cr-se-mch-food-08120501 by keralaguest

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									                 Health

                 Maternal and Child Health Community

                 Food and Nutrition Security
                 Community



The Maternal and Child Health Community
The Food and Nutrition Security Community
Consolidated Reply
Query: Reaching Out of School Adolescents for Anemia Control, from
Medical College Vadodara, Gujarat. (Comparative Experiences)
Compiled by Meghendra Banerjee and Gopi N Ghosh, Resource Persons; additional research
provided by Siddhartha Kumar and Bidisha Pillai, Research Associates
8 December 2005
________________________________________________________________________

Original Query: Prakash Kotecha, PSM Department, Medical College
Vadodara, Gujarat
Posted: 20 October 2005

Anemia in children is very high and that is reflected in all surveys. Anemia in pregnant mothers remain
very high after years of program to control anemia in pregnancy in place. We have realized that
pregnancy is too late a stage for anemia control and therefore we need to start efforts in anemia control
at an early stage. We started with UNICEF support "Adolescent Girls Anemia Control Program" through
schools in Vadodara district and based on our success model (For more details on this that we
documented in SCN meeting http://www.micronutrient.org/IDPAS/pdf/1578SCNReport2003-INDIA-
Kotecha.pdf), all 25 districts in Gujarat has now started this program in secondary schools. Once a week
IFA supplementation is given and health education brochures and posters are also given. Response is
good and 10 lakh Adolescent girls are now covered in Gujarat through schools.

Challenge is that we need to reach out to Adolescent girls who are not in the school and that forms larger
group (75% of Adolescent girls are not in school... many of them are married already). Through Kishori
Shakti Yojana some are targeted. But reaching out to out of school Adolescent girls has remained a
challenge to us though reaching through NGO and through ICDS some successes are achieved. I would
request members to share their wisdom and experiences to reach out to out of school
Adolescent girls and at later stage even boys to control anemia effectively.

--------------------------------------------------------------------------------------------------------------------
Responses were received, with thanks, from:

1. G.N.V.Brahmam, National Institute of Nutrition, Hyderabad
2. K.S.Umamani, PRC, ISEC, Bangalore
3. Paula Quigley, ECTA, New Delhi


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4. Kusum Gopal, LSE, UK
5. Mahtab S. Bamji, Dangoria Charitable Trust, Medak Dist., A.P
6. Gouri Kumra, Kolkata Response 1, Response 2
7. Prema Ramachandran, NFI, New Delhi
8. Biswajit Padhi, Srusti, Orissa
9. Anshu Sharma, NFI, New Delhi
10. M. S. Murthy, Sri Venkateswara Univeristy, Tirupati
11. Ashok K Paikaray, Mahavir Yubak Sangh, Orissa, Bhubaneswar
12. Meghendra Banerjee, WHO India, New Delhi
13. Abha Jha, CRS, Lucknow
14. V.R.Jani, Panchmahal Dist. Coop. Milk Producers’ Union, Godhra, Gujarat
15. Kamala Krishnaswamy, NIN,Emeritus Medical Scientist (ICMR), Hyderabad
16. Milind Shah, Rural Obstetrics Committee, FOGSI, Solapur Maharashtra

Further Contributions are welcome!
______________________________________________________________________

Summary of Responses

Members acknowledged the problem of Anemia as one that is endemic in India. Though the query was
specific to out of school Adolescent girls, members shared their experiences on targeting anemia with a
holistic approach as it affects many cross sections of our society. The prevalence of severe anemia in
Adolescent girls is much higher than in children and affects preschool children, pregnant and lactating
women, rural children, slum children, low middle class urban children and is also prevalent among high
income group educated families. Out of school Adolescent girls are at dual risk as they often get married
early and may conceive making them prone to early pregnancy and pregnancy related anemia. Members
shared various techniques and ways in which this problem could be addressed.

