Adolescent girls anaemia control programme Gujarat India

Document Sample
Adolescent girls anaemia control programme Gujarat India Powered By Docstoc
					Indian	J	Med	Res	130,	November	2009,	pp	584-589




Adolescent	girls’	anaemia	control	programme,	Gujarat,	India	

P.V.	Kotecha,	S.	Nirupam*	&	P.D.	Karkar**	


USAID Micronutrient & Child Blindness Project, New Delhi & Former Professor & Head of Department
of Preventive & Social Medicine, Government Medical College Vadodara, *Child Survival Specialist
UNICEF/ Myanmar, Health & Nutrition, UNICEF Gandhinagar & ** UNICEF, Gujarat, Department
of Preventive & Social Medicine, Medical College Vadodara, Gujarat, India


Received	April	24,	2009


              Background & objectives: In June 2000, Adolescent Anaemia Control Programme was initiated as a pilot
              programme in Vadodara district of Gujarat covering over 69000 girls in over 426 schools. Programme
              strategy was to provide once weekly fixed day (Wednesday) supervised iron folic acid (IFA) supplements
              to all adolescent girls in Grade 8-12. Currently, programme covers 10 lakh schoolgirls and 2.6 lakh out of
              school girls with a compliance rate of over 90 per cent as reported by education department. This study
              was undertaken to institutionalize once a week IFA supplementation in the schools for adolescent girls
              with built in compliance monitoring in one district and scale up the programme from its learning to all
              the districts as feasible.
              Methods: Baseline survey for three areas of Vadodara district, tribal, rural and urban from 10 schools
              each was conducted to collect data for anaemia prevalence. Education Inspectors were assigned
              responsibility to supervise and motivate teachers to try out innovative ideas to promote the programme.
              Simultaneously anganwadi workers of urban Vadodara were motivated to initiate IFA supplementation
              for out of schoolgirls on similar strategy. After approximately 17 months of intervention, impact study
              was conducted in the same 30 schools in November 2001 to obtain levels of anaemia and some of the
              paired data from the students who were part of the baseline study. Study also included knowledge
              and practices of the adolescent girls with reference to their dietary habits and package of intervention
              included nutrition education through schools by providing information and education material prepared
              by the government.
              Results: Baseline study had shown around 75 per cent anaemia prevalence, which was similar in all
              the three areas. Level of serum ferritin was also low. Impact evaluation showed reduction in anaemia
              prevalence by 21.5 per cent that is, from 74.7 per cent to 53.2 per cent (P<0.05). Further improvement in
              Hb was recorded among 80 per cent girls. Pre- and post-intervention also showed improvement in serum
              ferritin value. Programme is now scaled up to cover 10 lakh schoolgirls and 2.6 lakh out of school girls in
              the State. Out of schoolgirls is only small fraction of total out of schoolgirls in the state. Data on dietary
              and nutritional related knowledge and practices did not show significant changes among schoolgirls.
              Retention of messages specified in IEC material was not satisfactory.
              Interpretation & conclusions: Supervised, once a week IFA supplementation to adolescent girls through
              institutions specially, schools was found to be an effective intervention to reduce anaemia and was scalable
              within the system. The experience to educate the girls on dietary behaviour has not been satisfactory and
              covering all out of school girls is still a challenge to the success of anaemia control.

Key words Adolescent	girls	-	anaemia	-	control	programme	-	haemoglobin	-	IFA	supplementation	

                                                                   584
	                 KoTECHA	et al:	ADoLESCENT	GIRLS’	ANAEMIA	CoNTRoL	PRoGRAMME	IN	GUJARAT	                                      585

