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close this bookGuidelines for the Use of Iron Supplements to Prevent and Treat Iron Deficiency Anaemia (International Life Sciences Institute, 1998, 46 p.)
View the document(introduction...)
View the documentPreface
View the documentAcknowledgments
View the documentAbout INACG
View the documentBackground
View the documentPurpose of These Guidelines
View the documentOverview of Interventions for Controlling Iron Deficiency Anemia
View the documentSelecting and Prioritizing Interventions
View the documentGuidelines for Iron Supplementation to Prevent Iron Deficiency Anemia
View the documentGuidelines for Treatment or Referral of Severe Anemia in Primary Care Settings
View the documentFrom Guidelines to Programs
View the documentWhere to Go for More Help and Information
View the documentSelected Bibliography
View the documentAppendix A. Percentage and amount of iron in some commonly used iron compounds
View the documentAppendix B. Examples of materials used in iron supplementation programs
View the documentAppendix C. Addresses and World Wide Web sites for international agencies engaged in the control of iron deficiency anemia
View the documentAppendix D. Some sources of supplements and other supplies for iron supplementation programs

From Guidelines to Programs

The evidence is indisputable that iron supplements can substantially reduce iron deficiency anemia. However, there are also many experiences that show that iron supplementation programs do not always work. Fortunately, although every program will have its unique aspects, some general elements of a successful iron supplementation programs are beginning to emerge from these experiences. These elements are summarized in Figure 1

Figure 1. Elements of Successful Iron Supplementation Programs

Developing an iron supplementation program or revitalizing an established program that is not working well is a process that involves several interactive steps. There are lessons to be learned at each step of the process that might necessitate adjustments in decisions made in previous steps. One may set out to take each step in turn to establish the perfect program, but in reality, the best programs develop from constant learning and adjusting, especially at the beginning. Here is a summary of the key steps:

1. Establish a Policy

Policies are needed to legitimize program activities, establish standard practices within programs, and engender the resource base necessary to bring programs to life. These resources include not only funds, but people's time, equipment, and space and the credibility and influence of the policy-setting organization. If a policy for the control of iron deficiency anemia is not in place, it is important to establish one.

Policy makers often do not fully understand the cost of iron deficiency anemia to the national health and economy. They need to be informed of the prevalence of anemia in the population or targeted subgroups (e.g., pregnant women and infants); the major causes of anemia; its consequences for the individual, the family, the community and the economy; and the cost effectiveness of interventions. In many situations, all of this information is not available before a program is implemented, which illustrates the interactive nature of these various steps. As the program gains experience and is monitored and evaluated, there needs to be a regular flow of information back to policy makers so that policies can be adjusted and strengthened.

2. Get the Right Product

There are a wide variety of iron supplements in use around the world, and their quality varies. The quality of a supplement and its attractiveness to users is a major key to success. Iron supplementation programs to pregnant women typically use tablets, which are relatively inexpensive and easy to transport and store. UNICEF has supported the production of a tablet that contains 60 mg iron (as ferrous sulfate) and 250 µg folic acid but is now changing to a tablet that contains 60 mg iron plus 400 µg folic acid. Children younger than 2 years will likely need a liquid supplement that can be dropped into their mouth, although a powder or crushable tablet could be mixed with an infant food. The higher costs associated with a liquid formulation for young children must be weighed against the greater ease of its use and potential for greater compliance.

The appearance and packaging of supplements may greatly influence their attractiveness to users. The color used to coat tablets can carry positive or negative connotations for women. In many cultures, women prefer a red, sugar-coated tablet. The coating of tablets also influences their stability in different storage conditions and their taste. The packaging of a product not only influences its appeal, but its cost and the frequency of contacts needed to deliver it (i.e., how long one package will last). The size and quality of the packaging also determines its safety in the household. Packages of iron supplements that contain a total of more than 1 g iron (e.g., 16 tablets each containing 60 mg iron) could cause serious injury or death if ingested by a child, and as little as 400 mg may be fatal to an infant. It may be possible to work with a local pharmaceutical company to develop a product and packaging uniquely suited to the tastes and beliefs of the population.