The main nutritional problems of Adolescents as identified by the members - were micronutrient
deficiencies, iron deficiency anaemia in particular, and depending on the context, undernutrition or
obesity and co-morbidity. Like in any other age group, poor nutrition is usually the result of dietary
inadequacies, often combined with unhealthy lifestyles (bathing in unclean water pond, repeated use
of cloth in place of sanitary towel, consumption of junk food, long unclean nails) or infections (malaria,
hook worm infestations), which further compromise nutritional status. Dietary inadequacies (low
intake & poor bio availability of iron in phytate fibre-rich in Indian diet) are likely more of a threat among
Adolescents because of erratic eating patterns and specific psycho-social factors underlying these,
combined with the particularly high nutritional requirements for rapid growth.

Reaching the out of school Adolescents

Understanding the fact that a substantial portion of the Adolescent groups would be covered under the
antenatal schemes; the members felt that targeting school going Adolescents had a dual benefit, first
to improve their own health status and then they become advocates for their peers who don‟t come to
school. The other more common ways of covering the out of school Adolescents was suggested as
though ICDS services and Health care workers. Involving mother leaders (or educators) & self help
groups or groups like Milk Cooperatives was another suggestion. Reaching them at their workplace
was suggested to cover the working Adolescent.

On the more holistic side it was suggested to targeting the girls, their families and community as a whole
and imparting nutrition education (especially in vernacular) through behaviour change
communication – emphasizing on diet, iron & vitamin rich food (especially locally available ones).
Focusing on dietary intake of iron through improved diet & dietary diversification, including proper



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ways of cooking like washing vegetables, use of iron and iodine fortified salt, inclusion of food rich in iron
and energy like beetroot, carrot, banana fruit, banana stem, drumsticks, and green leafy vegetables such
as Amaranthus; whole grain products like gram flour (sattu) jowar, bajri, roti; Jaggery and ground
nut cakes, along with promotion of foods that help absorption of iron. Some of the ways of imparting
nutrition education, as suggested
 Nutrition education classes for Adolescent girls & their families
 Melava (mass meetings) for Adolescent girls & their families
 House visits by grass root level health workers, demonstrations of iron rich recipes
 Exhibitions, Movies, TV, Radio Programmes, Posters in Public Places
 Walks & rallies

Other Suggestions
 Integrating Anemia Control programme with existing programmes
 Including private & indigenous practitioners in the communication strategy and service delivery
 Screening & Therapy for pregnant Adolescent girls
 Using iron utensils for cooking, an old practice in rural areas helps to fortify food with iron
 Administering Biomedicines or IFA supplementation may be given with proper information with
   purpose explained properly, counseling and adequate supply with a mechanism to ensure (monitor)
   intake
 Introducing a small price for the iron tablets may increase its value, and improve its use.
 Developing appropriate Management Information Systems focusing on qualitative aspect.
________________________________________________________

Comparative Experiences

Tamil Nadu, Training Adolescent girls in RCH services (from Paula Quigley, ECTA, New Delhi)
   Non-school going Adolescent girls (aged 15 to 18) from the villages are selected and trained on
   hygiene, conception, antenatal (AN) care including taking care of 5 to 6 pregnant women in their
   village, providing advice on diet, regular consumption of Iron and Folic Acid (IFA) tablets and the
   benefits of breastfeeding, as well as persuading them to use institutional services. For more
   information see PROD below.

West Bengal, “Aao Gaon Chalen” – adopting vulnerable villages (from Gouri Kumra, Kolkata)
  In West Bengal free iron and folic acid is provided once in two months. Under the project, the
  members of IMA is adopting the most vulnerable villages according to prevalent major public health
  problems. Major emphasis is on the control of epidemics and endemics, maternal and child health,
  geriatric care and Adolescent health.

Orissa, Anemia Control under “Kishori Shakti Yojana” through ICDS services (from Prema
Ramachandran, NFI, New Delhi and Biswajit Padhi, Srusti, Orissa)
    The Department of Women and Child Development has been carrying out the programme aimed at
    improving the education, nutrition and health status of Adolescent girls. In some states there have
    been efforts to provide weekly IFA to Adolescent girls as a method to treat anemia.

