|Year : 2021 | Volume
| Issue : 1 | Page : 44-50
Prevalence of anaemia and compliance to weekly iron-folic acid supplementation programme amongst adolescents in selected schools of urban Puducherry, India
Sneha Anil Wangaskar, Swaroop Kumar Sahu, Marie Gilbert Majella, Sathish Rajaa
Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
|Date of Submission||13-Oct-2020|
|Date of Decision||18-Jan-2021|
|Date of Acceptance||21-Jan-2021|
|Date of Web Publication||25-Feb-2021|
Dr. Swaroop Kumar Sahu
Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry
Source of Support: None, Conflict of Interest: None
Context: Adolescents constitutes 21% of total Indian population. Iron deficiency anaemia has remained as a major nutritional problem amongst adolescents. To overcome this problem, Government of India started weekly iron-folic acid supplementation (WIFS) in 2012. Aims: Amongst adolescents in selected schools of urban Puducherry, to determine the prevalence of anaemia, proportion of those compliant to WIFS and to assess the sociodemographic and clinical factors associated with anaemia and compliance to WIFS. Subjects and Methods: A cross-sectional analytical study was conducted amongst school-going adolescents (10–18 years) in selected schools of Urban Puducherry. Data were collected using semi-structured, self-administered and pretested questionnaire. Haemoglobin estimation was done using a digital haemoglobinometer. Details regarding intake of iron and albendazole tablets were recorded. The anaemia status was evaluated as per World Health Organization guidelines. Results: The prevalence of anaemia was found to be 62.7% (95% confidence interval [CI]: 58.2–67.0). Proportion having mild, moderate and severe anaemia were 27.3%, 32.5% and 2.8% respectively. The proportion of adolescents compliant to WIFS was 67.7%. Late adolescents were significantly more associated with anaemia (adjusted prevalence ratio [aPR]: 1.7 95% CI: 1.0–3.0) as compared to early adolescents. Males were more compliant to iron-folic acid (IFA) tablets (aPR 1.4 95% CI: 1.0–1.8). Conclusions: More than half of adolescents were anaemic. This study emphasises on the fact that stricter supervision by teachers will result in better compliance to WIFS program. Strategies to improve WIFS compliance, imparting knowledge regarding IFA intake and involvement of school teachers will help to tackle anaemia amongst adolescents.
Keywords: Adolescent, anaemia, prevalence, schools, weekly iron-folic acid supplementation
|How to cite this article:|
Wangaskar SA, Sahu SK, Majella MG, Rajaa S. Prevalence of anaemia and compliance to weekly iron-folic acid supplementation programme amongst adolescents in selected schools of urban Puducherry, India. Niger Postgrad Med J 2021;28:44-50
|How to cite this URL:|
Wangaskar SA, Sahu SK, Majella MG, Rajaa S. Prevalence of anaemia and compliance to weekly iron-folic acid supplementation programme amongst adolescents in selected schools of urban Puducherry, India. Niger Postgrad Med J [serial online] 2021 [cited 2021 Jul 30];28:44-50. Available from: https://www.npmj.org/text.asp?2021/28/1/44/310163
| Introduction|| |
According to the World Health Organization (WHO), the adolescent period is the life spanning between 10 and 19 years. Adolescence is a period of transition between childhood to adulthood which occupies a very pivotal role in human life. In India, adolescents constitute 21% of the total population. In a developing country like India, adolescents suffer from various nutritional as well as non-nutritional problems. Anaemia is a common nutritional problem and a major public health issue amongst adolescents in the developing countries.
Globally, anaemia affects 24.8% of the population, predominantly non-pregnant women (30.2%)., According to the National Family Health Survey 4, the prevalence of anaemia amongst the 15–49 age group of men and non-pregnant women are15.9% and 53.2% respectively.
Major causes of anaemia amongst adolescents are lack of awareness regarding personal hygiene and diet, intestinal helminths and chronic infections which increases the demand for iron in the body. Anaemia attributes to the high maternal mortality ratio and high incidence of the low-birth weight babies. Previous studies have shown the adverse effects of anaemia on adolescents' cognitive function and mental health status. Anaemia also lowers adolescents learning capacity, academic achievements, school attendance and work performance., Optimally treating of anaemia in the adolescent age group helps to prevent its intergenerational impact, thus contributing to the reduction in maternal and infant morbidity.
