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Year : 2022  |  Volume : 66  |  Issue : 3  |  Page : 358-361  

Anemia control program in india needs to be more comprehensive

1 Research Scholar, MUHS and Associate Professor, Department of Community Medicine, Symbiosis Medical College for Women, SIU, Pune, Maharashtra, India
2 Dean, Dr. D. Y. Patil Medical College and Research Centre, Pune, Maharashtra, India
3 Consultant and Ex.Professor, Dr. D. Y. Patil Medical College and Research Centre, Pune, Maharashtra, India

Date of Submission12-Oct-2021
Date of Decision03-Aug-2022
Date of Acceptance03-Aug-2022
Date of Web Publication22-Sep-2022

Correspondence Address:
Priya Y Kulkarni
Symbiosis Medical College for Women, Lavale, Pune, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijph.ijph_1918_21

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Iron-deficiency anemia has continued to remain high in India. It is possibly due to relying on only iron–folic acid (IFA) supplementation through Anemia Control Program (ACP) that is National Iron Plus Initiative (NIPI). Based on the WHO's recommendations, we studied different interventions that can help to increase the effectiveness of NIPI such as Vitamin C supplementation with IFA, low-dose iron (LDI) with intensified health education (IHE), LDI with Vitamin C, and iron-rich food items to increase hemoglobin (Hb%) among adolescent girls through public–private partnership named Rashtriya Kishor Swasthya Karyakram. Increments in Hb after 12 weeks of interventions were compared with that of control groups one with NIPI and the other without any intervention. Highest increment in Hb% was observed in IFA under NIPI plus Vitamin C group, followed by LDI plus IHE group which was comparable to Hb increment in only the NIPI group. It emphasizes the need of making existing NIPI more stringent and comprehensive by integrating effective measures based on up-to-date scientific knowledge.

Keywords: Adolescent girls, Anemia Control Program, iron-deficiency anemia, National Iron Plus Initiative

How to cite this article:
Kulkarni PY, Bhawalkar JS, Jadhav AA. Anemia control program in india needs to be more comprehensive. Indian J Public Health 2022;66:358-61

How to cite this URL:
Kulkarni PY, Bhawalkar JS, Jadhav AA. Anemia control program in india needs to be more comprehensive. Indian J Public Health [serial online] 2022 [cited 2022 Sep 30];66:358-61. Available from:

Anemia is a major public health problem of global concern as still a third of the world's population is anemic. Majority of anemia exists in the form of iron-deficiency anemia (IDA). Most of IDA sufferers belong to low-and middle-income countries,[1] especially where nutritional deficiencies, worm infestations, and infection/inflammation are more prevalent. South East Asia Region (SEAR) including India contributes the highest IDA burden. IDA affects preschool children and women of reproductive age worst. It fuels maternal morbidity, and mortality and is the world's second leading cause of disability causing nearly 4% of Gross Domestic Product (GDP) loss.[1]

As per WHO, India belongs to high anemia prevalent areas where ≥40% of menstruating adult women and adolescent girls (AGs) are anemic. India ranked 170 out of 180 countries for anemia among women during Global Nutrition Survey, 2016.[2]

Oral iron supplementation is a preventive strategy for anemia control at the population level.

Based on it, India's National Nutritional Anemia Control Program (NNACP) was initiated in 1970. Its interventions were to provide iron and folic acid (IFA) tablets to all vulnerable groups by paramedical staff.[3] Several policy revisions in NNACP arrived at today's National Iron Plus Initiative (NIPI) with the decentralization of IFA supplies to states as per requirements.

In spite of several revisions and modifications in NNAPP, in fact, the prevalence of anemia among pregnant women (PW) is increased from 49.7% to 52.2% and among women of reproductive age group from 53.1% to 57.0% during NFHS second to fifth rounds.[4] Several studies report it is still higher as 84.9% among PW and 90.1% among AGs.[4] It makes India far away from the attainment of Sustainable Development Goals by 2030.[2],[5] Combating IDA among these groups is of utmost importance as it is a hidden cause of major maternal morbidities and mortalities as well as affect on their offspring.

There are many contexts specific issues behind the scene of IDA in India like scarce resources at family level, lack of knowledge and awareness, personal likes and dislikes, faulty cooking and food consumption practices, worm infestations, noncompliance to IFA supplementation with other lacunae under NIPI, and many more. NIPI needs to be strengthened to address these issues to combat IDA.

WHO recommends interventional research on iron supplementation by dose, frequency, duration, and additional nutrient/micronutrient, especially nonPW and AGs to help in decision-making regarding further policies to be incorporated in existing ACPs.[5]

We carried out an interventional follow-up study with the main objective to assess the effectiveness of Vitamin C supplementation with IFA under NIPI to improve hemoglobin (Hb) as it increases the bioavailability of available iron. Three secondary schools were randomly selected from one of the Municipal Corporations in Western Maharashtra. AGs studying in 7th–9th standard in these schools were recruited after seeking Ethical Committee Approval, due permissions, consent, and assent.