Gujarat, Anemia Control through Milk Cooperatives, (from V.R.Jani . Panchmahal Dist. Coop. Milk
Producers Union, GODHRA, Gujarat)
    In Gujarat more than 10000 villages have the Milk Cooperative. Many of these village
    Milk cooperatives often have Extension Programmes organized by the Trained Female and the Male
    Instructors on various aspects - aimed towards the overall betterment of the lives of the villagers.
    UNICEF has launched Anaemia control programme in collaboration with some of these Milk Unions in
    Gujarat, covering the Adolescent girls and the pregnant women.




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Maharashtra, Community Based Nutrition Education Programme (from Meghendra Banerjee,
Resource Person)
    Institute of Health Management – Pachod, in Maharashtra did a Community Based Randomised Trial
    to assess impact of Nutrition Education on anemia among Adolescent girls. As the part of this study
    one and half year intervention has planned to change dietary behaviours for prevention of anemia
    and implemented in a population of 8000.

Madhya Pradesh, Anemia Control in Urban Slums (from Siddhartha Kumar, Research Associate)
   CARE India‟s Improved Health Care for Adolescent Girls in Urban Slums project in Jabalpur, Madhya
   Pradesh targeted at 32,000 Adolescent girls in 143 slums to significantly reduce morbidity and
   mortality associated with reproductive health among Adolescent girls (married and unmarried).
________________________________________________________________________

Related Resources

Recommended Documentation

Training Adolescent girls to mobilise the community to use health services, Tamil Nadu (from
Paula Quigly, ECTA, New Delhi)
in Policy Reform Options Database (PROD)
http://www.prod-india.com/retopt2.asp?SD=27&SI=1&ROT=2
    A listing of the Tamilnadu experience on Adolescent girls for mobilizing community to use health
    services through behaviour change communication

Public Welfare Schemes, Govt. of Orissa (from Prema Ramachandran, NFI, New Delhi and Biswajit
Padhi, Srusti, Orissa)
http://orissagov.nic.in/e-magazine/orissaannualreference/ORA-2004/pdf/public_welfare_scheme.pdf (file
type .PDF, 26 KB)
    Gives a brief description on Orissa‟s adaptation of Kishori Shakti Yojana for Adolescent girls

Adolescent Girls Anaemia Control Program (Departments of Health & Education) Summary
Report, (from Prakash Kotecha, Medical College Vadodara, Gujarat)
Prakash V. Kotecha, Purvi Karkar, Medical College, Vadodara, Gujarat, India & Siddharth Nirupam
UNICEF, Gujarat, India
http://www.micronutrient.org/IDPAS/pdf/1578SCNReport2003-INDIA-Kotecha.pdf (file type .PDF. 1.2
MB)
    A detailed report on Adolescent Girls Anemia Control Programme in Gujarat

Kishori Shakti Yojana, Government of India (from Prema Ramchandran, NFI, New Delhi)
http://pib.nic.in/feature/feyr2000/fnov2000/f231120001.html
    The article explains the importance of the Kishori Shakti Yojana as part of the ICDS programme for
    Adolescent girls

District Level Household Surveys (DLHS), (from Anshu Sharma, NFI, New Delhi)
http://www.rchindia.org/rep/orissa/khordha/chep1.pdf (file type .PDF, 34KB)
    Shows a very high prevalence of anaemia in pre-school children, Adolescent girls and pregnant
    women to the tune of over 90% in all these vulnerable groups.

Effect of Using Iron Utensils vis-a-vis Teflon-coated Non-stick Wares on Ionisable Iron
Content of Traditional Vegetarian Food (from Milind Shah, Rural Obstetrics Committee, FOGSI,
Solapur)
Kakade Veena & Agte Vaishali (1997), J Food Sci Technol 34(5), pp.427-430.