	 Iron deficiency is the most common nutritional                 	 To	detect	anaemia	baseline	prevalence	of	70	per	cent	
disorder	 in	 the	 developing	 world	 and	 the	 most	            and	 detect	 the	 reduction	 of	 10	 per	 cent	 anaemia	 after	
common	 cause	 of	 nutritional	 anaemia	 in	 young	              intervention	 the	 sample	 size	 for	 of	 both	 the	 studies	 was	
children	 and	 women	 of	 reproductive	 age1. With 40            816	with	a	precision	of	5	per	cent	and	power	of	80	per	cent	
per	 cent	 prevalence	 of	 anaemia	 in	 the	 world	 on	 an	      (Epi	 Info	 2001)6.	 Since	 each	 area	 was	 studied	 for	 tribal	
average	 for	 the	 general	 population,	 the	 prevalence	        rural	 and	 urban	 separately,	 it	 was	 decided	 to	 study	 100	
in	the	developing	countries	tends	to	be	three	to	four	           girls	from	10	schools	to	derive	approximately	1000	school	
times	 higher	 than	 in	 the	 developed	 countries2.	 In	        girls	in	each	strata	reaching	to	total	of	3000	schoolgirls.
studies	conducted	in	developing	countries,	adolescent	           	 Schoolgirls	 were	 allowed	 to	 withdraw	 from	 the	
anaemia	 was	 reported	 as	 the	 greatest	 nutritional	          study	if	they	wanted	to,	based	on	ethical	ground.	About	
problem3.	In	India	the	reported	prevalence	was	55	per	           2860	 girls	 were	 enrolled	 for	 the	 baseline	 study	 and	
cent	for	boys	and	girls,	which	topped	the	prevalence	            2766	girls	for	the	impact	study.
among	all	the	six	countries	from	where	the	data	were	
collected.	                                                      	 Hundred	girls	from	each	school	from	the	grades	8	
                                                                 to	12	participated	in	the	blood	collection	for	baseline	
	 In	 the	 past	 decade,	 the	 widespread	 prevalence	           while	 for	 impact	 evaluation	 they	 were	 selected	 from	
of	 anaemia	 in	 adolescent	 girls	 in	 India	 is	 gaining	      grade	 9	 to	 12	 as	 grade	 8	 girls	 did	 not	 have	 one	 year	
increasing	 recognition.	 Adolescent	 girls	 are	 stated	        intervention	yet.	Schoolteacher	was	to	select	the	girls	
as an important beneficiary group in nutritional                 from	 each	 class	 proportionate	 to	 the	 total	 number	 in	
policy	 at	 national	 and	 state	 level	 (National	 nutrition	   the	respective	class.	All	these	girls	who	participated	in	
policy,	1993,	Gujarat	State	Nutrition	policy,	1998)4,5.	         the	 baseline	 study	 and	 were	 still	 in	 the	 school,	 were	
This	 has	 resulted	 in	 various	 programmes	 to	 combat	        recorded	to	obtain	paired	data.	
undernutrition and iron deficiency anaemia in this
groups	 in	 recent	 years.	 Further,	 once	 weekly	 iron	        Ethical issue:	 Consent	 note	 was	 given	 to	 every	
and	 folic	 acid	 (IFA)	 supplementation	 has	 been	             participant	who	was	explained	the	procedure	of	blood	
recommended	 as	 a	 promising	 strategy	 to	 combat	             collection	 and	 their	 option	 to	 volunteer	 the	 study.	
adolescent	anaemia.                                              Participation	 in	 the	 blood	 collection	 was	 voluntary.	
                                                                 Fifty	two	girls	opted	out	during	the	study	for	their	own	
	 In	 June	 2000,	 Adolescent	 Anaemia	 Control	                 reasons,	due	to	fear	of	prick	after	initially	agreeing	to	
Programme	 was	 initiated	 in	 Vadodara	 district,	              study.	Ethical	Committee	of	the	institute	for	research	
Gujarat,	covering	over	69000	school	girls.	The	main	             projects	 at	 Government	 Medical	 College,	 Vadodara,	
objective	of	the	programme	was	to	improve	the	poor	              had	reviewed	and	approved	the	study	protocol.
iron	 status	 of	 the	 adolescent	 girls.	 The	 intervention	
primarily	consisted	of	weekly	IFA	supplementation	to	            	 Postgraduate	 students	 from	 the	 Department	 of	
schoolgirls	 under	 direct	 supervision	 of	 class	 teacher	     Preventive	 and	 Social	 Medicine,	 Medical	 College,	
and nutrition education to the beneficiary girls and             Vadodara,	carried	out	data	collection	and	blood	sample	
teachers	 with	 the	 help	 of	 Information	 Education	           collection	from	the	schools	under	direct	supervision	of	
and	Communication	(IEC)	material.	Each	IFA	tablet	               the first author.
contained	 100	 mg	 elemental	 iron	 and	 0.5	 mg	 folic	        Data collection:	 Blood	 was	 collected	 in	 two	 vacuum	
acid.		                                                          tubes,	one	containing	ethylene	diamine	tetra	acetic	acid	
                  Material & Methods                             (EDTA)	and	the	other	plain	tube.	EDTA	tube	was	for	
                                                                 the	blood	 indices	while	plain	 tube	was	 for	 the	serum	
Sampling & sample size:	 Vadodara	 district	 has	 an	            ferritin.	The	tubes	used	were	Vacolect	(evacuated	blood	
area	of	7549.5	square	kilometres	with	a	population	of	           collection	 tube)	 having	 vacuum	 inside	 to	 facilitate	
3.64	million.	It	had	1543	villages	and	12	sub-districts	         drawing	of	the	blood	sample.		Participant	was	allowed	
(talukas)	 when	 the	 programme	 was	 initiated.	 All	           to leave the place after five minutes if she did not report
426	 schools	 of	 Vadodara	 district,	 having	 over	 69790	      any	problems	such	as	pain,	blood	oozing	or	giddiness.	
adolescent	girls	enrolled	as	the	students	in	grade	8	to	         The	blood	tubes	so	collected	were	stored	in	the	vaccine	
12	in	urban,	rural	and	tribal	areas	formed	the	universe	         carrier	and	were	brought	to	the	Central	Laboratory	of	
of	the	study.                                                    the	Medical	College,	Vadodara,	for	analysis.	
586	                                       INDIAN	J	MED	RES,	NoVEMBER	2009

