1
|
Roche ML, Samson KLI, Green TJ, Karakochuk CD, Martinez H. Perspective: Weekly Iron and Folic Acid Supplementation (WIFAS): A Critical Review and Rationale for Inclusion in the Essential Medicines List to Accelerate Anemia and Neural Tube Defects Reduction. Adv Nutr 2021; 12:334-342. [PMID: 33439978 PMCID: PMC8009743 DOI: 10.1093/advances/nmaa169] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 11/17/2020] [Accepted: 12/04/2020] [Indexed: 11/12/2022] Open
Abstract
Weekly iron and folic acid supplementation (WIFAS) is among the 8 key effective actions for improving adolescent nutrition included by the WHO in the 2018 guidelines. However, at present WIFAS in the WHO-recommended formulation is not included in the Model Essential Medicines List (MEML), limiting the potential for countries to import, produce, and prioritize this formulation as part of their national supply management and procurement plans for medicines. The WHO WIFAS guideline presents evidence that the formulation reduces anemia, but not that folic acid reduces neural tube defects (NTDs), because sufficient evidence was unavailable at the time of the last review. Recently, a 3-arm, parallel-group, randomized, double-blind, placebo-controlled folic acid efficacy trial on WIFAS was conducted to address this evidence gap. The study population included 331 women (18-45 y old), randomly assigned to 3 treatment groups, including a supplement with 60 mg Fe as ferrous fumarate and either 0 mg, 0.4 mg, or 2.8 mg of folic acid, to be consumed once weekly for 16 wk, followed by a 4-wk washout period. In this article we critically review how the outcomes of this folic acid efficacy trial, and how the evidence generated, could potentially be used to inform WHO WIFAS guidelines for the potential inclusion of this formulation on the MEML, and how this, in turn, may affect product availability. If the new evidence on weekly folic acid is assessed as adequately reducing the risk of NTDs, a guideline revision could be warranted and WIFAS could be presented to the MEML for the dual benefits of anemia reduction and NTD prevention. This inclusion could enable acceleration of implementing policies and programs to contribute to global anemia and NTD reduction efforts.
Collapse
Affiliation(s)
- Marion L Roche
- Global Technical Services, Nutrition International, Ottawa, Ontario, Canada
| | - Kaitlyn L I Samson
- Food, Nutrition, and Health, The University of British Columbia, Vancouver, British Columbia, Canada
- Healthy Starts, BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Tim J Green
- Women and Kids Theme, South Australia Health and Medical Research Institute, Adelaide, South Australia, Australia
- School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Crystal D Karakochuk
- Food, Nutrition, and Health, The University of British Columbia, Vancouver, British Columbia, Canada
- Healthy Starts, BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Homero Martinez
- Global Technical Services, Nutrition International, Ottawa, Ontario, Canada
- The Children's Hospital of Mexico, Mexico City, Mexico
| |
Collapse
|
2
|
Kamau MW, Kimani ST, Mirie W, Mugoya IK. Effect of a community-based approach of iron and folic acid supplementation on compliance by pregnant women in Kiambu County, Kenya: A quasi-experimental study. PLoS One 2020; 15:e0227351. [PMID: 31923240 PMCID: PMC6953847 DOI: 10.1371/journal.pone.0227351] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Accepted: 12/17/2019] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Iron and Folic Acid Supplementation (IFAS) is an essential and affordable intervention strategy for prevention of anaemia during pregnancy. The supplements are currently provided for free to pregnant women in Kenya during antenatal care (ANC), but compliance remains low over the years. There is need for diversification of IFAS programme implementation by exploring other distribution channels to complement existing antenatal distribution and ensure consistent access to IFAS supplements. OBJECTIVES To determine the effect of a community-based approach of IFAS distribution on compliance and assess side-effects experienced and their mitigation by pregnant women in Kiambu County. METHODOLOGY A pretest-posttest quasi-experimental study design was used, consisting of an intervention and a control group, among 340 pregnant women 15-49 years, in five health facilities in Lari Sub-County in Kiambu County, between June 2016 and March 2017. Community health volunteers provided IFAS supplements, counselling and weekly follow-up to pregnant women in the intervention group while the control group followed standard practice from health facilities. Baseline and endline data were collected during antenatal care and compared. Quantitative data was analyzed using STATA version 14. Analysis of effect of intervention was done using Difference-In-Difference regression approach. RESULTS Levels of compliance increased by 8% in intervention group and 6% in control group. There was increased awareness of IFAS side-effects across groups. The intervention group reported experiencing less side-effects and were better able to manage them compared to the control group. CONCLUSION Implementation a community-based approach improved maternal compliance with IFAS, awareness of IFAS side effects and their management, with better improvement being recorded in the intervention group. Hence, there is need to integrate community-based approach with antenatal distribution of IFAS to improve supplementation.