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   Effect of Using Iron Utensils vis-a-vis Teflon-coated Non-stick Wares on Ionisable Iron Content of
   Traditional Vegetarian Food, exploring feasibility in controlling anemia

Research and Dietary Promotion: Nutrition education intervention to improve hemoglobin
status of Adolescent girls in Urban slums, Pune. (from Meghendra Banerjee, Resource Person)
Ms. Rama Tupe, Research Officer of IHMP in 2003
http://www.micronutrient.org/idpas/dump/jess%20work/scn%20addendum/tupe.instituteofhealth.pune3.
doc.pdf (file type .PDF, 38 KB)
   Short write up on IHMP‟s nutrition education programme for Adolescents

Report of the Working Group on Adolescents for the Tenth Five Year Plan, Planning
Commission, Government of India (from Siddhartha Kumar, Research Associate)
http://planningcommission.nic.in/aboutus/committee/wrkgrp/wg_adolcnts.pdf (file type .PDF, 202 KB)
   Report of the working group on Adolescents for the tenth five year plan with recommendations.

Annual Report – CARE India (from Siddhartha Kumar, Research Associate)
http://www.careindia.org/july_AnnualReport.pdf (file type .PFD, 3.7 MB)
   Annual Report covers the Jabalpur case study for urban Adolescents – page 23, and other relevant
   cases

Reaching Out-of-School Youth with Reproductive Health and HIV/AIDS Information and
Services (from Siddhartha Kumar, Research Associate)
Youth Issues Paper 4, A. August Burns et al, 2004 Family Health International, USA
http://www.fhi.org/NR/rdonlyres/egkwwx7wo3ry3o5vwgn6bhsxcbir5fxzr2f23ke7r2dmnts2koqs6isgvbsydjl
yiuh5i33gmunfbh/YI4final.pdf (file type .PDF, 338KB)
   Strategy for reaching out of school youths, also explains the use of media, in chapter 3 (page no.9-
   14)

Reaching Out-of-School Youth in Uganda with Sexual and Reproductive Health Information
and Services (from Siddhartha Kumar, Research Associate)
African Youth Alliance, March 2005
http://www.path.org/files/AH_aya_oos_Uganda.pdf (file type, .PDF 378KB)
   Reaching out of School Youth in Uganda, African Youth Alliance, page-2.

Recommended Organizations

UNICEF, India (from V.R.Jani . Panchmahal Dist. Coop. Milk Producers Union, GODHRA, Gujarat &
Prakash Kotecha, Medical College Vadodara, Gujarat)
http://www.unicef.org/india/children_183.htm
   UNICEF has undertaken few programmes on school going & out of school Adolescents‟ anemia
   control programmes in India

Indian Medical Association (IMA) (from Gouri Kumra, Kolkata)
http://www.imanational.com/AaoGaon.asp
   IMA has undertaken the new rural medical plan – adopting most vulnerable villages and providing
   medical services there, also covering anemia issues

Institute of Health Management – Pachod (from Meghendra Banerjee, Resource Person)
http://www.ihmp.org/lifeskills_presentation.html
   An academic institute which has worked on Nutrition Education on anemia among Adolescent girls in
   urban & rural areas

CARE - India (from Siddhartha Kumar, Research Associate)



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http://www.careindia.org:8080/displaySector.jsp?sCode=CIS28
    Running one of the largest nutrition programmes in the country; also covers Adolescent nutrition
    issues

Adolescent Resource Centre, Child in need Institute, Kolkata (from Siddhartha Kumar, Research
Associate)
http://www.cini-india.org/arc.asp
    An NGO working on health of women and children, nutrition and development, Adolescent issues,
    following a life cycle approach covering Adolescent girls
_______________________________________________________________________________

Responses in Full

G.N.V.Brahmam, National Institute of Nutrition, Hyderabad

I strongly agree with you that the Adolescent girls have to be targeted for supplementation of IFA tablets
in order to prepare them for better motherhood. The girls who do not attend the schools may be covered
through ICDS services, for supervised once a week supplementation of IFA, as being adopted by States
like West Bengal.
_______________________________________________________________________________

K.S.Umamani, PRC, ISEC, Bangalore

Controlling Anemia among out of school Adolescent girls I suppose can only be done through Female
health assistants and may be we can try of women‟s self help groups. Or I suppose we can try with the
help of school attending girls only to give it to their peer groups who may be their friends who stay near
their house.
_______________________________________________________________________________