The primary outcome variable was the mean difference between Hb2 (post-intervention) and Hb1 (pre-intervention). For main intervention group (IG) of NIPI + Vitamin C, sample size for mean difference was calculated using formula: (σ12 + σ22)(Z1 − α/2 + Z1 − β)22 where, σ1 = 0.95, σ2 = 0.91, Z 1-α/2 = 96. For CI 95%, Z1-β =1.28 at power = β =90%, Δ = mean difference (Hb2-Hb1) =1.05 g%. Calculated sample size was 17, but we recruited one whole division for one intervention as students and teachers emphasized. Similarly, for all other IGs, actual Hb2 estimations exceeded the required sample size.

Hb1 and Hb2 estimations were carried out by Sahali's method by trained technicians. After Hb1 assessment, deworming was done by tablet Albendazole 400 mg under supervision. It was followed by 12 weeks (wk) of interventions, as shown in [Table 1].
Table 1: Intervention groups and interventions

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Hb2 assessment was done by the same technicians and procedures but they were blinded about control and different IGs. Anemia was graded as per the WHO Scale as severe, moderate, mild, and normal as Hb in g%: <7, 7–9.9, 10–11.9, and >12 g/dL, respectively.[6]

Mean Hb1 was 9.9 (+1.272, 6.5–12.0) g%, with quite a higher proportion,[7] (96.5%) of anemic AGs with moderate anemia in majority (65%). Underlying reasons in the study population can be from their lower socioeconomic background to lack of awareness of hazards of IDA, knowledge of its preventive measures, the importance of IFA consumption, etc., One percentage were severely anemic and referred to a higher center for further management.

After 12 weeks of interventions, mean Hb increased from 9.9 g% to 11.81 g%. Proportion of anemic AGs was significantly decreased from 96.5% to 56.6% (P < 0.001), the majority of them had mild anemia after the intervention. Moderate anemia decreased from 65% to 0.6%.

Paired t-test showed a significant rise in Hb% in all IGs (P < 0.001) except IG6, the control group (P = 0.3536) which did not receive IFA for the last 2 years and showed a slight decrease in Hb.

As shown in [Figure 1], IG2 which received IFA as per NIPI with Vitamin C 500 mg tablets showed the highest rise of 3.1 g% in Hb. IG1 and IG2 were significantly more to report side effects such as abdominal discomfort, nausea than IG3, and IG4 which received low-dose iron (LDI) (P < 0.001). However, there was no difference pertaining to side effects between IG1 and IG2 (P = 0.941) that is IFA with and without Vitamin C.
Figure 1: Difference between pre- and postintervention Hb%

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IG3 (LDI plus Vitamin C) showed lowest rise of 1.62 g% in Hb with lowest compliance as its weekly frequency was more. School teachers of IG3 could not assure compliance as they handed over both weekly doses to AGs in scarcity of time. IG4 (LDI plus intensified health education [IHE]) ranked second in increasing Hb (2.6 g%), while IG1 (NIPI without Vitamin C) and IG5 (IHE plus Rashtriya Kishor Swasthya Karyakram [RKSK]) group showed a comparable increase in Hb after 12 weeks of interventions.

One-way ANOVA for post hoc multiple comparisons using Tukey's HSD test at a 0.05 level of significance showed: Rise in Hb was significantly (P < 0.001): (1) higher in all IGs as compared to the control group, (2) higher in NIPI + Vitamin C group, (3) lower than others, except control group, in LDI + Vitamin C group (1.62%), and (4) lower in NIPI than NIPI + Vitamin C and LDI + IHE groups.

Thus, the addition of Vitamin C to weekly IFA under NIPI was the most effective intervention in a shorter period of 12 weeks than only IFA supplementation. Similar findings are being pointed out by the number of studies since decades ago, still awaiting required modification in the existing program.[8],[9],[10]

As per the NIPI strategy, AGs are supposed to get once weekly IFA for 52 weeks a year.[2] We identified lacunae in logistic supplies in existing NIPI that lead to nonconsumption of IFA supplementation by AGs for a long duration of 2 years. That was the reason behind the slight decrease in Hb in the control group, IG6. It shows the need of optimal use of resources and assurance of adequate, timely logistic supplies.

Study emphasized ongoing NIPI can improve and maintain Hb at a satisfactory level provided IFA supply and consumption is regular and adequate as for IG1. Weekly iron supplementation is the most appropriate, suitable, and feasible strategy which is followed under NIPI, as intestinal mucosal removal time is 5–6 days. Beneficiaries with side effects to higher doses can be given LDI which increases the frequency of IFA consumption per week and will need to ensure compliance. It can be combined with IHE.