Haemoglobin estimation:	For	haemoglobin	estimation	            Statistical	analysis:	Statistical	analysis	was	done	using	
ABACUS	cell	counter	(Diaton,	Austria)	was	used.	The	           Epi_Info	program	6_04	(2001)	version	and	includes	c2	
methodology	was	an	adaptation	of	the	standard	manual	          test	for	difference	of	proportion	and	t	test	for	difference	
cyanmethemoglobin	method.                                      of	means.	P	value	are	given	using	cut	off	at	0.05	levels.
	 Appropriate	quality	control	was	maintained.	Level	                              Results & Discussion
of anaemia was defined by WHO7	 criteria,	for	normal	
                                                               	 Baseline	study	was	collected	from	2860	girls	from	
with	haemoglobin	value	of	equal	to	or	more	than	120	
                                                               2977	enrolled	from	30	schools	(10	each	from	tribal,	rural	
g/l,	mild	anaemia	as	haemoglobin	value	of	100	up	to	
                                                               and	urban	area).	For	impact	study	17	months	later,	the	
119.9	 g/l,	 moderate	 anaemia	 as	 70	 to	 109.9	 g/l	 and	
                                                               study	was	done	in	the	same	30	schools	covering	2825	
severe	anaemia	as	less	than	70	g/l	of	blood.
                                                               girls.	 of	 the	 2825	 girls	 who	 initially	 volunteered,	 two	
Serum ferritin estimation:	 Serum	 ferritin	 estimation	       samples were clotted and five samples were inadequate.
was	done	at	Dr	Toprani’s	Laboratory,	Vadodara	using	
                                                               	 The	 data	 for	 1016	 girls	 were	 available	 for	
Immulite	 1000	 (immunoassay,	 DPC	 IMMULITE	
                                                               haemoglobin	and	665	girls	for	serum	ferritin	for	paired	
Chemiluminescent	 Analyzer)	 [Siemens	 Medical	
                                                               analysis	for	baseline	and	impact	studies	as	these	many	
Solutions	Diagnostics].
                                                               girls	were	present	in	both	the	samples.	
Intervention:	 Intervention	 included	 supervised	 iron	
                                                               Reduction in anaemia prevalence:	Reduction	of	anaemia	
supplementation once a week on every Wednesday,
                                                               prevalence	 was	 from	 74.7	 per	 cent	 at	 the	 baseline	 to	
dietary	advice	using	IEC	material	and	health	education	
                                                               53.2	per	cent	after	intervention	with	a	reduction	of	21.5	
on	 anaemia	 by	 various	 other	 promotional	 activities	
                                                               per	cent	and	ranged	from	16	to	24	per	cent	in	different	
like	 essay,	 slogan	 competitions,	 etc.	 Department	 of	
                                                               areas. The difference was significant for each area
education	 had	 trained	 two	 lady	 teachers	 from	 each	
                                                               (Table	 I).	At	 this	 stage,	 an	 appropriate	 interpretation	
school	 who	 were	 designated	 as	 liaison	 teachers.	
                                                               would	 have	 been	 to	 see	 a	 control	 group	 of	 girls	 in	
Teachers	were	also	trained	for	monitoring	compliance	
                                                               whom	the	intervention	was	not	done.	However,	as	the	
and	three	levels	of	monitoring	for	compliance	were	put	
                                                               entire	district	was	covered,	there	were	no	schoolgirls	in	