Paula Quigley, ECTA, New Delhi

There is a scheme in Tamil Nadu (not yet evaluated) which trains out-of-girl schools to be link workers
for RCH services in rural areas. Not quite the same thing but I‟m sure they could share the challenges
they have faced in identifying the girls and persuading them to participate.
It is in PROD ref no 73.
Training Adolescent girls to mobilise the community to use health services, Tamil Nadu
http://www.prod-india.com/retopt2.asp?SD=27&SI=1&ROT=2
_______________________________________________________________________________

Kusum Gopal, LSE, UK

Anaemia is an endemic problem in India and the suffering of mothers and women in general has serious
consequences in babies and health of children. It is thus important to focus on what is available -- natural
foods rich in iron and energy boosting --and, in the creation of clean, environmental support systems.

The provision of two nutritious meals in all schools and at workplaces where young girls and mothers are
employed would be useful. Kitchen gardens, diart farms and two community meals served each day
would be the best alternative. This would require structural changes and would also be cost effective.
Biomedicines should act only as a supplement- they cannot do much more than that in any event.

One of the main problems with policies in general to do with girls and MCH has been the ghettoisation-
separating a girl/woman from her family and cultural contexts. And this has to be addressed by
discussing fundamental questions of being born female. The focus should not be formal education but


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about dignity, politeness and guarantee of personhood and identity. Both men and boys need to made
aware just as much as older women who often exploit the younger women subjecting them to much
hardship-- daughters in law in a household often barely in their late teens take on a lot of work and men
need to be also taught to do more than merely assist in housework/ These require gentle persuasion
tactics and can effect powerful life changing remedies.
_______________________________________________________________________________

Mahtab S. Bamji, Dangoria Charitable Trust, Medak Dist., A.P

Sometime back the government of A.P. had some scheme of distributing iron folic acid tablets to
Adolescent girls with the help of Anganwadi workers. Some Anganwadi workers approached us to
educate the girls, since the response was poor. To our surprise we found that neither the girls nor their
parents knew the purpose of the tablets, and many just threw them out because they did not like them,
or had some side effects.

The message is: prepare the community by explaining to them the purpose of the programme before
starting it, so that they ask for it rather than thrusting it on them. Medical professionals- government
and private can be involved. A small price for the tablets may increase its value, and improve its use.
_______________________________________________________________________________

Gouri Kumra, Kolkata

Response 1

Multi Organizational mission mode - Integrated approach.
Working capacity gets enhanced manifold.
Challenges throw up opportunities
Educational reforms must be initiated. The mindset must change, showing willingness to take pragmatic
risks. Success will follow.
Core knowledge, knowledge society, knowledge creation and knowledge deployment.

Anaemia out of school

Visual effect -
1. Fat girls are more anaemic than thin girls.
2. Unwashed vegetables harbour worms , ova and cyst.
3. Beetroot, carrot, banana fruit, banana stem help to increase haemoglobin / blood content.
4. Delayed cycles are associated with multi-organ disease - needs to be evaluated.
5. Frequent cycles deplete food reserve.
6. Spacing of children will restore immunity.

POSTERS DEPICTING THESE MESSAGES SHOULD BE PASTED OUTSIDE TEMPLES, SCHOOLS, ASHRAMS
IN LOCAL LANGUAGES

AUDIO EFFECT.

Anganwadi workers should discuss one point at a time. Too much of knowledge could go unappreciated.

Indian medical association has adopted a project called “AAO GOAN CHALEN” Every city has adopted
one village eg west Bengal has adopted badu a village near Barasat . Aims - Free iron and folic acid
provided once in two months; Rotary and lions help to evaluate the haemoglobin; Doctors interact with
the inhabitants and appoint a leader.




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Movie halls should carry posters which is appreciated in between recreation..
_______________________________________________________________________________

Prema Ramchandran, NFI, New Delhi

Irrespective of the differences in income group, state of residence, in school or out of school anaemia in
Adolescent girls is widespread and severe anaemia is not uncommon. Out of school Adolescent girls often
get married early and may conceive; they incur the dual risk of too early pregnancy and pregnancy
anaemia. It is therefore important that efforts should be made to address the problem of anaemia in
Adolescent girls especially out of school Adolescent girls.