To overcome the problem of anaemia, the Government of India (GOI) has launched the National Iron-Plus Initiative through the life cycle approach. In this programme, iron-folic acid (IFA) tablets and albendazole are provided to children from 6 months to 19 years of age, women in the reproductive age group, pregnant and lactating females. GOI (The Ministry of Health and Family Welfare) in 2012 has launched universalisation of the weekly iron-folic acid supplementation (WIFS) Programme. WIFS is an evidence-based programmatic response to the existing anaemia situation amongst adolescent girls and boys; through supervised weekly ingestion of IFA tablets and biannual albendazole for helminths control. The long-term goal of the WIFS program is to break the intergenerational cycle of anaemia, while at the short term, it targets to improve human capital nutritionally. The programme is targeting 108 million adolescent girls and boys, which includes both school-going adolescent girls and boys (6th–12th classes) and adolescent girls who are not attending school.,
The present school-based study aimed to assess the prevalence of anaemia amongst the adolescents and their compliance to the WIFS programme amongst all the adolescents studying in government schools, present in a selected urban primary health centre area of Puducherry. We also wanted to assess the sociodemographic and clinical factors associated with anaemia and compliance to WIFS program (IFA supplementation).
| Subjects and Methods|| |
This human study was done after obtaining approval from the institute Scientific and Ethics committees for observational studies (JIP/IEC/2019/296 on 26/07/2019) JIPMER, Puducherry. A Cross-Sectional analytical study was conducted in schools in September and October 2019.
Considering that the proportion of anaemia amongst the school going adolescent as 52.9%; assuming the same expected prevalence (p) with an allowing error of 5% (absolute precision = d) and assuming 95% confidence level (Cl); Z value at 95% confidence interval = 1.96, using this formula of sample size (n = Z2 1−α P [1 − P]/d2) the sample size required for the study was 383 (calculated using OpenEpi v. 3.03).
Each medical college in India has an urban and rural primary health centre attached to the medical college for training students in a primary health care setting. The study was conducted in the field practice area of one of the urban health centres attached to a government medical college which catered to a population of around 10,000. This area had four government schools giving education to 6th–12th standard students. In these four schools, around 550 adolescents were being imparted education. Since this was a school-based study and the sample size required was more than two-thirds of the total children enrolled (i.e., 383 out of 550), we wanted to include all the children to ensure the availability of services to them through this project. We thus adapted universal sampling, as we included all adolescents present on the day of the survey in all the schools. In the process, a total of 499 adolescents studying in all the schools present in the area were enrolled in the study.
Before conducting the study written permission was obtained from the Directorate of School Education Puducherry, the Head of the corresponding schools and parents. Verbal assent was obtained from children aged 10–12 years and consent was obtained from the students aged 13–18 years. Separate questionnaires were given to students and parents. The parent's questionnaire had questions related to personal details of parent's such as their monthly income, education and occupation; this was given to students get it filled by any one of their parents i.e., either their father or mother. In case the parents did not know reading/writing and were unable to fill the questionnaire, the information was collected from the school records with the assistance of the class teacher. Information from adolescent students was collected using a separate questionnaire in their school premises. Both the parent's and student's questionnaire were pre-tested, semi-structured and self-administered questionnaire. The student's questionnaire included questions related to their dietary habits, physical activity, hygiene-related practices and comorbidities. To assess the compliance to the WIFS program, questions such as frequency of distribution and the intake of IFA tablets were asked for the last 1 month using the questionnaire. For the albendazole compliance history of last intake of albendazole tablet was asked, which was given every 6 months.
Adolescents were also clinically examined for vitamin deficiencies. For Anthropometric measurements, standard procedures were followed. Haemoglobin (Hb) was tested for 458 school-going adolescents and classified according to WHO criteria. Hb estimation was done using a digital haemoglobinometer ('Mission® Hb'). The study participants were categorized as mild, moderate or severe anaemic based on the WHO criteria. According to the WHO criteria, for all age groups (10–18 years), Hb <8 g/dl was considered as severe anaemia and (8–10.9) g/dl as moderate anaemia. For both boys and girls aged 10–11 years, Hb level of (11–11.4) g/dl was considered as mild anaemia, for 12–14 years both boys and girls and girls of 15–18 years, Hb level of (11–11.9) g/dl was mild anaemia and for 15–18 year boys, Hb level of (11–12.9) g/dl was considered as mild anaemia. Intake of four IFA tablets in the last 1 month was considered as compliant to WIFS, similarly, albendazole intake of one tablet in the last 6 months was considered as compliant to albendazole. Data was entered in EpiData Manager Software (version 126.96.36.199, The EpiData Association, Odense Denmark) and analysis was done using SPSS (version 22, IBM Corp, Armonk, NY, USA) and OpenEpi (2008 Andrew G. Dean and Kevin M. Sullivan, Atlanta, GA, USA). Continuous variables were summarised as mean (standard deviation [SD]) or median (IQR) based on the distribution of the data. The categorical variables were measured as frequency and proportion. The prevalence of anaemia and the proportion of compliance to the WIFS programme was reported as proportions with 95% CI. Association between sociodemographic factors and clinical factors with anaemia and compliance to the WIFS program was assessed using the Chi-square test and prevalence ratio (PR) with 95% CI. Multivariable analysis (adjusted prevalence ratios; aPR) was done to adjust for potential confounders by taking variables with P < 0.20 into the model.
| Results|| |
For our study, we had enrolled 499 students and amongst them 458 were tested for anaemia. The students who could not be contacted within two visits were excluded from the study.