Collapse
Affiliation(s)
| | | | - Waithira Mirie
- School of Nursing Sciences, University of Nairobi, Nairobi, Kenya
| | | |
Collapse
|
3
|
Fernández-Gaxiola AC, De-Regil LM. Intermittent iron supplementation for reducing anaemia and its associated impairments in adolescent and adult menstruating women. Cochrane Database Syst Rev 2019; 1:CD009218. [PMID: 30699468 PMCID: PMC6360921 DOI: 10.1002/14651858.cd009218.pub3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Anaemia is a condition in which the number of red blood cells is insufficient to meet physiologic needs; it is caused by many conditions, particularly iron deficiency. Traditionally, daily iron supplementation has been a standard practice for preventing and treating anaemia. However, its long-term use has been limited, as it has been associated with adverse side effects such as nausea, constipation, and teeth staining. Intermittent iron supplementation has been suggested as an effective and safer alternative to daily iron supplementation for preventing and reducing anaemia at the population level, especially in areas where this condition is highly prevalent. OBJECTIVES To assess the effects of intermittent oral iron supplementation, alone or in combination with other nutrients, on anaemia and its associated impairments among menstruating women, compared with no intervention, a placebo, or daily supplementation. SEARCH METHODS In February 2018, we searched CENTRAL, MEDLINE, Embase, nine other databases, and two trials registers. In March 2018, we also searched LILACS, IBECS and IMBIOMED. In addition, we examined reference lists, and contacted authors and known experts to identify additional studies. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs with either individual or cluster randomisation. Participants were menstruating women; that is, women beyond menarche and prior to menopause who were not pregnant or lactating and did not have a known condition that impeded the presence of menstrual periods. The intervention was the use of iron supplements intermittently (one, two or three times a week on non-consecutive days) compared with placebo, no intervention, or the same supplements provided on a daily basis. DATA COLLECTION AND ANALYSIS Both review authors independently assessed the eligibility of studies against the inclusion criteria, extracted data from included studies, checked data entry for accuracy, assessed the risk of bias of the included studies, and rated the quality of the evidence using GRADE. MAIN RESULTS We included 25 studies involving 10,996 women. Study methods were not well described in many of the included studies and thus assessing risk of bias was difficult. The main limitations of the studies were lack of blinding and high attrition. Studies were mainly funded by international organisations, universities, and ministries of health within the countries. Approximately one third of the included studies did not provide a funding source.Although quality across studies was variable, the results consistently showed that intermittent iron supplementation (alone or with any other vitamins and minerals) compared with no intervention or a placebo, reduced the risk of having anaemia (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.49 to 0.87; 11 studies, 3135 participants; low-quality evidence), and improved the concentration of haemoglobin (mean difference (MD) 5.19 g/L, 95% CI 3.07 to 7.32; 15 studies, 2886 participants; moderate-quality evidence), and ferritin (MD 7.46 μg/L, 95% CI 5.02 to 9.90; 7 studies, 1067 participants; low-quality evidence). Intermittent regimens may also reduce the risk of having iron deficiency (RR 0.50, 95% CI 0.24 to 1.04; 3 studies, 624 participants; low-quality evidence), but evidence was inconclusive regarding iron deficiency anaemia (RR 0.07, 95% CI 0.00 to 1.16; 1 study, 97 participants; very low-quality evidence) and all-cause morbidity (RR 1.12, 95% CI 0.82 to 1.52; 1 study, 119 participants; very low-quality evidence). Women in the control group were less likely to have any adverse side effects than those receiving intermittent iron supplements (RR 1.98, 95% CI 0.31 to 12.72; 3 studies, 630 participants; moderate-quality evidence).In comparison with daily supplementation, results showed that intermittent supplementation (alone or with any other vitamins and minerals) produced similar effects to daily supplementation (alone or with any other vitamins and minerals) on anaemia (RR 1.09, 95% CI 0.93 to 1.29; 8 studies, 1749 participants; moderate-quality evidence). Intermittent supplementation may produce similar haemoglobin concentrations (MD 0.43 g/L, 95% CI -1.44 to 2.31; 10 studies, 2127 participants; low-quality evidence) but lower ferritin concentrations on average (MD -6.07 μg/L, 95% CI -10.66 to -1.48; 4 studies, 988 participants; low-quality evidence) compared to daily supplementation. Compared to daily regimens, intermittent regimens may also reduce the risk of having iron deficiency (RR 4.30, 95% CI 0.56 to 33.20; 1 study, 198 participants; very low-quality evidence). Women receiving iron supplements intermittently were less likely to have any adverse side effects than those receiving iron supplements daily (RR 0.41, 95% CI 0.21 to 0.82; 6 studies, 1166 participants; moderate-quality evidence). No studies reported on the effect of intermittent regimens versus daily regimens on iron deficiency anaemia and all-cause morbidity.Information on disease outcomes, adherence, economic productivity, and work performance was scarce, and evidence about the effects of intermittent supplementation on these outcomes unclear.Overall, whether the supplements were given once or twice weekly, for less or more than three months, contained less or more than 60 mg of elemental iron per week, or given to populations with different degrees of anaemia at baseline did not seem to affect the findings. Furthermore, the response did not differ in areas where malaria was frequent, although very few trials were conducted in these settings. AUTHORS' CONCLUSIONS Intermittent iron supplementation may reduce anaemia and may improve iron stores among menstruating women in populations with different anaemia and malaria backgrounds. In comparison with daily supplementation, the provision of iron supplements intermittently is probably as effective in preventing or controlling anaemia. More information is needed on morbidity (including malaria outcomes), side effects, work performance, economic productivity, depression, and adherence to the intervention. The quality of this evidence base ranged from very low to moderate quality, suggesting that we are uncertain about these effects.
Collapse
|
4
|
Fisher J, Tran T, Luchters S, Tran TD, Hipgrave DB, Hanieh S, Tran H, Simpson J, Nguyen T, Le M, Biggs BA. Addressing multiple modifiable risks through structured community-based Learning Clubs to improve maternal and infant health and infant development in rural Vietnam: protocol for a parallel group cluster randomised controlled trial. BMJ Open 2018; 8:e023539. [PMID: 30018101 PMCID: PMC6059326 DOI: 10.1136/bmjopen-2018-023539] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 04/20/2018] [Accepted: 04/23/2018] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Optimal early childhood development is an international priority. Risks during pregnancy and early childhood have lasting effects because growth is rapid. We will test whether a complex intervention addressing multiple modifiable risks: maternal nutrition, mental health, parenting capabilities, infant health and development and gender-based violence, is effective in reducing deficient cognitive development among children aged two in rural Vietnam. METHODS AND ANALYSIS The Learning Clubs intervention is a structured programme combining perinatal stage-specific information, learning activities and social support. It comprises 20 modules, in 19 accessible, facilitated groups for women at a community centre and one home visit. Evidence-informed content is from interventions to address each risk tested in randomised controlled trials in other resource-constrained settings. Content has been translated and culturally adapted for Vietnam and acceptability and feasibility established in pilot testing.We will conduct a two-arm parallel-group cluster-randomised controlled trial, with the commune as clustering unit. An independent statistician will select 84/112 communes in Ha Nam Province and randomly assign 42 to the control arm providing usual care and 42 to the intervention arm. In total, 1008 pregnant women (12 per commune) from 84 clusters are needed to detect a difference in the primary outcome (Bayley Scales of Infant and Toddler Development Cognitive Score <1 SD below standardised norm for 2 years of age) of 15% in the control and 8% in the intervention arms, with 80% power, significance 0.05 and intracluster correlation coefficient 0.03. ETHICS AND DISSEMINATION Monash University Human Research Ethics Committee (Certificate Number 20160683), Melbourne, Victoria, Australia and the Institutional Review Board of the Hanoi School of Public Health (Certificate Number 017-377IDD- YTCC), Hanoi, Vietnam have approved the trial. Results will be disseminated through a comprehensive multistranded dissemination strategy including peer-reviewed publications, national and international conference presentations, seminars and technical and lay language reports. TRIAL REGISTRATION NUMBER ACTRN12617000442303; Pre-results.