However we also have to realise anaemia in Adolescent girls is a part of anaemia in of all segments of
population in India. The real long term solution to the problem is to improve dietary intake of iron
through dietary diversification; use of iron and iodine fortified salt is another sustainable and affordable
method of increasing the dietary intake of iron of all the family .

Studies carried out research workers in different parts of the country have shown that when counseled
and given IFA tablets Adolescent girls do take them and their haemoglobin status improves. These
however have not been scaled up.

The Department of Women and Child Development has been carrying out Kishory Shakti Yojana
aimed at empowering the Adolescent girls. Some of the major components under the programme aim at
improving the education, nutrition and health status of Adolescent girls. In some states there have been
efforts to provide weekly IFA to Adolescent girls as a method to treat anaemia. But coverage under this
programme was quite low. There was no effort to screen the girls for ascertaining the severity of
anaemia and tailoring the dose of iron based on the needs. Supply of IFA tablets was not regular and
continued IFA consumption was uncommon. There is a need to strengthen the supply line, provide
nutrition education so that there is regular consumption IFA and dietary diversification and improved iron
intake.

Pregnant Adolescent girls are to be treated as an especially vulnerable group and given appropriate
antenatal care which should include screening for anaemia and appropriate therapy.
_______________________________________________________________________________

Biswajit Padhi, Srusti, Orissa

The government of Orissa has also started a programme for Adolescents: they are given IFA through the
ICDS. The response has been mixed. But I think the people / Adolescent need to be trained / talked
before they take the tablets to get best results. As here the IFA is believed ( when given to pregnant
women) to increase the size of the child thus causing delivery complications- as they don't go for hospital
delivery, they believe a big child will cause delivery complications.
_______________________________________________________________________________

Anshu Sharma, NFI, New Delhi

Three major surveys have been under taken to assess prevalence of anaemia in India: the ICMR
micronutrient survey, NNMB survey in 9 states and the DLHS in all states. Data from all the
surveys have shown that prevalence of anaemia is very high (ranging between 80->90%) in
preschool children, pregnant and lactating women and Adolescent girls . Moderate and severe
anaemia is seen even among the upper income group educated families. There are interstate
differences in prevalence of anaemia which is perhaps attributable partly to differences in dietary
intake and partly to access to health care, but majority of the persons irrespective of age, income
group, state of residence and are anaemic .



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High prevalence of anaemia is due to

•       low dietary intake, poor iron and folic acid intake;
•       poor bio-availability of iron in phytate fibre-rich Indian diet; and
•       infection such as malaria, hook worm infestations.

Anaemia in Adolescent girls is in fact the continuation of the anaemia in childhood aggravated by the
onset of menstruation. It is noteworthy that the prevalence of severe anaemia in Adolescent girls is much
higher than the prevalence of anaemia in children.

Anaemic Adolescent girls face several problems including poor attention span, poor work capacity and
increases risk of infections. Anaemic Adolescent girls marry and conceive and incur the additional risk of
anaemia in pregnancy.

Research studies have shown that even weekly iron folate therapy has some beneficial impact. In spite of
the knowledge about all this there have been no efforts to initiate a programme to combat anaemia in
this group of future citizens.
_______________________________________________________________________________

M. S. Murthy, Sri Venkateswara Univeristy, Tirupati, Andhra Pradesh

I have great respect to all nutritionists and others involved on discussion in preventing anaemia among
Adolescent girls.

However, I request all of them to make the Adolescents appreciate about the nutrients available from
local sources.

Jaggery is a rich source of Iron and ground nut is rich in protein. All of us are aware of Lonavala Chikki
which is a cake of jaggery and ground nut. Adolescents or for that matter any mother may educated to
consume this chikki. It will prevent anaemia to a great extent.