in	to	the	system,	monitoring	by	student	herself	using	
                                                               this	district	who	were	not	part	of	the	programme	(this	
a	card,	class	level	monitoring	by	the	class	teacher	and	
                                                               being	operational	programme	situation	and	not	primary	
school	level	monitoring	pooling	the	data	from	all	class	
                                                               research).	 The	 reduction	 achieved	 was	 maximum	
for	the	school	by	liaison	teacher	under	school	principal’s	
                                                               in	 rural	 areas	 followed	 by	 urban	 areas	 both	 showing	
direct	 supervision.	These	 reports	 of	 compliance	 were	
                                                               a	 net	 reduction	 of	 over	 23	 per	 cent	 while	 tribal	 area	
sent	to	the	Department	of	Education,	where	block	and	
                                                               showed	about	16	per	cent	reduction	of	anaemia	(Table	
district	level	compliance	was	recorded.
                                                               I).	These	differences	could	be	because	of	difference	in	
	 For	 out	 of	 schoolgirls	 two	 approaches	 were	            the	compliance	of	IFA	tablets	by	the	girls	or	because	of	
attempted.	 one	 approach	 was	 to	 ask	 schoolgirls	          inherent	nature	of	differences	between	the	areas.	
to find 3 out of schoolgirls and provide them with
                                                               	 Mean	rise	of	haemoglobin	of	6.4	gm/l	with	regional	
education	 and	 IFA	 tablets.	 The	 other	 approach	 was	
                                                               differences	 seen	 maximum	 in	 rural	 area	 followed	 by	
through	 Integrated	 Child	 Development	 Services	
                                                               urban	 area	 and	 relatively	 the	 least	 rise	 was	 seen	 in	
(ICDS)	 aanganwadi worker (AWW). At this stage
                                                               tribal	area	(Table	II).
of	the	programme,	adolescent	girls	were	still	not	part	
of the ICDS programme for anaemia control. AWW                 Effect on anaemia prevalence by age:	 There	 was	 a	
were	tested	for	their	haemoglobin	values	and	after	their	      consistent	decline	of	anaemia	prevalence	across	all	the	
own	 anaemia	 correction,	 were	 motivated	 to	 take	 up	      ages	with	rise	in	mean	and	median	haemoglobin	after	
voluntarily	reaching	to	out	of	schoolgirls	in	their	area	         Table I.	Prevalence	of	anaemia	before	and	after	intervention
for	IFA	supplementation	on	weekly	basis	and	provide	                                Anaemia	prevalence                  χ2	test
the	 monitoring	 data	 through	 ICDS	 supervisors	 to	 the	
                                                                         Before	intervention    After	intervention
Department	of	Health.	
                                                               Area	      N	     Prevalence      N	     Prevalence     P	value	
	 After	 17	 months	 of	 intervention	 of	 which	 12	          Rural	     977       74.5         986       50.4        	<	0.05	
months	 were	 regular	 intervention	 excluding	 vacation	      Tribal	    895       73.7         775       57.5        	<	0.05	
period,	impact	evaluation	was	done	for	schoolgirls	in	         Urban	     988       75.8        1005       52.5        	<	0.05	
                                                               Total	    2860       74.7        2766       53.2        	<	0.05	
November	2001.
	                    KoTECHA	et al:	ADoLESCENT	GIRLS’	ANAEMIA	CoNTRoL	PRoGRAMME	IN	GUJARAT	                                                  587