Collapse
Affiliation(s)
- Jane Fisher
- School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
| | - Tuan Tran
- Research and Training Centre for Community Development, Hanoi, Vietnam
| | - Stanley Luchters
- School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
- Centre for International Health, Burnet Institute, Melbourne, Victoria, Australia
- International Centre for Reproductive Health, Department of Obstetrics and Gynaecology, Ghent University, Gent, Belgium
| | - Thach D Tran
- School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
- Research and Training Centre for Community Development, Hanoi, Vietnam
| | - David B Hipgrave
- New York Headquarters, United Nations Children’s Fund, New York City, New York, USA
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Sarah Hanieh
- Department of Medicine and Victorian Infectious Diseases Service, Doherty Institute, University of Melbourne, Melbourne, Victoria, Australia
| | - Ha Tran
- Research and Training Centre for Community Development, Hanoi, Vietnam
| | - Julie Simpson
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Trang Nguyen
- School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
- Research and Training Centre for Community Development, Hanoi, Vietnam
| | - Minh Le
- School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
| | - Beverley-Ann Biggs
- Department of Medicine and Victorian Infectious Diseases Service, Doherty Institute, University of Melbourne, Melbourne, Victoria, Australia
| |
Collapse
|
5
|
Berti C, Gaffey MF, Bhutta ZA, Cetin I. Multiple-micronutrient supplementation: Evidence from large-scale prenatal programmes on coverage, compliance and impact. MATERNAL AND CHILD NUTRITION 2017; 14 Suppl 5:e12531. [PMID: 29271119 PMCID: PMC6865895 DOI: 10.1111/mcn.12531] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 06/29/2017] [Accepted: 08/30/2017] [Indexed: 01/19/2023]
Abstract
Micronutrient deficiencies during pregnancy pose important challenges for public-health, given the potential adverse outcomes not only during pregnancy but across the life-course. Provision of iron-folic acid (IFA) supplements is the strategy most commonly practiced and recommended globally. How to successfully implement IFA and multiple micronutrient supplementation interventions among pregnant women and to achieve sustainable/permanent solutions to prenatal micronutrient deficiencies remain unresolved issues in many countries. This paper aims to analyse available experiences of prenatal IFA and multiple micronutrient interventions to distil learning for their effective planning and large-scale implementation. Relevant articles and programme-documentation were comprehensively identified from electronic databases, websites of major-agencies and through hand-searching of relevant documents. Retrieved documents were screened and potentially relevant reports were critically examined by the authors with the aim of identifying a set of case studies reflecting regional variation, a mix of implementation successes and failures, and a mix of programmes and large-scale experimental studies. Information on implementation, coverage, compliance, and impact was extracted from reports of large-scale interventions in Central America, Southeast Asia, South Asia, and Sub-Saharan Africa. The WHO/CDC Logic-Model for Micronutrient Interventions in Public Health was used as an organizing framework for analysing and presenting the evidence. Our findings suggest that to successfully implement supplementation interventions and achieve sustainable-permanent solutions efforts must focus on factors and processes related to quality, cost-effectiveness, coverage, utilization, demand, outcomes, impacts, and sustainability of programmes including strategic analysis, management, collaborations to pilot a project, and careful monitoring, midcourse corrections, supervision and logistical-support to gradually scaling it up.
Collapse
Affiliation(s)
- Cristiana Berti
- Department of Biomedical and Clinical Sciences, School of Medicine, University of Milan, Milan, Italy
| | - Michelle F Gaffey
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Department of Nutritional Sciences and Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada.,Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Irene Cetin
- Department of Biomedical and Clinical Sciences, School of Medicine, University of Milan, Milan, Italy
| |
Collapse
|
6
|
Firestone R, Rowe CJ, Modi SN, Sievers D. The effectiveness of social marketing in global health: a systematic review. Health Policy Plan 2016; 32:110-124. [DOI: 10.1093/heapol/czw088] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2016] [Indexed: 12/30/2022] Open
|
7
|
Shelley D, VanDevanter N, Cleland CC, Nguyen L, Nguyen N. Implementing tobacco use treatment guidelines in community health centers in Vietnam. Implement Sci 2015; 10:142. [PMID: 26453554 PMCID: PMC4600252 DOI: 10.1186/s13012-015-0328-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 09/18/2015] [Indexed: 11/29/2022] Open
Abstract
Background Vietnam has a smoking prevalence that is the second highest among Southeast Asian countries (SEACs). According to the World Health Organization (WHO), most reductions in mortality from tobacco use in the near future will be achieved through helping current users quit. Yet, largely due to a lack of research on strategies for implementing WHO-endorsed treatment guidelines in primary care settings, services to treat tobacco dependence are not readily available to smokers in low middle-income countries (LMICs) like Vietnam. The objective of this study is to conduct a cluster randomized controlled trial that compares the effectiveness of two system-level strategies for implementing evidence-based guidelines for the treatment of tobacco use in 26 public community health centers (CHCs) in Vietnam. Methods/Design The current study will use a cluster-randomized design and multiple data sources (patient exit interviews, provider and village health worker (VHW) surveys, and semi-structured provider/VHW interviews) to study the process of adapting and implementing clinical practice guidelines in Vietnam and theory-driven mechanisms hypothesized to explain the comparative effectiveness of the two strategies for implementation. CHCs will be randomly assigned to either of the following: (1) training plus clinical reminder system (TC) or (2) TC + referral to a VHW (TCR) for three in person counseling sessions. The primary outcome is provider adherence to tobacco use treatment guidelines. The secondary outcome is 6-month biochemically verified smoking abstinence. Discussion The proposed implementation strategies draw on evidence-based approaches and a growing literature that supports the effectiveness of integrating community health workers as members of the health care team to improve access to preventive services. We hypothesize that the value of these implementation strategies is additive and that incorporating a referral resource that allows providers to delegate the task of offering counseling (TCR) will be superior to TC alone in improving delivery of cessation assistance to smokers. The findings of this research have potential to guide large-scale adoption of promising strategies for implementing and disseminating tobacco use treatment guidelines throughout the public health system in Vietnam and will serve as a model for similar action in other LMICs. Trial registration NCT01967654 Electronic supplementary material The online version of this article (doi:10.1186/s13012-015-0328-8) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Donna Shelley
- Department of Population Health, New York University School of Medicine, 227 East 30th Street, 7th floor, New York, NY, 10016, USA.