Once a product is chosen, a system must be made for ordering, storing, and transporting supplements to their point of distribution to consumers. Although these processes may seem straightforward, they have been major problem areas in the past. A lack of supplies within programs is a well-documented problem. The number of supplements needed in a given period should be based on the actual number of intended recipients (e.g., pregnant women or children younger than 2 years). Usually this number can be estimated from census information. A good rule of thumb is to procure the estimated number needed plus a 25% surplus. The frequency of procurements will depend upon the storage life of the supplements. This needs to be carefully planned, as out-of-date supplements represent lost money and lost opportunities to improve people's health.

3. Choose Effective Delivery Systems

People planning iron deficiency anemia control programs are encouraged to explore nontraditional modes for delivering supplements. Traditionally, iron supplementation programs have been delivered through health centers, but a wider variety of delivery systems are being tried to increase coverage and compliance. One innovative approach is to distribute iron tablets during national immunization days. Increasingly, the private sector is an important means of making iron supplements available to consumers. This requires collaboration with pharmaceutical industries to market the iron tablets attractively, regulate their quality and labeling, and ensure they are available in small villages. In several places people have discovered that even the poor are willing to spend small amounts on medications and tonics. Use of traditional healers and birth attendants, schools, religious centers, community centers, women's groups, and factories are all being tried.

Qualitative research (e.g., focus groups and interviews) with target groups in representative communities should focus on their access to different delivery systems and users' perceptions of them. It is essential to realistically assess the coverage through different mechanisms. Where they exist, community health committees should be important partners in developing and implementing appropriate supplementation strategies.

A key to the success of any delivery system is the people who work there. Do women or other users feel good about interacting with these people? Can the people become truly committed to implementing the iron supplementation program, or are there important structural barriers (e.g., staff lack facilities and time), social barriers, or political barriers? The answers to the latter question will depend in part on the strength of the policy, because strong policies can create the resource base needed to overcome existing barriers.

4. Linking with Other Health and Nutrition Activities

As described in the first part of this document, supplementation maybe an essential intervention for some target groups in the population, but supplementation must be combined with other interventions to effectively control anemia. Building linkages with these programs will broaden the efforts to combat iron deficiency anemia and may increase the base of support for iron supplementation programs. Contacts with young children, pregnant women, and perhaps other groups through health services can be used to ensure or reinforce supplementation. Immunization programs provide an opportunity for reminding child caregivers of supplementation protocols and for providing or selling supplements for young children or lactating women. Where other nutrition interventions are being implemented, aspects of the anemia control strategy may be effectively integrated. Examples include periodic distribution of anthelminthics with vitamin A supplements and screening for severe anemia in growth-monitoring programs for young children. Important linkages may also be made with agriculture or nutrition programs that carry out nutrition education or that might generate food intake data needed to plan an iron fortification program. Other potential partners are food industries that might participate in fortification efforts, family planning programs, obstetricians and midwives, pediatricians, and malaria and helminth control programs.

5. Develop a Communications Strategy

A strategy is needed to communicate the plan and purpose of the program at multiple levels. To start a new program or to revitalize an existing one, many agents - from community members to health planners - need to act in new ways. Evaluations of unsuccessful programs have shown that health care personnel at all levels were confused or ignorant about the program plan and objectives. Often health care workers need to be educated about iron deficiency anemia almost as much as do community members. Even health care workers who are not directly involved in distributing supplements should be knowledgeable about the program so that they reinforce the program messages in their work.

Materials can be developed to help recipients remember to take supplements and to help health care workers (or other distributors) to distribute supplements appropriately and counsel pregnant women (or other users) about their use. Some examples are included in Appendix B. Communications strategies need to be reviewed and adjusted as people's experience and knowledge evolve. For example, as women become used to taking iron supplements, different messages maybe needed to promote long-term compliance. Some of the most important objectives of the communications strategy and also potential points of resistance are summarized in Table 10.

6. Monitoring and Evaluation

Monitoring and evaluation are essential to the life of any program and should be planned and integrated from the start of the program. Monitoring is the continual activity of collecting information about the different parts of the program, whereas evaluation may be periodic and involves judgement about whether the program is working. These activities provide opportunities to reward excellence within the system, identify and solve problems in program implementation, and provide the additional information that policy makers need to revise and strengthen policies. Several types of monitoring and evaluation activities can be carried out; these may be grouped into two general categories.

