Download - Adolescent Nutrition_Roche
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Weekly Iron Folic Acid Supplementation to reduce Adolescent Anemia: From Policy to
Programs
Marion Roche, Micronutrient Initiative CORE Group Spring 2015, Global Health Practitioners
Conference, Alexandria, April 14th
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WHA nutrition targets 2025
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Women today - 3.5 billion!
600 M 10-24 years living in LMIC countries UNFPA, 2014
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Women today - anaemia
Stevens, et al, 2013
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Anemia in Adolescent Girls & Women
• 21 countries assessed by UNICEF, > 1 in 3 girls are anaemic a • 4 of 8 African countries reviewed >40% anemia in 12-14 years of age • In India 55.8% of adolescents aged 15–19 years are reported to be
anaemic • Ages 15–19 have the greatest total energy requirement compared to
any age group (~2,420 kcal/day)b • Higher needs for micronutrients: Iron, vitamin D, calcium & Zinc • Low dietary availability of iron • Parasitic infections add to iron deficiency burden
(aUNICEF, 2012, bWoodruff and Duffield, 2000)
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Age of first pregnancy
UNICEF 2014
• Adolescent pregnancy: 17-20 M • 95% occur in low- and middle-income countries
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Lost Potential from Anemia in Adolescent Girls & Women
1. School performance
2. Loss productivity
3. Reproductive performance
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Intermittent Iron and Folic Acid Supplementation
http://apps.who.int/iris/bitstream/10665/44649/1/9789241502023_eng.pdf
WHO Recommendation Intermittent iron and folic acid supplementation is recommended as a public health intervention in menstruating women living in settings where anaemia is highly prevalent, to improve their haemoglobin concentrations and iron status and reduce the risk of anaemia • Complement with deworming
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Intermittent Iron and Folic Acid Supplementation
http://apps.who.int/iris/bitstream/10665/44649/1/9789241502023_eng.pdf
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Review of Existing Examples of Weekly IFA Supplementation
• Past supplementation programmes not implemented effectively in preventing and controlling iron deficiency & anaemia
• WHO global consultation on weekly iron and folic acid supplementation for preventing anemia in women of reproductive age (2007) recommended review of programs:
• ► critical elements of weekly iron and folic acid supplementation programmes were identified
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WHO Review in 2007: Ten successful pilot projects in 6 countries were identified
• Population size targeted varied from large to small:
– 4 in India (several million school age girls) – 2 in Vietnam (30,000 to 250,000 WRA in communities) – 1 in Cambodia (30,000 WRA in factories, communities &
schools) – 1 in the Philippines (30,000 WRA in communities and schools) – 1 in Lao PDR (1,500 schoolgirls and WRA in villages) – 1 in Egypt (6 million school girls and boys)
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Project approaches • Two distinct program approaches were used and are
recommended:
1) free WIFS supply for socio-economically disadvantaged groups 2) social marketing of WIFS to WRA who can purchase low cost IFA supplements
• Potential Impact:
– reduction of - 9% to - 57% in prevalence of anaemia, during 6 to 16 months of supplementation
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Opportunities
• Delivery platforms for IFA supplements: – schools – health sector – Workplace settings – women’s & community organizations – Peer to peer outreach Delivery channels for messages: -peers, teachers, radio, SMS and text messages, TV, local
markets/billboards, faith based leaders
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School Programs: Role of the Teacher
• Distribute IFA supplements • Monitor/ Record consumption of IFA supplementation • Encourage Consumption & Counsel on Strategies to avoid Side
effects • Nutrition education as part of school curriculum
Photos from WHO program Gujurat, India
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Community Level Outreach
• Outreach to adolescents with other community groups & women’s organizations
• Faith based and community leaders reaching those who are married as adolescents
One in three girls in developing countries are married before the age of 18 and a startling one in nine before the age of 15 (UNFPA, 2012)
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Workplace Setting: Engaging employers, supervisors and leaders • Distribution setting for IFA
supplements • Distribution channel for
messages to support adherence and provide awareness on anemia
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Health System: Frontline health workers
• Adolescents unlikely to seek treatment of anemia from health facility unprompted
• Delivery of IFA supplements and promotion by frontline health workers
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Peer to peer outreach
• School girls reaching out of school girls • Core groups of 15-20 school girls • Each school girl reach 1-3 out of school girls • Need support and engagement from parents
and community and husbands • Can provide IFA supplements and monitor
consumption • Peers trained to provide counseling
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Product & Promotion Appeal for Adolescents
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Weekly iron-folic acid supplementation for adolescent girls in Chhattisgarh, India
School Girls • Teachers distributed IFA • Teachers encouraged and
monitored consumption of IFA • Training of Teachers • Behaviour Change
Interventions
Out of School Girls • Delivery of IFA supplements
through Integrated Child Development Centres
• Messages Delivered by Peers
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Challenges: 1. Irregular procurement and distribution mechanism and need to
streamline procurement and distribution systems
2. Reporting systems need to be improved. 3. Improve convergence between Education , Health facility and ICDS at
block level.
4. Importance of Influencing and Engaging teachers
5. Continued innovations needed to reach out of school girls
Lessons for Scale Up Phase
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DEMONSTRATION PHASE (2010-2012)
SCALE-UP PHASE (2013 ONWARDS)
Number of Schools
424 23,000
School-going adolescents reached
66,709 3.56 million
Number of Community based Centres
6,832 43,763
Out-of-School adolescents reached
29,008 250,000
Project Reach
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57.1
47.9
72.3
34.2 30.1
24.8
0
10
20
30
40
50
60
70
80
Received IFA (80 % of recommended dose)
Consumed IFA (80 % of recommended dose)
Consumed at least 1 dose of Deworming
School going Out of school
Demonstration Phase: Proportion of Adolescent Girls consuming IFA and Deworming at endline
p<0.01 for differences in the three indicators between the groups
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65
75
25 20
0
10
20
30
40
50
60
70
80
School Going Out of School
Full dose of Weekly IFA One Albendazole Tablet
Scale-Up Phase: Proportion of Adolescents consuming IFA and Albendazole during Scale-Up
Data from State – Jan to Mar 2014
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85.2 88.9
71
82
0
20
40
60
80
100
Anemia among school going AGs
Anemia among out of school AGs
Baseline %Endline %
Anemia - Baseline vs Endline
Perc
enta
ge
Unpublished data; Baseline N = 961 (SG: 482, OS: 479); Endline N = 1869 (SG: 455, OS: 1414 p<0.01 for differences in anaemia between baseline and endline in both groups
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Take Home Messages for Implementing Effective Weekly IFA for Adolescents
1. Advocate for this intervention and ensure supplements available as effective anemia reduction strategy for adolescents themselves and as young WRA (future moms)
2. Engage policy makers in programs and raise awareness on anemia in adolescents
3. Distinct Delivery Channels – Schools, Community, Workplace
4. Develop Appealing and Packaging 5. Provide free supplements for low SES adolescents
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Take Home Messages for Implementing Effective Weekly IFA for Adolescents
6. Assess market demand for purchasing supplements by
market segments 7. Create partnerships for supply management (health,
schools, workplaces, private pharmacies) 8. Monitor and encourage consumption -Peer support by
school girls for out of school girls 9. Improve communication and appealing messaging is
critical 10.Select fixed day for consumption
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THANK YOU
Dr Tommaso Cavalli-Sforza- Photo credits and WHO program examples Manpreet Chadha and Pravin Khobragade of MI India for sharing Chhattisgarh Dr. Luz Maria de Regil, Director MI Research and Evaluation Unit