| | - Nancy VanDevanter
- New York University College of Nursing, 433 First Ave, New York, NY, 10010, USA.
| | - Charles C Cleland
- Center for Drug Use and HIV Research, New York University College of Nursing, 433 First Ave, New York, NY, 10010, USA.
| | - Linh Nguyen
- Institute of Social Medical Studies, No. 18, Lot 12B, Trung Yen 10, Trung Hoa, Cau Giay District, Hanoi, Vietnam.
| | - Nam Nguyen
- Institute of Social Medical Studies, No. 18, Lot 12B, Trung Yen 10, Trung Hoa, Cau Giay District, Hanoi, Vietnam.
| |
Collapse
|
8
|
Gunaratna NS, Masanja H, Mrema S, Levira F, Spiegelman D, Hertzmark E, Saronga N, Irema K, Shuma M, Elisaria E, Fawzi W. Multivitamin and iron supplementation to prevent periconceptional anemia in rural tanzanian women: a randomized, controlled trial. PLoS One 2015; 10:e0121552. [PMID: 25905863 PMCID: PMC4408096 DOI: 10.1371/journal.pone.0121552] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Accepted: 02/12/2015] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE Women's nutritional status during conception and early pregnancy can influence maternal and infant outcomes. This study examined the efficacy of pre-pregnancy supplementation with iron and multivitamins to reduce the prevalence of anemia during the periconceptional period among rural Tanzanian women and adolescent girls. DESIGN A double-blind, randomized controlled trial was conducted in which participants were individually randomized to receive daily oral supplements of folic acid alone, folic acid and iron, or folic acid, iron, and vitamins A, B-complex, C, and E at approximately single recommended dietary allowance (RDA) doses for six months. SETTING Rural Rufiji District, Tanzania. SUBJECTS Non-pregnant women and adolescent girls aged 15-29 years (n = 802). RESULTS The study arms were comparable in demographic and socioeconomic characteristics, food security, nutritional status, pregnancy history, and compliance with the regimen (p>0.05). In total, 561 participants (70%) completed the study and were included in the intention-to-treat analysis. Hemoglobin levels were not different across treatments (median: 11.1 g/dL, Q1-Q3: 10.0-12.4 g/dL, p = 0.65). However, compared with the folic acid arm (28%), there was a significant reduction in the risk of hypochromic microcytic anemia in the folic acid and iron arm (17%, RR: 0.61, 95% CI: 0.42-0.90, p = 0.01) and the folic acid, iron, and multivitamin arm (19%, RR: 0.66, 95% CI: 0.45-0.96, p = 0.03). Inverse probability of treatment weighting (IPTW) to adjust for potential selection bias due to loss to follow-up did not materially change these results. The effect of the regimens was not modified by frequency of household meat consumption, baseline underweight status, parity, breastfeeding status, or level of compliance (in all cases, p for interaction>0.2). CONCLUSIONS Daily oral supplementation with iron and folic acid among women and adolescents prior to pregnancy reduces risk of anemia. The potential benefits of supplementation on the risk of periconceptional anemia and adverse pregnancy outcomes warrant investigation in larger studies. TRIAL REGISTRATION ClinicalTrials.gov NCT01183572.
Collapse
Affiliation(s)
- Nilupa S. Gunaratna
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | | | | | | | - Donna Spiegelman
- Departments of Epidemiology, Biostatistics, and Nutrition, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Ellen Hertzmark
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Naomi Saronga
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Kahema Irema
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Mary Shuma
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | | | - Wafaie Fawzi
- Departments of Global Health and Population, Epidemiology, and Nutrition, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
| |
Collapse
|
9
|
Shelley D, Nguyen L, Pham H, VanDevanter N, Nguyen N. Barriers and facilitators to expanding the role of community health workers to include smoking cessation services in Vietnam: a qualitative analysis. BMC Health Serv Res 2014; 14:606. [PMID: 25424494 PMCID: PMC4247125 DOI: 10.1186/s12913-014-0606-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 11/17/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite high smoking rates, cessation services are largely unavailable in Vietnam. This study explored attitudes and beliefs of community health workers (CHWs) towards expanding their role to include delivering tobacco use treatment (TUT), and potential barriers and facilitators associated with implementing a strategy in which health centers would refer patients to CHWs for cessation services. METHODS We conducted four focus groups with 29 CHWs recruited from four district community health centers (CHCs) in Hanoi, Vietnam. RESULTS Participants supported expanding their role saying that it fit well with their current responsibilities. They further endorsed the feasibility of serving as a referral resource for providers in local CHCs expressing the belief that CHWs were "more suitable than their clinical colleagues" to offer cessation assistance. The most frequently cited barrier to routinely offering cessation services was that despite enacting a National Tobacco Control Action plan, cessation is not one of the national prevention priorities. As a result, CHWs have not been "assigned" to help smokers quit by the Ministry of Health. Additional barriers included lack of training and time constraints. CONCLUSION Focus groups suggest that implementing a systems-level intervention that allows providers to refer smokers to CHWs is a promising model for extending the treatment of tobacco use beyond primary care settings and increasing access to smoking cessation services in Vietnam. There is a need to test the cost-effectiveness of this and other strategies for implementing TUT guidelines to support and inform national tobacco control policies in Vietnam and other low-and middle-income countries.
