Community-based interventions : implications for childhood anemia prevention and control in India

Abstract: Background: Nutritional iron deficiency is the number one cause of anemia worldwide. Iron deficiency anemia has morbidity and mortality effects borne predominantly by premenopausal women and children living in South Asia and sub-Saharan Africa. Community-based interventions have successfully addressed several global health problems, although there is limited evidence of their effectiveness for childhood anemia. The overall aim of this thesis was to test the hypothesis that community-based education and counseling delivered to mothers of anemic children by health workers would improve anemia cure rates. Methods: The thesis included 4 studies, two of which (Study I and II) were cross sectional studies constituting the background for intervention design. The social cognitive theory framework guided the development of the intervention, which consisted of five monthly education sessions delivered by a health worker covering: i) maternal anemia awareness, ii) adherence to iron treatment, iii) dietary modification, and iv) hygiene and sanitation. The intervention was evaluated in a pragmatic mixed methods trial conducted among 12-59 month old children from 55 villages of the Chamarajnagar district, Karnataka. Villages (and health workers therein) were randomly assigned 1:1 to provide anemic children either the usual iron treatment alone or the same treatment complemented by education and counseling of their mothers/caregivers. The primary trial outcome was the difference in anemia cure rates (return of hemoglobin to ≥11g/dL) at the end of six months. Thematic analysis with the framework method was utilized to understand health workers acceptance of the intervention and their perceptions of obstacles and opportunities connected to its implementation (Study III). A cluster randomized trial contrasting intervention to usual treatment condition was used to study the effects of the intervention (Study IV). The statistical analysis was conducted taking into account the cluster design, using multilevel regression. Results: A high prevalence of childhood anemia was found in healthy rural toddlers (75%) mainly due to iron deficiency anemia (Study 1). Coverage of children with iron supplements from the national anemia control program was low (Study II). Health workers delivering the intervention found it acceptable and feasible to implement during routine work activities (Study III). After six months, anemic children in the intervention group had significantly higher anemia cure rates compared with anemic children in the usual treatment group (55.5% vs. 41.4%; relative risk ratio 1.33, confidence interval [CI], 1.04-1.69). The proportion of anemic children consuming >75% of prescribed iron was higher in the intervention group compared with the usual treatment group (61.7% vs. 48.4%; p=0.001). The results indicated that seven mothers needed to be counselled in order to cure one anemic child (Study IV). Conclusions: The studies included in this thesis indicate that mother/caregiver education achieved a perceivable improvement to the cure rate of nutritional iron deficiency anemia in children from rural India, probably through improved adherence to iron treatment. High intervention acceptance at the health worker level suggests that wider implementation is possible. Scientific evaluations of community-based interventions are feasible even in rural disadvantaged environments.