IHE helps to improve the perception about need and mandate of IFA consumption. IHE regarding nutrition and importance of iron supplements primed well to AGs in IG4. It received LDI + IHE and ranked second to increase Hb, although it had more frequency per week and less supervision by school teachers. Barriers to compliance to IFA can be addressed through IHE and behavior change communication.[6] In the absence of IHE, LDI + Vitamin C (IG3) was the least effective regimen with lower compliance.

It shows the importance of strengthening and intensifying health and nutrition educational activities under NIPI by trained health personnel to facilitate desirable behavior change to overcome IDA. Existing human resources implementing NIPI were overburdened to pay attention to NIPI and to health and nutrition educational activities.

IHE can be integrated in school activities with delegation of its responsibility to medical and nursing colleges in the vicinity for more sustainable outcomes. Supplying iron-rich food items through public–private partnership (PPP) such as RKSK would also add synergy to the already existing program.

Thus, iron supplementation should only be one of the components of comprehensive, integrated ACP. Existing ACP, NIPI needs to be strengthened urgently by integrating well-researched measures which are proven to be effective such as Vitamin C supplementation with IFA, LDI to AGs getting side effects to higher dose, IHE by trained health personnel, and distributing iron-rich food items through schools through PPPs. Multiple micronutrient supplements and iron fortification of some food items can also be considered.[10]

There is hardly any study reporting effectiveness of multiple interventions for rise in Hb among AGs as in the present study, e.g., NIPI + Vitamin C, LDI + Vitamin C, LDI + IHE, and IHE + RKSK as well as only NIPI. Novelty of the study is that it brings out the number of ways in which the effectiveness of existing NIPI can be enhanced. For example: If IFA supplementation is not at all acceptable at the beneficiary level, other measures can be made available through different stakeholders like in the present study, we included for IHE + RKSK.

NIPI will hardly succeed by relying on already fatigued human resources. Instead of relying on school teachers, NIPI needs a

dedicated task force to work for the program which can take care of screening and referral for other diseases also through schools. There is a need of an hour to incorporate some activities in existing NIPI like periodic screening of anemia; record keeping of Hb%, IFA consumption and reasons behind non-consumption by use of up-to-date technology; treatment of mild to moderate anemia, timely referral of severe anemics to higher center and their follow up to be taken care by such task force.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Chaparro CM, Suchdev PS. Anemia epidemiology, pathophysiology, and etiology in low- and middle-income countries. Ann N Y Acad Sci 2019;1450:15-31.  Back to cited text no. 1
International Food Policy Research Institute. Global Nutrition Report 2016: From Promise to Impact: Ending Malnutrition by 2030. Washington, DC: International Food Policy Research Institute; 2016. p. 123-4.  Back to cited text no. 2
Ministry of Health and Family Welfare. Policy on Control of Nutritional Anemia. New Delhi: MoHFW, Government of India; 1991.  Back to cited text no. 3
Toteja GS, Singh P, Dhillon BS, Saxena BN, Ahmed FU, Singh RP, et al. Prevalence of anemia among pregnant women and adolescent girls in 16 districts of India. Food Nutr Bull 2006;27:311-5.  Back to cited text no. 4
Ministry of Health and Family Welfare. Guidelines for Control of Iron Deficiency Anemia. National Iron Plus Initiative. New Delhi: MoHFW, Government of India; 2013.  Back to cited text no. 5
Ministry of Health and Family Welfare. Operational Framework: Weekly Iron and Folic Acid Supplementation Programme for Adolescents. New Delhi: MoHFW, Government of India; 2012. Available from: [Last accessed on 2022 Jun 15].  Back to cited text no. 6
Bodat S, Bodat R, Vinjamuri PV, Rathore AR. Prevalence of anemia among school going adolescent girls in rural area of Pune, Maharashtra, India. Int J Reprod Contracept Obstet Gynecol 2020;9:1596-602.  Back to cited text no. 7
Sharma A, Prasad K, Rao KV. Identification of an appropriate strategy to control anemia in adolescent girls of poor communities. Indian Pediatr 2000;37:261-7.  Back to cited text no. 8
Ahmed F, Khan MR, Akhtaruzzaman M, Karim R, Marks GC, Banu CP, et al. Efficacy of twice-weekly multiple micronutrient supplementation for improving the hemoglobin and micronutrient status of anemic adolescent schoolgirls in Bangladesh. Am J Clin Nutr 2005;82:829-35.  Back to cited text no. 9
Ahmed F, Khan MR, Akhtaruzzaman M, Karim R, Williams G, Torlesse H, et al. Long-term intermittent multiple micronutrient supplementation enhances hemoglobin and micronutrient status more than iron+folic acid supplementation in Bangladeshi rural adolescent girls with nutritional anemia. J Nutr 2010;140:1879-86.  Back to cited text no. 10


  [Figure 1]

  [Table 1]


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