Collapse
Affiliation(s)
- Donna Shelley
- />Department of Population Health, New York University School of Medicine, 227 East 30th Street, New York, NY 10016 USA
| | - Linh Nguyen
- />Institute of Social Medical Studies, Hanoi, Vietnam
| | - Hieu Pham
- />Rush Medical College, Chicago, NY USA
| | - Nancy VanDevanter
- />New York University College of Nursing, Global Institute for Public Health, New York, NY USA
| | - Nam Nguyen
- />Institute of Social Medical Studies, Hanoi, Vietnam
| |
Collapse
|
10
|
Abstract
INTRODUCTION There is increasingly a double burden of under-nutrition and obesity in women of reproductive age. Preconception underweight or overweight, short stature and micronutrient deficiencies all contribute to excess maternal and fetal complications during pregnancy. METHODS A systematic review and meta-analysis of the evidence was conducted to ascertain the possible impact of preconception care for adolescents, women and couples of reproductive age on maternal, newborn and child health (MNCH) outcomes. A comprehensive strategy was used to search electronic reference libraries, and both observational and clinical controlled trials were included. Cross-referencing and a separate search strategy for each preconception risk and intervention ensured wider study capture. RESULTS Maternal pre-pregnancy weight is a significant factor in the preconception period with underweight contributing to a 32% higher risk of preterm birth, and obesity more than doubling the risk for preeclampsia, gestational diabetes. Overweight women are more likely to undergo a Cesarean delivery, and their newborns have higher chances of being born with a neural tube or congenital heart defect. Among nutrition-specific interventions, preconception folic acid supplementation has the strongest evidence of effect, preventing 69% of recurrent neural tube defects. Multiple micronutrient supplementation shows promise to reduce the rates of congenital anomalies and risk of preeclampsia. Although over 40% of women worldwide are anemic in the preconception period, only one study has shown a risk for low birth weight. CONCLUSION All women, but especially those who become pregnant in adolescence or have closely-spaced pregnancies (inter-pregnancy interval less than six months), require nutritional assessment and appropriate intervention in the preconception period with an emphasis on optimizing maternal body mass index and micronutrient reserves. Increasing coverage of nutrition-specific and nutrition-sensitive strategies (such as food fortification; integration of nutrition initiatives with other maternal and child health interventions; and community based platforms) is necessary among adolescent girls and women of reproductive age. The effectiveness of interventions will need to be simultaneously monitored, and form the basis for the development of improved delivery strategies and new nutritional interventions.
Collapse
Affiliation(s)
- Sohni V Dean
- Division of Women and Child Health, Aga Khan University Karachi, Pakistan
| | - Zohra S Lassi
- Division of Women and Child Health, Aga Khan University Karachi, Pakistan
| | - Ayesha M Imam
- Division of Women and Child Health, Aga Khan University Karachi, Pakistan
| | - Zulfiqar A Bhutta
- Division of Women and Child Health, Aga Khan University Karachi, Pakistan
| |
Collapse
|
11
|
Abstract
The notion of preconception care aims to target the existing risks before pregnancy, whereby resources may be used to improve reproductive health and optimize knowledge before conceiving. The preconception period provides an opportunity to intervene earlier to optimize the health of potential mothers (and fathers) and to prevent harmful exposures from affecting the developing fetus. These interventions include birth spacing and preventing teenage pregnancy, promotion of contraceptive use, optimization of weight and micronutrient status, prevention and management of infectious diseases, and screening for and managing chronic conditions. Given existing interventions and the need to organize services to optimize delivery of care in a logical and effective manner, interventions are frequently co-packaged or bundled together. This paper highlights packages of preconception interventions that can be combined and co-delivered to women through various delivery channels and provides a logical framework for development of such packages in varying contexts.
Collapse
Affiliation(s)
- Zohra S Lassi
- Division of Women and Child Health, Aga Khan University Karachi, Pakistan
| | - Sohni V Dean
- Division of Women and Child Health, Aga Khan University Karachi, Pakistan
| | - Dania Mallick
- Division of Women and Child Health, Aga Khan University Karachi, Pakistan
| | - Zulfiqar A Bhutta
- Division of Women and Child Health, Aga Khan University Karachi, Pakistan
| |
Collapse
|
12
|
Hanieh S, Ha TT, Simpson JA, Casey GJ, Khuong NC, Thoang DD, Thuy TT, Pasricha SR, Tran TD, Tuan T, Dwyer T, Fisher J, Biggs BA. The effect of intermittent antenatal iron supplementation on maternal and infant outcomes in rural Viet Nam: a cluster randomised trial. PLoS Med 2013; 10:e1001470. [PMID: 23853552 PMCID: PMC3708703 DOI: 10.1371/journal.pmed.1001470] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 05/01/2013] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Anemia affects over 500 million women, and in pregnancy is associated with impaired maternal and infant outcomes. Intermittent antenatal iron supplementation is an attractive alternative to daily dosing; however, the impact of this strategy on infant outcomes remains unclear. We compared the effect of intermittent antenatal iron supplementation with daily iron supplementation on maternal and infant outcomes in rural Viet Nam. METHODS AND FINDINGS This cluster randomised trial was conducted in Ha Nam province, Viet Nam. 1,258 pregnant women (< 16 wk gestation) in 104 communes were assigned to daily iron-folic acid (IFA), twice weekly IFA, or twice weekly multiple micronutrient (MMN) supplementation. Primary outcome was birth weight. Mean birth weight was 3,148 g (standard deviation 416). There was no difference in the birth weights of infants of women receiving twice weekly IFA compared to daily IFA (mean difference [MD] 28 g; 95% CI -22 to 78), or twice weekly MMN compared to daily IFA (MD -36.8 g; 95% CI -82 to 8.2). At 32 wk gestation, maternal ferritin was lower in women receiving twice weekly IFA compared to daily IFA (geometric mean ratio 0.73; 95% CI 0.67 to 0.80), and in women receiving twice weekly MMN compared to daily IFA (geometric mean ratio 0.62; 95% CI 0.57 to 0.68), but there was no difference in hemoglobin levels. Infants of mothers who received twice weekly IFA had higher cognitive scores at 6 mo of age compared to those who received daily IFA (MD 1.89; 95% CI 0.23 to 3.56). CONCLUSIONS Twice weekly antenatal IFA or MMN did not produce a clinically important difference in birth weight, when compared to daily IFA supplementation. The significant improvement in infant cognitive outcomes at 6 mo of age following twice weekly antenatal IFA requires further exploration, and provides additional support for the use of intermittent, rather than daily, antenatal IFA in populations with low rates of iron deficiency. TRIAL REGISTRATION Australia New Zealand Clinical Trials Registry 12610000944033.