[Table 1] explains the sociodemographic variables of the study participants, a majority (59.9%) of the participants belonged to the age group of 15–18 years with the mean age (SD) of 14.7 (1.9) and most of them were females (71.1%). About half (51.1%) of the enrolled adolescents were in Class XI and XII. Most of the mothers of the adolescents were homemakers (47%) and most of their father (49%) worked as daily wage workers. More than three-fourth (81.9%) of the participant's belonged to lower socioeconomic status. Majority of the adolescents were taking nonvegetarian diet (95.6%) and tap water was for drinking (72.1%). More than half of the adolescents (58.9%) were not engaged in regular physical activity. About 454 (91%) adolescents washed their hands before having meal and 491 (98.4%) adolescents washed their hands after defecation. During the clinical examination, it was observed that 171 (34.3%) had palmar pallor.
|Table 1: Sociodemographic and clinical characteristics of adolescents in selected schools of urban Puducherry (n=499)|
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The prevalence of anaemia was found to be 62.7% (95% CI 58.2–67.0). The prevalence of mild, moderate and severe anaemia was 27.3% (95% CI 23.4–31.5), 32.5% (95% CI 28.4–36.9) and 2.8% (95% CI 1.6–4.7), respectively. The overall mean Hb level was found to be 11.2 ± 1.5 g/dl.
Amongst the adolescents in the selected schools, 378 students reported of receiving IFA tablets in the last month in school, of which 67.7% were compliant to IFA tablets. Compliance to biannually distributed deworming tablets was 87.7%.
[Table 2] shows, the association of various sociodemographic factors and clinical factors with prevalence of anaemia amongst the adolescents. The factors such as 'age', 'habit of drinking tea/coffee within an hour after major meals' and 'non-compliance to WIFS' were found to be associated with anaemia. Adjusted analysis revealed that late adolescents (15–18 years) was significantly more associated with anaemia (aPR: 1.7 95% CI: 1.0–3.0) as compared to early adolescents (10–11 years).
|Table 2: Association of socio-demographic factors and clinical factors with anemia amongst the adolescentsin selected schools of urban Puducherry (n=458)|
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[Table 3] explains the association between sociodemographic factors and clinical factors with compliance to the WIFS programme. In bivariate analysis, factors such as 'age', 'gender', 'parent's education', 'parent's occupation', 'socioeconomic class' and 'anaemia status' were found to be significantly associated with compliance to IFA tablets. In the multivariable adjusted analysis, 'age' and 'gender' were found to be significantly associated with compliance to IFA tablets.
|Table 3: Association of sociodemographic factors and clinical factor with compliance to weekly iron-folic acid supplementation programme amongst the adolescent in selected schools of urban Puducherry|
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Early adolescents (10–11 years) were 2.1 (1.4–3.3) times more compliant with WIFS programme as compared to late adolescents (15–18 years). Similarly, adolescents aged 12–14 years were 2.0 (1.4–2.8) times more compliant to WIFS programme as compared to adolescent aged 15–18 years, which was statistical significance. Males were 1.4 (1.0–1.8) times more compliant to IFA tablets use as compared to females, this association was statistically significant.
| Discussion|| |
The present study was conducted in Puducherry, India, which has a population of around 10 lakhs (1 million). Adolescents constitute 17% of the total population. Health-care facilities in Puducherry included 27 primary health care centres, 2 community health centres and 9 medical colleges. All the medical colleges in India have an urban and rural health centre where the medical students are exposed to the training related to the functioning of a primary health centre. The present study was conducted in one of the urban health centres attached to a government medical college. This urban health centre area had four government schools where adolescents were being imparted school education. All the adolescent students of these four schools were included in the study. The urban health centre conducts an adolescent-friendly health clinic every Saturday, as per Rashtriya Kishor Swasthya Karyakram guidelines. In school, weekly once IFA supplementation is given to all adolescents through the WIFS programme on a fixed day under the supervision of school teachers. The present study is expected to assess the magnitude of the problem of anaemia amongst the adolescents attending schools and to assess if the adolescents were compliant to IFA and albendazole tablets as distributed under the WIFS programme.