In the first category of activity, specific program activities are monitored to assess whether all parts of the system are working as planned (sometimes called process evaluation). This level of evaluation is essential to all programs. This level maybe expanded to include the assessment of knowledge, attitudes, and practices of program agents and beneficiaries, and the compliance of beneficiaries with supplement usage. Measurable outcomes are listed in Table 11. Data on these outcomes will provide information about whether the implementation plan is functioning. It is critical that the information is compiled and reported so that the people implementing the program learn from the evaluation.

Table 10. Scope and behavior goals of an effective communications strategy for iron supplementation programs


Behavior Goal


Pregnant women, mothers

Obtain and use iron supplement at right frequency and dose

Women not asking for services or knowing where they are
Lack of awareness of anemia and how to prevent it
Lack of knowledge of how to manage side effects
Fears, beliefs, and suspicions (e.g. that iron pills will make baby too big)

Health care providers

Distribute or sell iron supplements and counsel women properly about their use

Lack of awareness and knowledge
Poor communication skills Infrequent contacts with pregnant women
Providers may act disrespectfully to women

Health planners and drug managers

Train and supervise staff, monitor supplies, and manage resources

Lack of awareness of purpose of program
May be part of poorly functioning system

Agents in complementary activities, such as family planning workers, midwives, and pediatricians

Support and reinforce messages of iron supplementation program, integrate anemia education into their activities

Lack of awareness of anemia and iron supplementation activities
False sense of competition or threat between health care agents

Policy makers

Make and enforce necessary policies and allocate sufficient resources

Lack of awareness of cost of iron deficiency anemia to health and economy of society

Table 11. Measurable outcomes in process evaluation

· A budget dedicated and spent
· Supplements and other supplies procured
· Quality of supplements
· Provision of adequate storage
· Distribution system in place
· Availability of supplements at distribution points
· Training activities planned and conducted for health care workers and others as needed
· Knowledge, attitudes, and practices of health care workers and other agents
· Community education programs in place
· Knowledge, attitudes, and practices of community leaders, family decision makers, and mothers
· Number of supplements distributed
· Number of supplements reported received by mothers
· Program coverage (percentage of intended recipients who actually received supplements)

· Number of supplements consumed by women/infants

The second category of activity is to measure changes in iron deficiency anemia in target groups (sometimes called impact evaluation). One approach is to periodically conduct surveys of anemia (or iron deficiency anemia, if possible) in the target groups in the community. Ideally, a survey is carried out before the program is initiated, and follow-up surveys are conducted at intervals of 2-5 years after the program has begun. Demographic and health surveys in several countries now include hemoglobin measurements, and these are excellent resources for program evaluation. Coverage and compliance of iron supplementation by target individuals can also be ascertained within periodic surveys. It is especially important to do this if compliance (i.e., how many supplements are actually consumed) is not assessed as part of program monitoring. These periodic surveys let health planners and policy makers know whether anemia prevalence is declining. It is difficult to conclude with certainty that the changes observed in anemia rates result directly from the activities of the supplementation program. However, evidence from this type of evaluation can be very influential in maintaining political support for policies and programs or advocating for additional iron deficiency anemia control activities. Usually program effect, if it is assessed at all, is assessed in this way.

Sometimes resources are available to do a more in-depth evaluation of effect. The strength of evidence about program effect will be increased if iron status is linked to coverage and compliance at the level of the individual. If data are collected to show that the general nutritional status of the population has not changed, improvements in women's hemoglobin levels can be attributed with greater confidence to program activities. The strongest level of evidence about effect is obtained if individuals' iron status is measured before and after supplementation (e.g., early and late in pregnancy or postpartum or in infants at 6 and 12 months), and the change in status is linked to degree of iron supplement usage.

7. Development of an Applied Research Program to Support Program Activities

Experience has shown that programs to control anemia and other forms of malnutrition are most successful in countries where they are supported by one or more teams of researchers dedicated to carrying out applied research related to nutrition interventions. A few noteworthy examples are Chile, Argentina, and Venezuela in the control of anemia and Indonesia and Guatemala in the control of vitamin A deficiency. In each of these countries, scientists at local universities or institutes carried out critical research needed to develop, evaluate, and refine program strategies; and in each of these countries the nutritional problem has been substantially reduced. Where such linkages between applied research and programs do not already exist, they should be encouraged in every way by program planners and implementers. These collaborations provide technical support for programs and also provide invaluable opportunities for nutrition and public health scientists to carry out research that will have an enduring effect in their country.