weekly Iron and Folic Acid Supplementation in Jharkhand, India Minimizing Challenges, Maximizing Opportunities.

Objectives: Jharkhand is a predominantly tribal Indian state. Home to 3.5 million adolescent girls, two-thirds of Jharkhand's adolescent girls were reported to be anaemic. In 2000, the Government of Jharkhand launched the Adolescent Girls Anemia Control Programme (AGACP) in five of its 24 districts with technical support by UNICEF. This presentation summarizes a decade of experience in scaling up Jharkhand's AGACP. Methods: In its initial phase, the programme covered around 250,000 school-going adolescent girls in 2800 schools. The intervention included weekly iron and folic acid (IFA) supplementation, bi-annual deworming, and nutrition counselling. The second phase was launched in 2009 to cover two million adolescent girls. During this phase the programme faced important challenges due to a break-down in the supply chain of IFA supplements and deworming tablets. However, weekly nutrition counselling sessions continued. The third phase of the programme was inaugurated in 2012 with the advent of the National Weekly Iron and Folic Acid Supplementation (WIFS) programme implemented in a convergent manner by the Departments of Health and Family Welfare, Women and Child Development, and Education. Results: The programme has been universalized across all 24 districts, by the state government. Currently, the programme covers 3 million adolescents. Conclusions: Approaches used for stabilizing the programme are valuable lessons (do's and dont's) in piloting, stabilizing and scaling up a large scale programme for the control of anaemia in adolescent girls in resource-constrained settings.

Nutritional Disparities among Women in Urban India.

The paper presents a wealth quartile analysis of the urban subset of the third round of Demographic Health Survey of India to unmask intra-urban nutrition disparities in women. Maternal thinness and moderate/ severe anaemia among women of the poorest urban quartile was 38.5% and 20% respectively and 1.5-1.8 times higher than the rest of urban population. Receipt of pre- and postnatal nutrition and health education and compliance to iron folic acid tablets during pregnancy was low across all quartiles. One-fourth (24.5%) of households in the lowest urban quartile consumed salt with no iodine content, which was 2.8 times higher than rest of the urban population (8.7%). The study highlights the need to use poor-specific urban data for planning and suggests (i) routine field assessment of maternal nutritional status in outreach programmes, (ii) improving access to food subsidies, subsidized adequately-iodized salt and food supplementation programmes, (iii) identifying alternative iron supplementation methods, and (iv) institutionalizing counselling days.

Birth Preparedness and Complication Readiness among Slum Women in Indore City, India.

Three hundred twelve mothers of infants aged 2-4 months in 11 slums of Indore, India, were interviewed to assess birth preparedness and complication readiness (BPACR) among them. The mothers were asked whether they followed the desired four steps while pregnant: identified a trained birth attendant, identified a health facility, arranged for transport, and saved money for emergency. Taking at least three steps was considered being well-prepared. Taking two or less steps was considered being less-prepared. One hundred forty-nine mothers (47.8%) were well-prepared. Factors associated with well-preparedness were assessed using adjusted multivariate models. Factors associated with well-preparedness were maternal literacy [odds ratio (OR)=1.9, (95%) confidence interval (CI) 1.1-3.4] and availing of antenatal services (OR=1.7, CI 1.05- 2.8). Deliveries in the slum-home were high (56.4%). Among these, skilled attendance was low (7.4%); 77.3% of them were assisted by traditional birth attendants. Skilled attendance during delivery was three times higher in well-prepared mothers compared to less-prepared mothers (OR: 3.0, CI 1.6-5.4) Antenatal outreach sessions can be used for promoting BPACR. It will be important to increase the competency of slum-based traditional birth attendants, along with promoting institutional deliveries.

Human touch to detect hypothermia in neonates in indian slum dwellings.