Green leafy vegetables such as Amaranthus and other greens provide iron to the people.
_______________________________________________________________________________

Ashok K Paikaray, Mahavir Yubak Sangh, Orissa

Time has come for a change. We should opt for herbal against chemical. Putting more stress on
consuming medicines, tablets or vitamins can not solve this problem. Instead of putting them on
medicines we should emphasize more on HOME HERBAL GARDEN. We can have our food supplement as
well as medicinal value. Taking into the case of DRUMSTICK which is full of iron.
_______________________________________________________________________________

Meghendra Banerjee, WHO India, New Delhi

At the outset I would like to thank you all very much for your views and so many interesting inputs. Now
may I take this opportunity to try to revisit the query posted by Dr. Kotecha – looking for “innovative
ideas to REACH the out of school Adolescents”? For example a response from Dr. Bamji referred to a
model in Andhrapradesh where Iron tablets were distributed through the Anganwadi Worker. If we are
talking about intra familial distribution of food and promotion of iron rich locally grown vegetables, is
there some example where these have been tried out and we can learn from – any Behaviour Change
Communication material already in the public domain?




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I would like to give one example of work by Institute of Health Management – Pachod, in Maharashtra
who did a Community Based Randomised Trial to assess impact of Nutrition Education on anemia among
Adolescent girls. As the part of this study one and half year intervention has planned to change dietary
behaviours for prevention of anemia and implemented in 8000 population.

Description of Nutrition Education Intervention:

Nutrition education was given to the Adolescent girls and their families in various ways. Messages
regarding diet, iron rich and Vitamin C rich food consumption were developed and given to the girls. The
messages were repeated using different methods so as to have impact on their diet behaviour.

Ways of imparting Nutrition Education:

•      Nutrition education classes for Adolescent girls
•      Melava (mass meetings) for Adolescent girls
•      House visits by grassroot level health workers
•      Demonstrations of iron rich recipes
•      Exhibitions
•      Providing information on cheap and seasonally available local foods.

You                      can                   find                        more                      at
http://www.micronutrient.org/idpas/dump/jess%20work/scn%20addendum/tupe.instituteofhealth.pune3.
doc.pdf - a two pager on the study by Ms. Rama Tupe, Research Officer of IHMP in 2003; from where
I have cited this example and http://www.ihmp.org/lifeskills_presentation.html - for the overall impact
and results.
_______________________________________________________________________________

Abha Jha, CRS, Lucknow

We do understand that the program managers should plan and focus more on developing innovative
programs in order to prevent anemia amongst Adolescent girls and women. In my view, the most
important steps would be to

• Explore possibilities to integrate Anemia prevention program in to the various existing programs
•   dentify gaps in the ongoing programs
•   Take immediate corrective measures to bridge the gaps
•   Effective periodic monitoring plans to assess the progress of activities
• Develop appropriate Management Information system, which focuses primarily on qualitative aspect
   as compared to quantitative aspect of the program. For example, the indicator for IFA coverage
   would be % of Women and Adolescent girls consuming IFA instead of % of Women and Adolescent
   girls receiving IFA. It would help the managers to focus more on bringing about sustainable
   behavioural change among the program participants from the initial stage of program
   implementation.
•   End evaluation to assess the impact of the program.
_______________________________________________________________________________

V.R.Jani , Panchmahal Dist. Coop. Milk Producers’ Union, Godhra, Gujarat

Anaemia is very common in rural part of our region i.e. Panchmahal and Dahod Districts. Many cases
have been diagnosed as ''Sickle cell Anaemia" in the tribal belt of eastern part of Gujarat. The efforts to
control the condition are insufficient.




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In Gujarat more than 10000 villages have the MILK COOPERATIVE. The Village Milk Cooperatives are
affiliated to District Milk Unions; and the District Milk Unions are affiliated to the State Federation. Many
of these village Milk cooperatives often have Extension Programmes organized by the Trained Female and
the Male Instructors on various aspects - aimed towards the overall betterment of the lives of the
villagers.

