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 Table of Contents  
Year : 2017  |  Volume : 61  |  Issue : 1  |  Page : 37-42  

Directly observed iron supplementation for control of iron deficiency anemia

1 Assistant Professor, Public Health and Epidemiology, IIHMR University, Jaipur; Senior Resident, Centre for Community Medicine, All Institute of Medical Sciences, New Delhi, India
2 Junior Resident, Centre for Community Medicine, All Institute of Medical Sciences, New Delhi, India
3 Senior Program Officer, ICCIDD New Delhi and Assistant Professor, AIIMS, Rishikesh, ICCIDD, New Delhi, India
4 Assistant Professor, Centre for Community Medicine, All Institute of Medical Sciences, New Delhi, India
5 Professor, Centre for Community Medicine, All Institute of Medical Sciences, New Delhi, India
6 Professor and Head, Centre for Community Medicine, All Institute of Medical Sciences, New Delhi, India

Date of Web Publication16-Feb-2017

Correspondence Address:
Kapil Yadav
Room No. 25,Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi - 110 029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-557X.200250

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Anemia is major public health problem affecting 1.6 billion people worldwide. The poor compliance of iron supplementation remains main contributor for high prevalence of anemia. The current paper reviewed the effectiveness of direct observation of oral iron supplementation on anemia. A systematic search was performed through electronic databases and local libraries. Search strategies used subject headings and key words “directly observed” and “iron supplementation.” Searches were sought through April 2014. A total of 14 articles were included in the study. Findings were presented in three categories. First, all of those reported an improvement in compliance of iron supplementation. Second, reduction in the prevalence of anemia was reported by all and third, all except one reported increased blood hemoglobin level. Directly observed an iron supplementation is an effective approach for prevention and management of anemia in vulnerable groups. However, larger trials are needed before concluding that scaling up directly observed iron supplementation through community health volunteers would be beneficial.

Keywords: Anemia, compliance, directly observed iron supplementation, hemoglobin, prevalence

How to cite this article:
Bairwa M, Ahamed F, Sinha S, Yadav K, Kant S, Pandav CS. Directly observed iron supplementation for control of iron deficiency anemia. Indian J Public Health 2017;61:37-42

How to cite this URL:
Bairwa M, Ahamed F, Sinha S, Yadav K, Kant S, Pandav CS. Directly observed iron supplementation for control of iron deficiency anemia. Indian J Public Health [serial online] 2017 [cited 2022 Oct 6];61:37-42. Available from:

   Introduction Top

Anemia is major public health problem affecting 1.6 billion people in both developing and developed countries with serious consequences like increased risk of maternal and childhood mortality.[1] According to the World Health Organization, iron deficiency anemia (IDA) resulted in 273,000 deaths in 2004, with 97% of the deaths occurring in low- and middle-income countries.[2] Nutritional iron deficiency is highest in population segments that are at peak rates of growth and thus have a higher requirement of iron, namely, infants, young children, and pregnant women.[3] According to Global Database on Anemia, the prevalence of anemia was greatest among preschool children (47.4%) and pregnant women (41.8%).[1] As per National Family Health Survey-3 2005–2006, about 58% of pregnant women and 78.9% children aged 6–35 months were anemic in India.[4] Iron supplementation is a primary strategy to combat IDA in India. However, the success of iron supplementation depends largely on the effectiveness of the delivery system and compliance of the target recipients. Nationwide surveys indicate that only 31% pregnant women in India took iron supplements for >90 days.[5] The poor compliance of iron supplement consumption amongst pregnant and lactating women and children is one of the main reasons for continued high prevalence of anemia.[6]

Direct observation of iron supplementation is considered a novel approach for improving compliance. The current paper reviews the available scientific literature to study the effectiveness of direct observation of oral iron supplementation on IDA among the vulnerable age groups.

   Materials And Methods Top

Data sources and search strategy

A systematic search was performed by two authors independently using electronic as well as manual method. The electronic search was done with PubMed, Google Scholar, Cochrane Library, Medline (Ovid), IndMed, Embase, World Health Organization, and Biomed Central Databases. Search strategies used subject headings and key words (“directly observed” and “iron supplementation”). The bibliographies of relevant guidelines, reviews, and reports were also read to identify relevant primary reports. Manual search was done at B.B. Dikshit Library of All India Institute of Medical Sciences, New Delhi, and National Medical Library, New Delhi.