Objective. To assess the validity of human touch (HT) method to measure hypothermia compared against axillary digital thermometry (ADT) and study association of hypothermia with poor suckle and underweight status in newborns and environmental temperature in 11 slums of Indore city, India. Methods. Field supervisors of slum-based health volunteers measured body temperature of 152 newborns by HT and ADT, observed suckling and weighed newborns. Underweight status was determined using WHO growth standards. Results. Hypothermia prevalence (axillary temperature <36.5oC) was 30.9%. Prevalence varied by season but insignificantly. Hypothermia was insignificantly associated with poor suckle (31% vs 19.7%, p=0.21) and undernutrition (33.3% vs 25.3%, p=0.4). HT had moderate diagnostic accuracy when compared with ADT (kappa: 0.38, sensitivity: 74.5%, specificity: 68.5%). Conclusions. HT emerged simpler and programmatically feasible. There is a need to examine whether trained and supervised community-based health workers and mothers can use HT accurately to identify and manage hypothermia and other simple signs of newborn illness using minimal algorithm at home and more confidently refer such newborns to proximal facilities linked to the program to ensure prompt management of illness.

Iodine deficiency and development of brain.

Iodine is a trace element essential for the synthesis of triodothyronine (T3) and thyroxine (T4). Inadequate intake of iodine leads to insufficient production of these hormones, which play a vital role in the process of early growth and development of most organs, especially the brain. The neurological sequele of iodine deficiency are mediated by thyroid hormone deficiency, varying from minimal brain function to a syndrome of severe intellectual disability. All the basic processes of neurogenesis: cellular proliferation, differentiation, migration, and selective cell death are impaired during period of brain growth spurt. Evidence suggests alterations in synaptology, neurons, myelin sheaths, glial cells, and morphology of cerebrum and cerebellum in severe iodine deficiency. Foetal thyroid ontogenesis occurs after the first trimester. Until then foetus is dependent on maternal T4. A thyroid dependent event important for subsequent brain development occurs in the beginning of the third trimester of pregnancy.

Elimination of iodine deficiency disorders in Delhi.

OBJECTIVE: The present study was conducted in year 2002 in NCT of Delhi with the objective to re-assess the prevalence of iodine deficiency disorders. METHODS: A total of 7009 children in the age group of 6-11 years were clinically examined for presence of goiter. A total of 991 salt samples were also collected randomly. On the spot casual urine samples were collected from 1395 children. RESULTS: The total goiter prevalence was found to be 6.2%. The percentage of children with urinary iodine excretion (UIE) of < 20.0, 20.0- < 50.0, 50.0-99.9 and 100.0 microg/l and above was 0.8, 1.8, 8.7 and 88.7%, respectively. The median UIE level was 200 microg/L. The assessment of iodine content of salt revealed that only 16% of the families were consuming salt with iodine content less than 5 ppm. CONCLUSION: The findings of the present study indicated that the population is in a transition phase from iodine deficient (as revealed by Total Goiter Prevalence) to iodine sufficient nutriture (as revealed by median UIE 200 microg/l). A significant progress has been achieved towards elimination of IDD from NCT of Delhi.

Effect of nutrition education of mothers on infant feeding practices.

OBJECTIVE: To assess current infant feeding practices (IFP) in a relocated slum, to identity the lacunae, to outline, implement, and evaluate the gain in awareness and IFP followed by mothers. METHODS: Thirty-five mothers of infants aged 5-19 months were interviewed. Based on lacunae, Nutrition Education (NE) was imparted to mothers over two months. Tools used were individual counseling, participatory learning methods, positive deviance and early adopters approach aided with existing information education communication materials. Monthly weight and length of infants was also taken. Awareness and practices on infant feeding (IF) were reviewed at mid and post NE. RESULTS: Areas of concern at baseline were (i) discarding colostrum (77.0%), (ii) feeding prelacteals (80.0%), (iii) initiation of breast-feeding (BF) after 3 days (54.3%), (iv) absence of exclusive breast-feeding (86.3%), (v) delayed complementary feeding (CF) and (vi) feeding CF grossly inadequate in quality, quantity, frequency and consistency. Post NE results revealed an improved awareness about IF amongst the mothers. An improvement was seen in variety, quantity and consistency of CF fed. Active feeding behaviours were adopted (6.6% pre-NE vs 66.6% post-NE). Early adopters (24%) served as motivators. Weight for age and weight for length showed improvement. CONCLUSION: NE programs of shorter duration using a 'communication mix' of channels with repeated reinforcement can bring about improvement not only in awareness but also in IFP.