Collapse
Affiliation(s)
- Sarah Hanieh
- Department of Medicine, University of Melbourne, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Tran T. Ha
- Research and Training Centre for Community Development, Hanoi, Viet Nam
| | - Julie A. Simpson
- Centre for Molecular, Environmental, Genetic and Analytic Epidemiology, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Gerard J. Casey
- Department of Medicine, University of Melbourne, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Nguyen C. Khuong
- Provincial Centre of Preventive Medicine, Ha Nam Province, Viet Nam
| | - Dang D. Thoang
- Provincial Centre of Preventive Medicine, Ha Nam Province, Viet Nam
| | - Tran T. Thuy
- Research and Training Centre for Community Development, Hanoi, Viet Nam
| | - Sant-Rayn Pasricha
- Department of Medicine, University of Melbourne, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Thach D. Tran
- Research and Training Centre for Community Development, Hanoi, Viet Nam
- The Jean Hailes Research Unit, School of Public Health and Preventive Medicine, Monash University, Victoria, Australia
- Centre for Women's Health Gender and Society, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia
| | - Tran Tuan
- Research and Training Centre for Community Development, Hanoi, Viet Nam
| | - Terence Dwyer
- Murdoch Childrens Research Institute, The Royal Children's Hospital, Parkville Victoria, Australia
| | - Jane Fisher
- The Jean Hailes Research Unit, School of Public Health and Preventive Medicine, Monash University, Victoria, Australia
| | - Beverley-Ann Biggs
- Department of Medicine, University of Melbourne, Royal Melbourne Hospital, Parkville, Victoria, Australia
- The Victorian Infectious Diseases Service, Royal Melbourne Hospital, Parkville Victoria, Australia
| |
Collapse
|
13
|
Casey GJ, Montresor A, Cavalli-Sforza LT, Thu H, Phu LB, Tinh TT, Tien NT, Phuc TQ, Biggs BA. Elimination of iron deficiency anemia and soil transmitted helminth infection: evidence from a fifty-four month iron-folic acid and de-worming program. PLoS Negl Trop Dis 2013; 7:e2146. [PMID: 23593517 PMCID: PMC3623698 DOI: 10.1371/journal.pntd.0002146] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2012] [Accepted: 02/21/2013] [Indexed: 11/18/2022] Open
Abstract
Background Intermittent iron-folic acid supplementation and regular de-worming are effective initiatives to reduce anemia, iron deficiency, iron deficiency anemia, and soil transmitted helminth infections in women of reproductive age. However, few studies have assessed the long-term effectiveness of population-based interventions delivered in resource-constrained settings. Methodology/Principal Findings The objectives were to evaluate the impact of weekly iron-folic acid supplementation and de-worming on mean hemoglobin and the prevalence of anaemia, iron deficiency, and soil transmitted helminth infection in a rural population of women in northern Vietnam and to identify predictive factors for hematological outcomes. A prospective cohort design was used to evaluate a population-based supplementation and deworming program over 54 months. The 389 participants were enrolled just prior to commencement of the intervention. After 54 months 76% (95% CI [68%, 84%]) were taking the iron-folic acid supplement and 95% (95% CI [93%, 98%]) had taken the most recently distributed deworming treatment. Mean hemoglobin rose from 122 g/L (95% CI [120, 124]) to 131 g/L (95% CI [128, 134]) and anemia prevalence fell from 38% (95% CI [31%, 45%]) to 18% (95% CI [12%, 23%]); however, results differed significantly between ethnic groups. Iron deficiency fell from 23% (95% CI [17%, 29%]) to 8% (95% CI [4%, 12%]), while the prevalence of iron deficiency anemia was reduced to 4% (95% CI [1%, 7%]). The prevalence of hookworm infection was reduced from 76% (95% CI [68%, 83%]) to 11% (95% CI [5%, 18%]). The level of moderate or heavy infestation of any soil-transmitted helminth was reduced to less than 1%. Conclusions/Significance Population-based interventions can efficiently and effectively reduce anemia and practically eliminate iron deficiency anemia and moderate to heavy soil transmitted helminth infections, maintaining them below the level of public health concern. Nutritional deficiencies are common in women in rural and disadvantaged regions, and, in particular, iron and folate deficiencies may impact their health and that of their offspring. Weekly iron-folic acid supplementation and regular deworming help to prevent these deficiencies, yet many women in developing countries do not have access to these interventions. Using the local health system, we implemented a weekly iron-folic acid supplementation program with regular deworming for approximately 250,000 women in a rural mountainous province of Viet Nam. We present the results of a survey of women's iron and worm infection status after the program has been running for 54 months. Overall, anemia prevalence fell from 38% to 18%, iron deficiency fell from 23% to 8% and the prevalence of iron deficiency anemia was reduced to 4%. The level of moderate or heavy infestation of any soil-transmitted worm infection was reduced to less than 1%. These results show that a health system-based program can reduce and maintain the prevalence of these diseases in the community at a level where they do not constitute a public health risk.