UNICEF has launched Anaemia control programme in collaboration with some of these Milk Unions in
Gujarat, covering the Adolescent girls and the pregnant women. Such well established and trustworthy
infrastructure facilities can be explored to expand the implementation of Anemia Control Programmes.
The District Health Departments and some NGOs may be involved to chalk out the joint programme. The
supervision and monitoring of the programme should be with an Independent Agency, may be
Govt./NGO. Only joint efforts and team work can achieve the desired results in such massive task.
_______________________________________________________________________________

Kamala Krishnaswamy, NIN,Emeritus Medical Scientist (ICMR), Hyderabad
India has never investigated the causes of anaemia in detail. Though Iron deficiency may be common,
others nutritional problems such as vitamin A, riboflavin, pyridoxine, folic acid, B-12 and sickle cell
anaemia, malaria etc .need to be examined. Co-coordinated efforts are needed.

School health programmes may be used for prevention and treatment.
_______________________________________________________________________________

Gouri Kumra, Kolkata

Response 2

Anaemia can be conquered by individual means.
Anaemia affects the

1.      Poor economic status.
2.      Rural children.
3.      Slum children.
4.      Low middle class urban children.

Convergence of Ideas

Individual efforts like:-
1.      Wash the vegetables before cooking.
2.      Choice of food- promote intake of whole grain products like gram flour (sattu) jowar, bajri, rotti,
        banana stem and banana flower.
3.      Avoid consumption of junk food. ( poor connectivity between urban and rural areas has          not
        deterred the consumption in rural area).
4.      Proper hygiene- Poor hygiene is most common in Bengal. Girls have a bath in ponds which if
        infested with worms can lead to anaemia.
Moreover poor girls do not use sanitary towels they use old cloth which is washed every month. This
leads to pelvic inflammatory diseases, white discharge which makes their immune status spoor.

Causes:-

Along with the above mentioned ones;
When the nails are not trimmed, sanitation is poor, cyst formation all lead to infestation and hence
Anaemia.
Irregular meals lead to Obesity and thus risk of anaemia.



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Spicy and sour foods induce acidity which increases mal absorption leading to Anaemia and over eating.
To inform and relate these facts we should conduct Anaemia walks with school children from urban areas
and also Doctors visiting rural areas.

Public places should have posters to in force and illustrate the above mentioned points.

Audio effect can be drilled by informing on the radio and distributing complimentary tapes with food
products.

Communication between anganwadi workers and doctors need to be improved.
_______________________________________________________________________________

Milind Shah, Rural Obstetrics Committee, FOGSI, Solapur Maharashtra

This is very important aspect. There is also one study conducted where using iron utensils for cooking
which is a very common tradition in many rural areas also helps to receive iron from food.

Summary: Use of iron utensils was assessed for bioavailability of contaminated iron during cooking
process with Teflon coated wares as controls. Experiments were undertaken using 34 commonly used
recipes for which iron utensils are used traditionally. There was significant increase in total ionisable iron
as well as total iron content due to use of iron utensils (p<0.05). Bioavailable contaminated iron
calculated as % increase in ionisable iron to increase in total iron, was found to be highest in foods
prepared by roasting (8-12%), followed by shallow pan frying (6-8%) and baking (4-6%). Further when
bioavailable iron content was computed in composite diets for moderately active men and women with
use of iron utensils, it was found to be increased by 1.8-2.2 mg/day.

I don't have soft copy of this paper but I can give u details.

This study was conducted at Agharkar Research Institute, Pune and published it in J.Food Sci. Techno. in
1997.

KAKADE VEENA & AGTE VAISHALI (1997), Effect of Using Iron Utensils vis-a-vis Teflon-coated Non-stick
Wares on Ionisable Iron Content of Traditional Vegetarian Food. J Food Sci Technol 34(5), pp.427-430.
_______________________________________________________________________________

                         Many thanks to all who contributed to this query!

If you have further information to share on this topic, please send it to Solution Exchange for the
Maternal and Child Health Community in India at se-mch@groups.solutionexchange-un.net.in or se-
food@groups.solutionexchange-un.net.in or with the subject reading „Re: [se-mch][se-food] Query:
Reaching Out of School Adolescents for Anemia Control, from Medical College Vadodara, Gujarat
(Comparative Experiences).

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