In the present study, the overall prevalence of anaemia amongst the adolescents was found to be 62.7% (95% CI [58.2%–67.1%]). Our result was in line with other studies done in Puducherry (54.3%) and Tamil Nadu (52.8%)., A study conducted by Toteja et al. amongst adolescents in 16 districts from 11 states in India reported that the prevalence of anaemia was found to be higher (90.1%). However, studies conducted amongst adolescents from Kerala and Nepal reported relatively lower anaemia prevalence of 31.4% and 31%, respectively.,
The prevalence of anaemia was higher amongst adolescents belonging to low and middle socioeconomic status. Similar findings were reported from studies conducted in Chandigarh (India), Tamil Nadu (India) and South Ethiopia.,, This finding may be due to the differences in the availability of healthy food, education and awareness amongst the parents of adolescents hailing from different socioeconomic status.
We also found that there was an association between drinking of tea/coffee within an hour of meals with anaemia. The polyphenols in tea/coffee inhibit the absorption of non-haeme iron absorption. This chelation (binding) of the non-haeme iron makes iron unavailable for utilisation. Similar findings were found in a study conducted in Kerala.
The present study showed that 65.2% of boys and 61.8% of girls had anaemia. However, in our study, the prevalence of anaemia was not significantly associated with gender. This is consistent with the results of another study conducted in Puducherry. But in contrast to this finding, the studies conducted in Tamil Nadu and Chandigarh showed that the prevalence of anaemia was higher amongst females as compared to that of the males.,
As mentioned earlier, the prevalence of anaemia amongst adolescent girls in our study was found to be 61.8%. Similar, findings were reported from the studies done in other states of India such as Madhya Pradesh (52%) and Chattisgarh (61%)., However, studies conducted in Maharashtra state (87%) and Chennai (79%) of Tamil Nadu state reported a higher prevalence of anaemia amongst adolescent girls., This difference in the prevalence of anaemia in various places of India may be due to the differences in sociocultural practices and availability and accessibility of health-care services to adolescents in various study settings.
In our study, late adolescents suffered more anaemia as compared to early adolescents. Similar results were seen in studies conducted in Puducherry and Tamil Nadu., This could probably be due to changes in dietary habits and nutritional requirements amongst adolescents in different age groups.
In the present study, compliance to WIFS was found to be 67.7%, which was similar to the findings of the study conducted in West Bengal. However, compliance was higher in the present study when compared to the survey conducted in Haryana and Delhi. In the current study, if we exclude one school with poor compliance to IFA, the compliance to IFA was quite high in the other three schools (91.7%). The reason for higher compliance to IFA amongst these school students may be due to better supervision of their school teachers, ensuring that students take the IFA tablets in front of them. Intervention studies conducted in India and other countries have shown that there was decrease in anaemia prevalence where school students complied more to the WIFS programme., Compliance was more amongst early adolescents compared to late adolescents. On enquiring from the school staff regarding the same, it was observed that IFA intake supervision by their teachers were more strictly monitored amongst students reading in 6th–10th class as compared to higher class students.
In the present study, children of parents who had higher educational status reported poor adherence to IFA. Similarly, girls were less compliant to IFA supplementation as compared to the males.
The compliance to albendazole tablet in our study was 87.7%, whereas in a study conducted in West Bengal, it was 96%. There are chances that recall bias could have affected the results of the present study for assessing compliance to albendazole as a history of albendazole was assessed over the last 6 months.
There were four government schools in the area and all the adolescents in all these four schools were included in the study to assess the prevalence of anaemia amongst them and also assess their compliance to the WIFS program. It is thus expected that the results of the present study can represent the scenario in other government schools in similar settings. It is good that standard procedure was followed for assessing Hb status; it was assessed using a portable instrument ('Mission® Hb']).
The limitations of the study include recall bias and social desirability bias. Recall bias could have occurred while collecting data from the early adolescents (as albendazole is recommended every 6 months, recalling the intake could have been difficult for the students) and social desirability bias may be present while collecting the information regarding compliance to the WIFS programme, especially from late adolescent students. Being a cross-sectional study, establishing temporality and causation is not possible. The burden and the risk factor found were region-specific, so generalizability is possible only for a similar study setting. The study population was school-going adolescents, so it may not reflect the true burden of a problem in the community.
| Conclusion|| |
More than half of the adolescents had anaemia. This study clearly shows that stricter supervision by teachers can result in better compliance to the WIFS programme. Anaemia was more amongst those who were not compliant to WIFS tablets. More focus on late adolescents is necessary to improve compliance to IFA and improve their anaemia status. Strategies to improve WIFS compliance, imparting knowledge regarding dos and don'ts while taking IFA and involvement of school teachers will help to tackle anaemia amongst adolescents.
Special thanks to the Directorate of School education Puducherry for giving permission to conduct the study. We would like to thanks to the school authorities, adolescents who participated in this study and urban health centre staff. We would also like to express our gratitude to JIPMER Intramural grand Committee for supporting financially.
Financial support and sponsorship
Grants received from Intra-Mural fund.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]