Collapse
Affiliation(s)
- Gerard J. Casey
- Department of Medicine, The University of Melbourne, The Royal Melbourne Hospital, Parkville, Australia
| | | | | | - Hoang Thu
- Centre of Malariology, Parasitology and Entomology, Yen Bai, Vietnam
| | - Luong B. Phu
- Centre of Malariology, Parasitology and Entomology, Yen Bai, Vietnam
| | - Ta T. Tinh
- National Institute of Malariology, Parasitology and Entomology, Hanoi, Vietnam
| | - Nong T. Tien
- National Institute of Malariology, Parasitology and Entomology, Hanoi, Vietnam
| | - Tran Q. Phuc
- National Institute of Malariology, Parasitology and Entomology, Hanoi, Vietnam
| | - Beverley-Ann Biggs
- Department of Medicine, The University of Melbourne, The Royal Melbourne Hospital, Parkville, Australia
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, Parkville, Australia
- * E-mail:
| |
Collapse
|
14
|
Siridamrongvattana S, Van Hoa N, Sanchaisuriya K, Dung N, Hoa PTT, Sanchaisuriya P, Fucharoen G, Fucharoen S, Schelp FP. Burden of anemia in relation to thalassemia and iron deficiency among Vietnamese pregnant women. Acta Haematol 2013; 130:281-7. [PMID: 23970041 DOI: 10.1159/000351168] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Accepted: 04/08/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND AIMS Information about the extent to which anemia is related to thalassemia and iron deficiency (ID) is not available in Vietnam. This study investigated the burden of anemia in relation to thalassemia and ID among Vietnamese pregnant women. METHODS A cross-sectional study was conducted in Thua Thien Hue, Central Vietnam. Blood samples taken from 399 pregnant women with a gestational age <12 weeks were analyzed. Anemia was defined as Hb levels <11 g/dl, and ID as ferritin values <15 ng/ml. RESULTS Out of 399 participants, 77 (19.3%) were anemic. While the prevalence of ID was 20.1%, the prevalence of ID anemia was 6.0%. The overall prevalence of thalassemia was 7.3%. Of the 77 anemic women, 24 (31.2%) had ID, and 20 (26.0%) had thalassemia genes. The rest (42.9%) were anemic due to unknown causes. CONCLUSIONS The results indicate that ID remains a significant health burden among the study population, together with anemia caused by unknown factors. Thalassemias appear not to contribute to a great extent to anemia among Vietnamese pregnant women. Other causes need to be investigated further in order to develop an effective control program for anemia within the population.
Collapse
Affiliation(s)
- Sirivara Siridamrongvattana
- Centre for Research and Development of Medical Diagnostic Laboratories, Faculty of Associated Medical Sciences, Khon Kaen University, Khon Kaen, Thailand
| | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Passerini L, Casey GJ, Biggs BA, Cong DT, Phu LB, Phuc TQ, Carone M, Montresor A. Increased birth weight associated with regular pre-pregnancy deworming and weekly iron-folic acid supplementation for Vietnamese women. PLoS Negl Trop Dis 2012; 6:e1608. [PMID: 22509421 PMCID: PMC3317901 DOI: 10.1371/journal.pntd.0001608] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2011] [Accepted: 02/28/2012] [Indexed: 12/31/2022] Open
Abstract
Background Hookworm infections are significant public health issues in South-East Asia. In women of reproductive age, chronic hookworm infections cause iron deficiency anaemia, which, upon pregnancy, can lead to intrauterine growth restriction and low birth weight. Low birth weight is an important risk factor for neonatal and infant mortality and morbidity. Methodology We investigated the association between neonatal birth weight and a 4-monthly deworming and weekly iron-folic acid supplementation program given to women of reproductive age in north-west Vietnam. The program was made available to all women of reproductive age (estimated 51,623) in two districts in Yen Bai Province for 20 months prior to commencement of birth weight data collection. Data were obtained for births at the district hospitals of the two intervention districts as well as from two control districts where women did not have access to the intervention, but had similar maternal and child health indicators and socio-economic backgrounds. The primary outcome was low birth weight. Principal Findings The birth weights of 463 infants born in district hospitals in the intervention (168) and control districts (295) were recorded. Twenty-six months after the program was started, the prevalence of low birth weight was 3% in intervention districts compared to 7.4% in control districts (adjusted odds ratio 0.29, 95% confidence interval 0.10 to 0.81, p = 0.017). The mean birth weight was 124 g (CI 68 - 255 g, p<0.001) greater in the intervention districts compared to control districts. Conclusions/Significance The findings of this study suggest that providing women with regular deworming and weekly iron-folic acid supplements before pregnancy is associated with a reduced prevalence of low birth weight in rural Vietnam. The impact of this health system-integrated intervention on birth outcomes should be further evaluated through a more extensive randomised-controlled trial. Low birth weight is an important risk factor for neonatal and infant morbidity and mortality and may impact on growth and development. Maternal iron deficiency anaemia contributes to intrauterine growth restriction and low birth weight. Hookworm infections and an iron-depleted diet may lead to iron deficiency anaemia, and both are common in many developing countries. A pilot program of deworming and weekly iron-folic acid supplementation for non-pregnant women aiming to prevent iron deficiency was implemented in northern Vietnam. We compared the birth weight of babies born to women who had had access to the intervention to babies born in districts where the intervention had not been implemented. The mean birth weight of the intervention districts' babies was 124 g more than the control districts' babies; the prevalence of low birth weight was also reduced. These results suggest that providing women with deworming and weekly iron-folic acid supplements before pregnancy is associated with increased birth weight in rural Vietnam. This intervention was provided as a health system integrated program which could be replicated in other at-risk rural areas. If so it could increase the impact of prenatal and antenatal programs, improving the health of both women and newborns.
Collapse
|
16
|
Goonewardene M, Shehata M, Hamad A. Anaemia in pregnancy. Best Pract Res Clin Obstet Gynaecol 2011; 26:3-24. [PMID: 22138002 DOI: 10.1016/j.bpobgyn.2011.10.010] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Revised: 10/19/2011] [Accepted: 10/19/2011] [Indexed: 11/16/2022]
Abstract
Anaemia in pregnancy, defined as a haemoglobin concentration (Hb) < 110 g/L, affects more than 56 million women globally, two thirds of them being from Asia. Multiple factors lead to anaemia in pregnancy, nutritional iron deficiency anaemia (IDA) being the commonest. Underlying inflammatory conditions, physiological haemodilution and several factors affecting Hb and iron status in pregnancy lead to difficulties in establishing a definitive diagnosis. IDA is associated with increased maternal and perinatal morbidity and mortality, and long-term adverse effects in the new born. Strategies to prevent anaemia in pregnancy and its adverse effects include treatment of underlying conditions, iron and folate supplementation given weekly for all menstruating women including adolescents and daily for women during pregnancy and the post partum period, and delayed clamping of the umbilical cord at delivery. Oral iron is preferable to intravenous therapy for treatment of IDA. B12 and folate deficiencies in pregnancy are rare and may be due to inadequate dietary intake with the latter being more common. These vitamins play an important role in embryo genesis and hence any relative deficiencies may result in congenital abnormalities. Finding the underlying cause are crucial to the management of these deficiencies. Haemolytic anaemias rare also rare in pregnancy, but may have life-threatening complications if the diagnosis is not made in good time and acted upon appropriately.