    Table II.	Mean	haemoglobin	before	and	after	intervention
                          Haemoglobin	g/l                    t	test
          	Before	Intervention      After	Intervention     P	value
Rural	      977    110.8±14.0	       986     118.1±11.4	   	<	0.05	
Tribal	     895    110.9±14.1	       775     116.5±13.1	   	<	0.05	
Urban	      988    110.6±14.4	      1005     116.9±13.5	   	<	0.05	
Total	     2860    110.8±14.2	      2766     117.2±12.7	   	<	0.05	

intervention	for	17	months	as	compared	to	the	levels	of	
before	intervention	(Table	III).	
     When the prevalence of anaemia declined and mean                            Fig. 1.	Haemoglobin	curve	before	and	after	intervention.
haemoglobin	increased,	it	was	expected	that	the	entire	
curve	for	haemoglobin	would	shift	to	the	right	(Fig.	1).	
So	not	only	anaemia	prevalence	decreased	but	the	level	
of	 severity	 also	 decreased.	 This	 has	 been	 documented	
in	two	different	ways:	one	by	categorizing	the	severity	
of	anaemia	and	the	other	by	seeing	severity	at	different	
cut-off	points.	Severe	anaemia	prevalence	reduced	from	
1.6	 per	 cent	 at	 baseline	 to	 0.5	 per	 cent	 in	 the	 impact	
study,	 suggesting	 a	 reduction	 of	 68	 per	 cent	 in	 severe	
anaemia	 from	 the	 baseline	 value.	 Similar	 reduction	
values	for	moderate	and	mild	anaemia	were	51	and	22	
per	cent.	The	proportion	of	normal	girls	(non	anaemic	                      Fig. 2.	 Prevalence	 of	 anaemia	 at	 different	 haemoglobin	 cut-off	
girls)	 increased	 from	 25.3	 to	 46.8	 per	 cent	 suggesting	             points	before	and	after	intervention.
a	rise	of	normal	girls	by	85	per	cent	from	the	baseline	
anaemic	level	(Table	IV).	Fig.	2	shows	the	cumulative	                      of	 three	 girls	 in	 the	baseline	 study.	For	 impact	 study,	 it	
percentage	 of	 anaemia	 at	 different	 cut-off	 Hb	 levels	                was	restricted	to	one	out	of	three	girls	due	to	cost	factor.	
before	 and	 after	 intervention.	 Data	 suggested	 that	 the	              Serum	ferritin	was	estimated	for	1983	school	girls	before	
reduction	of	anaemia	was	about	28.8	per	cent	at	120	g/l	                    the	intervention	was	initiated.	In	the	impact	study,	serum	
cut-off	point	while	at	100	g/l	cut-off	point	the	reduction	                 ferritin	 was	 estimated	 for	 804	 girls	 of	 whom	 665	 were	
is	52.7	per	cent	as	compared	to	the	baseline	value.	Thus	                   those	who	had	earlier	participated	in	the	baseline	study.
the	intervention	has	not	only	led	to	decrease	in	anaemia	
                                                                            	 Table	 V	 shows	 the	 proportion	 of	 girls	 having	
prevalence	but	the	level	of	severity	was	also	decreased.	
                                                                            serum	 ferritin	 less	 than	 12	 ng/ml,	 a	 cut-off	 used	 by	
Serum	ferritin	status:	Serum	ferritin	is	a	sensitive	indicator	             WHO UNICEF, UNU8	to	label	poor	iron	storage.	There	
of iron deficiency and indicative of iron stores, hence                     was	 an	 improvement	 of	 iron	 store	 after	 intervention:	
serum	 ferritin	 estimation	 was	 also	 included	 in	 the	 data	            proportion	with	low	serum	ferritin	declined	from	49.7	
collection.	It	was	envisaged	to	do	serum	ferritin	for	2	out	                to	 39.4	 per	 cent	 and	 was	 consistent	 in	 all	 the	 areas.	