For unpublished studies and gray literature, dissertation abstracts international, Information and Library Network Centre (INFLIBNET), Scholarius and Eldis were searched. Online searches of major conference proceedings were conducted to identify unpublished literature. “ResearchGate,” a social networking site for scientists and researchers, was also used to procure information on unpublished literature. For studies requiring clarification, authors were contacted. The last date of literature search was June 30, 2013. There were no limitations placed on publication date, type or language.

The following three outcome indicators were selected to assess the impact of direct observation: (a) improvement in compliance; (b) improvement in mean hemoglobin level; and (c) decrease in the prevalence of anemia.

Study selection and data extraction

Strict criteria were followed to determine the inclusion of the available literature. The study had to meet the following criteria to get selected: Original research, community/population-based study; having provided information on study setting, sample size, and vehicle (direct observer) of iron and folic acid (IFA) distribution.

After initial screening of titles and abstracts, full-text publications of eligible studies were reviewed. Discrepancies about inclusion of studies and interpretation of data were resolved by discussion among the reviewers. Data from all studies meeting the inclusion criteria were abstracted into a tabular form. Abstraction of key variables with regard to the study identifiers, study settings, study design, and IFA tablets supplementation vehicle (direct observer), sample size and follow-up period, compliance to IFA supplementation, improvement in mean hemoglobin, and decrease in anemia prevalence was done.

Quality assessment of studies

The quality of studies was assessed by two authors independently using the adapted Mirza, and Jenkins checklist.[7] Adaptations were made based on the principles relevant for the aims of this particular review, with more importance given to the methodological rigor of the study.

The checklist included the following quality criteria: (i) Aims/objectives clearly mentioned; (ii) adequate sample size or justification; (iii) representative sample, with justification; (iv) clear inclusion and exclusion criteria; (v) important operational definitions such as “anemia” and “compliance” clearly defined; (vi) response rate and reason(s) for nonresponse provided; (vii) data collection method(s); and (viii) appropriateness of statistical analyses applied. One point was given for a “yes” answer and none for a “no” answer. We included studies that scored ≥4, out of the maximum possible score of 8 points. Differences were discussed with senior authors and consensus reached. Using this checklist, authors assessed 14 studies and were found suitable to be included in the article.

   Results Top

Literature review yielded a total of 13928 records, out of which 22 references were relevant to our study [Figure 1]. Of those, eight studies were excluded because of following reasons: Four studies did not have a comparison group,[8],[9],[10],[11] three studies were duplicate,[12],[13],[14] and one study was a meta-analysis.[15] Thus, a total of 14 studies that compared supervised versus unsupervised oral iron supplementation among children and women were included in the study.
Figure 1: Selection strategy.

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Of all the studies included in this review; eight were randomized control trials (RCTs), one cluster RCT, and five before and after intervention study [Table 1].[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29] All the studies, except one, were conducted in developing countries [18] during 1988–2013. All studies were, conducted in rural areas, either community based,[16],[17],[18],[20],[24],[26],[28],[29] school based [19],[21],[22],[25],[27] or mixed.[23] The sample size in the studies varied from 80 to 2825.[18],[25] Of the 14 studies reviewed, five were conducted among adolescent girls,[19],[21],[23],[25],[27] three among pregnant women,[17],[24],[26] two among under 6-year children,[18],[20] one each among 6–12-year-old children,[22] among young women and adolescent girls,[28] and among adult men and women.[16],[29]
Table 1: Summary of studies on directly observed iron supplementation