Collapse
Affiliation(s)
- Malik Goonewardene
- Department of Obstetrics and Gynaecology, University of Ruhuna, Faculty of Medicine, Galle, Sri Lanka.
| | | | | |
Collapse
|
17
|
Weekly iron-folic acid supplementation with regular deworming is cost-effective in preventing anaemia in women of reproductive age in Vietnam. PLoS One 2011; 6:e23723. [PMID: 21931611 PMCID: PMC3169551 DOI: 10.1371/journal.pone.0023723] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2011] [Accepted: 07/22/2011] [Indexed: 01/07/2023] Open
Abstract
Background To estimate the cost and cost-effectiveness of a project administering de-worming and weekly iron-folic acid supplementation to control anaemia in women of reproductive age in Yen Bai province, Vietnam. Methods and Findings Cost effectiveness was evaluated using data on programmatic costs based on two surveys in 2006 and 2009 and impact on anaemia and iron status collected in 2006, 2007, and 2008. Data on initial costs for training and educational materials were obtained from the records of the National Institute of Malariology, Parasitology and Entomology and the Yen Bai Malaria Control Program. Structured questionnaires for health workers at district, commune and village level were used to collect ongoing distribution and monitoring costs, and for participants to collect transport and loss of earnings costs. The cost per woman treated (defined as consuming at least 75% of the recommended intake) was USD0.76 per annum. This estimate includes financial costs (for supplies, training), and costs of health care workers' time. Prevalence of anaemia fell from 38% at baseline, to 20% after 12 months. Thus, the cost-effectiveness of the project is assessed at USD 4.24 per anaemia case prevented per year. Based on estimated productivity gains for adult women, the benefit:cost ratio is 6.7∶1. Cost of the supplements and anthelminthics was 47% of the total, while costs of training, monitoring, and health workers' time accounted for 53%. Conclusion The study shows that weekly iron-folic acid supplementation and regular de-worming is a low-cost and cost-effective intervention and would be appropriate for population-based introduction in settings with a high prevalence of anaemia and iron deficiency and low malaria infection rates.
Collapse
|
18
|
Pasricha SR, Biggs BA, Prashanth NS, Sudarshan H, Moodie R, Black J, Shet A. Factors influencing receipt of iron supplementation by young children and their mothers in rural India: local and national cross-sectional studies. BMC Public Health 2011; 11:617. [PMID: 21810279 PMCID: PMC3171369 DOI: 10.1186/1471-2458-11-617] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Accepted: 08/03/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In India, 55% of women and 69.5% of preschool children are anaemic despite national policies recommending routine iron supplementation. Understanding factors associated with receipt of iron in the field could help optimise implementation of anaemia control policies. Thus, we undertook 1) a cross-sectional study to evaluate iron supplementation to children (and mothers) in rural Karnataka, India, and 2) an analysis of all-India rural data from the National Family Health Study 2005-6 (NFHS-3). METHODS All children aged 12-23 months and their mothers served by 6 of 8 randomly selected sub-centres managed by 2 rural Primary Health Centres of rural Karnataka were eligible for the Karnataka Study, conducted between August and October 2008. Socioeconomic and demographic data, access to health services and iron receipt were recorded. Secondly, NFHS-3 rural data were analysed. For both studies, logistic regression was used to evaluate factors associated with receipt of iron. RESULTS The Karnataka Study recruited 405 children and 377 of their mothers. 41.5% of children had received iron, and 11.5% received iron through the public system. By multiple logistic regression, factors associated with children's receipt of iron included: wealth (Odds Ratio (OR) 2.63 [95% CI 1.11, 6.24] for top vs bottom wealth quintile), male sex (OR 2.45 [1.47, 4.10]), mother receiving postnatal iron (OR 2.31 [1.25, 4.28]), mother having undergone antenatal blood test (OR 2.10 [1.09, 4.03]); Muslim religion (OR 0.02 [0.00, 0.27]), attendance at Anganwadi centre (OR 0.23 [0.11, 0.49]), fully vaccinated (OR 0.33 [0.15, 0.75]), or children of mothers with more antenatal health visits (8-9 visits OR 0.25 [0.11, 0.55]) were less likely to receive iron. Nationally, 3.7% of rural children were receiving iron; this was associated with wealth (OR 1.12 [1.02, 1.23] per quintile), maternal education (compared with no education: completed secondary education OR 2.15 [1.17, 3.97], maternal antenatal iron (2.24 [1.56, 3.22]), and child attending an Anganwadi (OR 1.47 [1.20, 1.80]). CONCLUSION In rural India, public distribution of iron to children is inadequate and disparities exist. Measures to optimize receipt of government supplied iron to all children regardless of wealth and ethnic background could help alleviate anaemia in this population.
Collapse
Affiliation(s)
- Sant-Rayn Pasricha
- The Nossal Institute for Global Health, Faculty of Medicine, Dentistry andHealth Sciences, The University of Melbourne, Carlton, Victoria, Australia
| | | | | | | | | | | | | |
Collapse
|
19
|
Twenty-first century progress toward the global control of human hookworm infection. Curr Infect Dis Rep 2011; 13:210-7. [PMID: 21462001 DOI: 10.1007/s11908-011-0182-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Hookworms are bloodsucking nematodes that afflict up to 740 million persons in tropical and subtropical regions, with Asia and sub-Saharan Africa exhibiting particularly high infection rates. Prevalence, intensity, and pathology often vary considerably at both the regional and local level, and may be influenced by coinfection with other parasitic infections such as malaria. Immunoepidemiological studies suggest that hookworms manipulate the host immune response and may provide some protection from allergy and asthma. There has been substantial progress in elucidating the molecular pathogenesis of hookworm disease, with anticoagulants, protease inhibitors, digestive proteases, and novel excretory/secretory proteins being of particular interest. Mass chemotherapy remains a mainstay of hookworm control strategies, although continued use of drugs may lead to reduced efficacy and treatment failures have been observed. Consequently, a need exists for innovative approaches, such as vaccination; recent studies have identified and/or evaluated candidate vaccine antigens in human and animal models.
Collapse
|