                                    Table III.	Prevalence	of	anaemia	by	age	before	and	after	intervention
Age	in		                                    Anaemia	prevalence	(%)							                               Before		                 After	
completed	            N                 Before	                N                  After		        intervention	median		    intervention	median		
years	                              	intervention                             intervention              Hb	g/l                   Hb	g/l
12                     92                71.7                                                            115
13                    581                69.4                  173                43.9                   115                      121
14                    834                76.1                  705                49.9                   112                      120
15                    727                76.3                  806                52.6                   112                      119
16                    326                76.1                  609                57.0                   112                      118
17                    155                72.3                  340                56.8                   112                      118
18                     54                74.1                  109                59.6                   111                      117
19                     25                  80                   26                57.7                   111                      117
Total	               2797                74.7                 2762                53.2                   113                      119
Age	of	63	girls	in	the	baseline	and	4	girls	in	the	impact	study	not	available
588	                                                      INDIAN	J	MED	RES,	NoVEMBER	2009


                                 Table IV. Prevalence	of	anaemia	according	to	severity	before	and	after	intervention
									Area                                                  Anaemia	level	(Hb	in	g/l)	in	schoolgirls	in	percentage
                                        Severe                        Moderate                        Mild                       Normal
                                          Hb                              Hb                           Hb                          Hb
                                         <	70                         70	to	99.9                  100	to	119.9                    >=120
                                Baseline       Impact           Baseline       Impact        Baseline        Impact       Baseline      Impact
Tribal                            1.5               0.5           14.5            7.7          57.8           49.3          26.3          42.5
Rural                             1.8               0.4           13.8            5.0          58.9           45.0          25.5           9.6
Urban                             1.5               0.6           16.9            9.5          57.4           42.5          24.2          47.5
Total                             1.6               0.5           15.1            7.4          58.0           45.3          25.3          46.8
Reduction	as	%	from	                    68.75                            50.99                         21.9             84.98%	rise	in	normal	girls	
baseline                                                                                                                     after	programme


Table V.	 Area	 wise	 serum	 ferritin	 status	 before	 and	 after	                anaemic.	 Net	 result	 was	 20.8	 per	 cent	 reduction	 of	
intervention	                                                                     anaemic	prevalence	(Table	VII).
Area                               Serum	ferritin                                 Utilization	of	IEC	material	by	the	participants:	There	
            Per	cent	<12	ng/ml	                   Mean	±	SD                       were	two	types	of	IEC	material	given	to	the	schools	-	a	
           Before	        After              Before	       After                  brochure	for	every	girl	and	for	every	teacher,	and	two	
          (n=1983)      (n=804)             (n=1983)     (n=804)                  poster	sets	of	three	posters	each.	During	data	collection	
Tribal      46.3          37.1             18.6	±	19.4	 21.3	±	20.8		             every	participating	girl	was	given	a	structured	proforma	
Rural       50.5          40.1             16.8	±	17.2 22.2	±	24.8                to	obtain	information	about	the	IEC	material	received	
Urban       52.6          40.5             16.8	±	20.4 23.1	±	24.0
Total       49.7          39.4             17.4	±	18.8 22.2	±	23.6                by	her,	the	messages	read,	and	understood	by	her.
c2=24.75	P<0.001                                                                  	 Three	 fourth	 (72.4%)	 of	 2766	 girls	 received	 the	
                                                                                  brochure.	 In	 urban	 school,	 fewer	 girls	 (i.e.,	 50.5%)	 as	
                                                                                  compared	to	86	per	cent	girls	in	rural	schools	and	82.4	
The	 improvement	 was	 maximum	 in	 rural	 areas	 and	                            per	 cent	 girls	 in	 tribal	 schools.	A	 majority	 (87.2%)	 of	
minimum	in	tribal	areas	for	serum	ferritin;	consistent	                           the	girls	had	read	the	brochure,	either	all	by	themselves	
with	the	improvement	observed	in	anaemia	prevalence	                              (57.2%)	 or	 with	 their	 friends	 (55.1%)	 or	 with	 their	
(Table	III).                                                                      teachers	and	friends	(23.1%).	Two	third	(65.4%)	of	the	
	 Data	for	1016	girls	were	available	for	haemoglobin	                             girls	who	received	brochure	mentioned	that	at	least	one	
comparison,	and	665	girls	for	serum	ferritin	comparison	                          of	their	parents	had	read	the	brochure.	In	case	of	20.2	per	
for	 paired	 analysis.	 There	 was	 about	 20	 per	 cent	                         cent	girls	both	their	parents	had	read	the	brochure.	
reduction	in	anaemic	girls	after	intervention	and	serum	                          	 Regional	difference	was	noted	here:	77.2	per	cent	
ferritin	level	increased	(Table	VI).                                              of	 rural	 girls’	 parents,	 65.7	 per	 cent	 of	 urban	 girls’	
	 one	 third	 (34.9%)	 of	 anaemic	 girls	 became	 non	                           parents,	and	49.4	per	cent	of	tribal	girls’	parents	(at	least	
anaemic. One-fifth (19.8%) non anaemic girls, i.e.,	           	                  one	parent)	had	read	the	brochure.	The	reason	was	that	
5.1	 per	 cent	 of	 the	 total	 girls	 (52/1016)	 girls	 turned	                  17.9	per	cent	of	the	tribal	girls’	parents	were	illiterate	