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The methods used for hemoglobin estimation were HemoCue method in three studies,[21],[22],[24] cyanmethemoglobin method in six studies [16],[23],[25],[27],[28],[29] and Sahli's method,[26] Coulter Counter [27] and microhematocrit method in one study [19] each. Two of the studies did not mention method of estimation of hemoglobin.[17],[18] Iron supplementation were supervised by school teachers and drug distributors in four studies each, volunteers in three studies, traditional birth attendants in two studies, and pediatric nurse in one study. Iron supplementation was supervised daily in eight studies, and weekly in four. In one study, it was supervised both daily and weekly, and in another study, twice weekly. The duration of iron supplementation ranged from 3 to 17 months. Lower duration was found in daily supplementation group and higher duration in weekly supplementation group. The composition of supplemented iron (tablets and syrup) ranged from 60 mg elemental iron only to 100 mg elemental iron plus 5 mg folic acid tablets. The dosage for syrup was 3–5 mg/kg body weight of elemental iron. The main findings in the review are as follows:

Improvement in compliance

Ten among fourteen studies reported compliance of iron supplementation [Table 1]. All studies showed improvement in compliance of iron supplementation. Large improvement in compliance to iron supplementation was observed in supervised groups (60%–100%) as compared to unsupervised groups (<5%–60% respectively).

Anemia prevalence reduction

All studies reported a reduction in the prevalence of anemia; which ranged from 17% to 55% in daily supervised groups and 0.5%–56.7% in weekly and biweekly supervised groups.

Improvement of hemoglobin level

All studies except Horjus et al.[21] reported an increase in blood hemoglobin level. In the study by Bharti et al.[28] the mean hemoglobin increased was as high as 2.6 g/dL. The increase in blood hemoglobin level was found to be greater in population with low hemoglobin level as compared to population with normal hemoglobin level.

   Discussion Top

The current review documents improvement in compliance, mean hemoglobin level, and reduction in anemia prevalence in school children, adolescents, and pregnant women as a result of directly observed supervision of iron supplementation and so can be a potentially effective way of management of IDA.

The directly observed therapy for tuberculosis, popularly known as directly observed therapy short course (DOTS) has proved to be effective in the reduction of disease burden and treatment of tuberculosis in many countries [30] and has been retained as an integral component of recently revised expanded framework of DOTS strategy.[31] DOTS had also been shown effective using school teachers in the management of asthma in adolescents.[32]

Low compliance has been the Achilles' heel of oral iron supplementation program in India. The National Nutritional Anemia Program was started in the year 1970.[33] The compliance to iron supplementation in pregnancy is dismal 30%. The compliance is even less for the under-five children. One of the essential requirements for directly observed iron supplementation is the availability of community-based functionary. India is unique in this aspect, with two sets of community-based workers, accredited social health activist, and Anganwadi worker (ICDS worker) being available in every village/habitation. Alternatively, school teachers, traditional birth attendants, community volunteers, drug distributors, and nurses can also be used to ensure directly observed iron supplementation. In other countries of the world, similar cadre of community workers such as Bangladesh Rural Advancement Committee's Shasthya Shebikas, millennium villages program's community health volunteers, Lady Health Workers in Pakistan, Brazil's Agentes de Saxude, Ethiopia's Health Extension Workers, can also be potential agents for direct observation of iron supplementation in community settings.[34]

Feasibility of directly observed iron therapy is already documented over a large geographic area by successful implementation of adolescent anemia control program at district level covering 1 million school girls and 0.26 million out-of-school girls in Gujarat, and nearly 0.15 million adolescent girls in the state of Uttar Pradesh, India.[23],[25]

The major limitation of the review was the availability of few studies assessing the effect of directly observed supplementation. In the available studies, the lack of blinding made the interpretation of the study findings difficult. Since blinding was not present in the studies, possible biases (observer bias) cannot be ruled out.

   Conclusion Top

This review concludes that directly observed an iron supplementation is an effective approach for prevention and management of anemia in school children, adolescents, and pregnant women. Community health volunteers can be potential community level agent of improvement in maternal and child health in India as well other developing countries. Thus, larger trials are required to generate evidence to support the community health volunteers among vulnerable age groups, preferably with blinding procedure.

Financial support and sponsorship


Conflicts of interest

The authors declare that they have no competing interests.

