Meeting on weekly iron/folic acid supplementation for preventing anaemia in women of reproductive age in the western pacific region (2003)
The WHO Regional Office for the Western Pacific sponsored unsupervised effectiveness projects in Cambodia, the Philippines and Viet Nam to reduce the prevalence of iron deficiency (ID) and iron deficiency anaemia (IDA) in women of reproductive age (WRA) through the weekly distribution of iron/folic acid supplements (WIFS) introduced to the target populations concurrent with an intensive community mobilization and social marketing programme. The linked approach—new for the Region—was proposed to enhance acceptance of the supplements and compliance in using them, thus overcoming the relatively unsuccessful programmes of supplement distribution to control anaemia that have been on-going for years through distribution of free supplements through the health system. Community workers in each country received training in counselling, and community groups were mobilized and educated about ID, IDA and local food sources rich in iron to be consumed along with WIFS for anaemia control. The advocacy campaign was focused on the four ‘Ps’—product, place, price, and promotion—to guide development of appropriate information, education and communication (IEC) materials. The target population in Cambodia was non-pregnant WRAs in factories, schools and rural villages. In the Philippines and Viet Nam both pregnant and non-pregnant village women were targeted. A uniform supplement containing 60 mg iron as ferrous sulfate + 3.5 mg folic acid for non-pregnant WRAs, or 120 mg iron as ferrous sulfate + 3.5 mg folic acid for pregnant women, was taken weekly as appropriate for each target population. Supplements were provided free of charge to pregnant women through health centre units and sold to non-pregnant WRAs for an affordable price by community collaborators, except among factory workers in Cambodia where governmental regulations required employers to provide free health care. Community committees managed funds collected from sales using some to compensate sales agents (about 20%) and some for maintenance of the programme (about 30%). The remaining funds were deposited into community banks or revolving funds which were controlled at the community level (about 50%). Outcome measures included an evaluation of changes from baseline in knowledge, attitudes and practices (KAP), and changes in the prevalence of anaemia (haemoglobin values [Hb]), at 4, 9 and 12 months during the year of intervention. In the Philippines and Viet Nam, iron status as indicated by serum ferritin values (SF) and transferrin receptors (TR) were also evaluated.
The social marketing/mobilization effort in all three countries resulted in significant positive KAP changes in awareness of iron-rich foods, knowledge of ID and IDA, and attitudes toward acceptance of weekly supplements. Anaemia prevalence declined in schoolgirls in Cambodia, but not among rural women and WRAs in factories. Pregnant and non-pregnant women in the Philippines who took the WIFS improved in iron status (SF values) but there was only an insignificant impact on anaemia, probably because of the contribution of other causes of anaemia, perhaps lack of other hematinic micronutrients, but not infections. In Viet Nam, anaemia prevalence declined very significantly, but remained relatively high, while iron status improved, indicating, as in the Philippines, that other causes of anaemia were not addressed by WIFS alone. The Viet Nam project provided evidence that pre-pregnancy consumption of WIFS for a minimum of three months, but better if six months, can reduce significantly the likelihood that a woman will become anaemic during pregnancy. Deworming did not improve the effectiveness of WIFS in reducing anaemia, but did reduce the intensity of hookworm load and should be continued. In all three countries, WIFS is an important intervention for anaemia control, but should be accompanied with additional programmes to control the other causes of