                Table VI.	Comparison	between	the	total	data	of	the	baseline	and	impact	study	with	the	paired	sub	sample	of	the	study
                                                          Before	intervention                                   After	intervention
                                              Total                       Paired	girls                   Total                  Paired	girls		
                                             N=2860                         N=1016                      N=2766                    N=1016
Mean	Hb	(g/l)                              110.8	±	14.2                   111.0	±	13.7                117.2	±	12.7             117.3		±		12.9
Per	cent	anaemic                               74.7                           74.2                        53.2                      53.4
                                             N=1983                      Paired	N=665                   N=804                  Paired	N=665
Percentage	with	serum	ferritin		               49.7                           50.1                        39.4                      41.4
<12	ng/ml
Serum	ferritin	median	(ng/ml)                   12.1                            11.9                     16.5                        15.3
	                   KoTECHA	et al:	ADoLESCENT	GIRLS’	ANAEMIA	CoNTRoL	PRoGRAMME	IN	GUJARAT	                                               589


Table VII.	Anaemia	 status	 among	 1016	 girls	 studied	 before	 and	   ferritin data of over 800 girls confirmed the validity
after	intervention	to	show	migration	of	individual	girls	from	their	    and consistency of the finding. Thus, this strategy of
status	at	baseline	study	period	and	after	intervention                  once	 a	 week	 IFA	 supplementation	 when	 given	 under	
                         Before	        Before	      Total	             supervision	was	effective.	
                      intervention	  intervention	
                                                                        	 Based	on	the	success	of	the	schoolgirls	model	the	
                      anaemic	(%)	 non	anaemic	(%)    (%)
                                                                        programme	has	been	scaled	up	within	the	system	and	
After	intervention	 491	(65.1)	        52	(19.8)	  543	(53.4)	
anaemic	
                                                                        with	inbuilt	monitoring	is	working	successfully.	
After	intervention	 263	(34.9)	       210	(80.2)	  473	(46.6)	                                Acknowledgment
non	anaemic	
                       754	(74.2)     262	(25.8)	  1016	(100)	               Authors thank UNICEF Gujarat for financial assistance
													Total,	%     100            100          100               for the fieldwork, Department of Health and Family Welfare
                                                                        and	 Department	 of	 Education,	 Government	 of	 Gujarat,	 for	 their	
                                                                        permission	to	carry	out	studies	in	the	schools	and	Drs	R.Z.	Patel	
while	only	4.5	per	cent	of	urban	girls’	parents	and	3.8	                and	H.T.	Toprani	for	laboratory	support.	
per	cent	of	the	rural	girls’	parents	were	illiterate.	For	
50.4	per	cent	of	the	girls’	other	family	members	beside	                                           References
their	parents	had	also	read	the	brochure.                               1.	   ACC/SCN.	 (United	 Nations	 Administrative	 Committee	 on	
                                                                              Coordination/Sub-Committee	on	Nutrition)	Statements	on	iron	