   References Top

De Benoist B. Worldwide Prevalence of Anemia 1993-2005. WHO Global Database on Anaemia. Geneva: World Health Organization; 2008.  Back to cited text no. 1
Mathers C, Steven G, Mascharenhas M. Global Health Risk: Mortality and Burden of Disease Attributable to Selected Major Risks. Geneva, Switzerland: World Health Organization; 2009.  Back to cited text no. 2
Beard JL. Effectiveness and strategies of iron supplementation during pregnancy. Am J Clin Nutr 2000;71 5 Suppl: 1288S-94S.  Back to cited text no. 3
IIPS. National Family Health Survey (NFHS-3), 2005-2006: Key Indicators for India from NFHS-3. Mumbai: IIPS; 2007.  Back to cited text no. 4
UNICEF. National Factsheet. Coverage Evaluation Survey, 2009. New Delhi: UNICEF India Country Office; 2010.  Back to cited text no. 5
Cembranel F, Corso AC, González-Chica DA. Coverage and adequacy of ferrous sulfate supplementation in the prevention of anemia among children treated at health centers of Florianopolis, Santa Catarina. Rev Paul Pediatr 2013;31:315-23.  Back to cited text no. 6
Upadhyay RP, Krishnan A, Rai SK, Chinnakali P, Odukoya O. Need to focus beyond the medical causes: A systematic review of the social factors affecting neonatal deaths. Paediatr Perinat Epidemiol 2014;28:127-37.  Back to cited text no. 7
Tee ES, Kandiah M, Awin N, Chong SM, Satgunasingam N, Kamarudin L, et al. School-administered weekly iron-folate supplements improve hemoglobin and ferritin concentrations in Malaysian adolescent girls. Am J Clin Nutr 1999;69:1249-56.  Back to cited text no. 8
Hall A, Roschnik N, Ouattara F, Touré I, Maiga F, Sacko M, et al. A randomised trial in Mali of the effectiveness of weekly iron supplements given by teachers on the haemoglobin concentrations of schoolchildren. Public Health Nutr 2002;5:413-8.  Back to cited text no. 9
Roschnik N, Parawan A, Baylon MA, Chua T, Hall A. Weekly iron supplements given by teachers sustain the haemoglobin concentration of schoolchildren in the Philippines. Trop Med Int Health 2004;9:904-9.  Back to cited text no. 10
Roberfroid D, Huybregts L, Lanou H, Henry MC, Meda N, Menten J, et al. Effects of maternal multiple micronutrient supplementation on fetal growth: A double-blind randomized controlled trial in rural Burkina Faso. Am J Clin Nutr 2008;88:1330-40.  Back to cited text no. 11
Bharti S. Feasibility of “directly observed home-based twice-daily iron therapy” (DOHBIT) for management of anemia in rural patients: A pilot study. Indian J Med Sci 2004;58:431-8.  Back to cited text no. 12
[PUBMED]  Medknow Journal  
Bilimale A. Influence of Directly Observed Iron Therapy on Adherence to Iron Tablets Consumption By Pregnant Women in a Rural Field Practice Area – A Controlled Trial. MD (Dissertation), KLE University Belgaum, Karnataka; 2009.  Back to cited text no. 13
Roley J. School-based Iron Plus Folic Acid Supplementation for Adolescent Girls, Manica Province, Mozambique. Project Summary and Endline Evaluation April 2003. Maputo (Moçambique): Helen Keller International; 2003.  Back to cited text no. 14
Beaton HG, McCabe PG. Efficiency of Intermittent Iron Supplementation in the Control of Iron Deficiency Anemia in Developing Countries. An Analysis of Experience: Final Report to the Micronutrient Initiative. Ontario: The Micronutrient Initiative; 1999.  Back to cited text no. 15
Charoenlarp P, Dhanamitta S, Kaewvichit R, Silprasert A, Suwanaradd C, Na-Nakorn S, et al. A WHO collaborative study on iron supplementation in Burma and in Thailand. Am J Clin Nutr 1988;47:280-97.  Back to cited text no. 16
Robinson SJ. Working with Traditional Birth Attendants to Improve Iron Tablet Utilization by Pregnant women. Arlington (Virginia): John Snow, Inc.;1998.  Back to cited text no. 17
Kruske SG, Ruben AR, Brewster DR. An iron treatment trial in an aboriginal community: Improving non-adherence. J Paediatr Child Health 1999;35:153-8.  Back to cited text no. 18
Shah BK, Gupta P. Weekly vs daily iron and folic acid supplementation in adolescent Nepalese girls. Arch Pediatr Adolesc Med 2002;156:131-5.  Back to cited text no. 19
Desai MR, Dhar R, Rosen DH, Kariuki SK, Shi YP, Kager PA, et al. Daily iron supplementation is more efficacious than twice weekly iron supplementation for the treatment of childhood anemia in Western Kenya. J Nutr 2004;134:1167-74.  Back to cited text no. 20
Horjus P, Aguayo VM, Roley JA, Pene MC, Meershoek SP. School-based iron and folic acid supplementation for adolescent girls: Findings from Manica Province, Mozambique. Food Nutr Bull 2005;26:281-6.  Back to cited text no. 21
Risonar MG, Tengco LW, Rayco-Solon P, Solon FS. The effect of a school-based weekly iron supplementation delivery system among anemic schoolchildren in the Philippines. Eur J Clin Nutr 2008;62:991-6.  Back to cited text no. 22
Vir SC, Singh N, Nigam AK, Jain R. Weekly iron and folic acid supplementation with counseling reduces anemia in adolescent girls: A large-scale effectiveness study in Uttar Pradesh, India. Food Nutr Bull 2008;29:186-94.  Back to cited text no. 23
Risonar MG, Rayco-Solon P, Tengco LW, Sarol JN Jr., Paulino LS, Solon FS. Effectiveness of a redesigned iron supplementation delivery system for pregnant women in Negros Occidental, Philippines. Public Health Nutr 2009;12:932-40.  Back to cited text no. 24
Kotecha PV, Nirupam S, Karkar PD. Adolescent girls' anaemia control programme, Gujarat, India. Indian J Med Res 2009;130:584-9.  Back to cited text no. 25
[PUBMED]  Medknow Journal  
Billimale A, Anjum J, Sangolli HN, Mallapur M. Improving adherence to oral iron supplementation during pregnancy. Australas Med J 2010;3:281-90.  Back to cited text no. 26
Chakma T, Vinay Rao P, Meshram PK. Factors associated with high compliance/feasibility during iron and folic acid supplementation in a tribal area of Madhya Pradesh, India. Public Health Nutr 2013;16:377-80.  Back to cited text no. 27
Bharti S, Bharti B, Naseem S, Attri SV. A community-based cluster randomized controlled trial of “directly observed home-based daily iron therapy” in lowering prevalence of anemia in rural women and adolescent girls. Asia Pac J Public Health 2015;27:NP1333-44.  Back to cited text no. 28
Mahanta TG, Trackroo A, Mahanta BN. Effect of directly observed iron therapy (DOIT) in anaemia and productivity – A community based intervention study in Dibrugarh, Assam. Indian J Appl Res 2013;3:22-5.  Back to cited text no. 29
Marica C, Didilescu C, Galie N, Chiotan D, Zellweger JP, Sotgiu G, et al. Reversing the tuberculosis upwards trend: A success story in Romania. Eur Respir J 2009;33:168-70.  Back to cited text no. 30
WHO Global Tuberculosis Programme. An expanded DOTS framework for effective tuberculosis control: Stop TB communicable diseases. Geneva: World Health Organization; 2002.  Back to cited text no. 31
Halterman JS, Riekert K, Bayer A, Fagnano M, Tremblay P, Blaakman S, et al. A pilot study to enhance preventive asthma care among urban adolescents with asthma. J Asthma 2011;48:523-30.  Back to cited text no. 32
Ministry of Health and Family Welfare. National Nutritional Anemia Control Programme, Annual Report (1970-1971). New Delhi: Govt. of India; 1980.  Back to cited text no. 33
Liu A, Sullivan S, Khan M, Sachs S, Singh P. Community health workers in global health: Scale and scalability. Mt Sinai J Med 2011;78:419-35.  Back to cited text no. 34


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