     When asked to recall up to 3 messages from the                           deficiency control: June 1990, Dublin. In: Gillespie SR, Mason
brochure,	56.3	per	cent	did	not	respond.	Almost	all	(99%)	                    JB,	Kevany	J,	editors.	Controlling Iron Deficiency.	ACC/SCN,	
of	those	who	responded	had	at	least	one	correct	message	                      World Health Organization, Geneva, Switzerland, State-of-the-
recalled.	 More	 urban	 girls	 compared	 to	 rural	 girls	 and	               Art	Series,	Nutrition	Policy	Discussion	paper	9;	1991.
tribal	girls	were	able	to	recall	at	least	one	message.	Almost	          2.    Gillespie S. Major issues in the control of iron deficiency.
41	per	cent	of	those	responded	were	able	to	recall	all	the	                   Micronutrient	Initiative/UNICEF,	USA;	1998.
three	correct	messages	from	the	brochure.                               3.	   Kurtz KM, Johnson-Welch C. The nutrition and lives of
                                                                              adolescents	 in	 developing	 countries:	 Findings	 from	 the	
Scale	 up:	 Based	 on	 the	 successful	 model	 of	 school	                    nutrition of adolescent girls’ research programme. Washington,
girls	 intervention,	 in	 a	 phased	 manner	 Government	                      DC: International Center for Research on Women; 1994.
of	Gujarat	expanded	by	June	2005	the	programme	to	                      4.	   National Nutrition Policy.	 New	 Delhi:	 Health	 and	 Family	
all	25	districts	of	the	State	covering	every	public	and	                      Welfare Department, Government of India; 1993.
private	school	(7462	schools)	covering	over	10.7	lakh	                  5.	   Gujarat	 State	 Nutrition	 Policy.	 Gandhinagar:	 Health	 and	
girls.	Department	of	Education	regularly	monitored	the	                       Family Welfare Department, Government of Gujarat; 1998.
programme	and	reported	compliance	was	90	per	cent.                      6.	   Epi_Info,	Version	6.04_d.	A	word	processing,	Database,	and	
                                                                              Statistical	Programme	for	Public	Health	on	IBM-compatible	
	 The	 programme	 of	 IFA	 supplementation	 continues.	                       Microcomputers.	Centers	for	Disease	Control	and	Prevention.	
What is documented here was at the interval of 17 months                      Atlanta,	Georgia,	USA	Developed	by	Dean	AG,	Coulombier	
of	 intervention	 in	 a	 complete	 programme	 situation	 and	                 D,	Brendel	KA,	Smith	DC,	Burton	AG,	Dicker	RC,	Sullivan	
not	in	a	research	project	mode.	The	programme	envisages	                      K,	Fagan	RF,	Arner	TG,	2001.
continuing	 IFA	 supplementation	 to	 all	 adolescent	                  7.    World Health Organization. Nutritional anaemia: Report of
schoolgirls	all	throughout	their	study	period.	                               a WHO Scientific Group,	 Technical	 Report	 Series	 No	 405,	
                                                                              Geneva: World Health Organization; 1968.
	 once	a	week	supervised	IFA	supplementation	has	                       8.    WHO UNICEF, UNU. Iron deficiency anaemia: assessment,
proved	its	potential	of	not	only	improving	haemoglobin	                       prevention and control. A guide for programme managers.	
but	 also	 improvement	 of	 iron	 stores.	 The	 serum	                        Geneva: World Health Organization; 2001. WHO/NHD/01.3.



Reprint requests:	Dr	P.V.	Kotecha,	Technical	Advisor,	USAID	Micronutrient	&	Child	Blindness	Project,	2	C-2	Parkwood	Apt
	                 Raotula	Ram	Marg,	New	Delhi	110	022,	India
	                 e-mail:	pvkotecha@yahoo.co.uk; pkotecha@aed.org

				
DOCUMENT INFO