Utilization of positive deviance analysis in evaluating community-based nutrition programs: an application to the Dular program in Bihar, India

BACKGROUND: Positive deviance is increasingly employed in international development activities to permit the utilization of proven local solutions. Including positive deviance methods in evaluation analysis, particularly in places like Bihar, India, where the rates of child underweight hover at 55%, can help identify project activities and household characteristics that affect key outcomes. These can, in turn, inform decision-making regarding the intensification of particularly promising activities. OBJECTIVES: To apply positive deviance analysis to the Dular program in Bihar, a community-based nutrition program that seeks to improve the impact of India's Integrated Child Development Services on young children. METHODS: In order to assure that desired program outcomes were not dependent on higher economic status, the analysis isolated a subset of program beneficiaries--the poorest children with the best nutritional outcomes--and examined the behavioral and project factors that may have brought about positive results in this subgroup. The data for this analysis were drawn from a 2005 program evaluation with a sample of 1,560 children. RESULTS: The analysis found that positive deviant children with normal nutritional status in the poorest 50% of Dular households were introduced to complementary food almost 2 months earlier (7.18 vs. 9.02 months of age) than severely malnourished children, were more than twice as likely to use soap for handwashing after defecation (25.0% vs. 11.8%), and were more than seven times as likely to have literate mothers (25.0% vs. 3.5%). CONCLUSIONS: The analysis suggests that programmatic efforts relating to these activities have been particularly effective and may well deserve increased investment.     

Women's empowerment and domestic violence: the role of sociocultural determinants in maternal and child undernutrition in tribal and rural communities in South India

BACKGROUND: Moderate malnutrition continues to affect 46% of children under five years of age and 47% of rural women in India. Women's lack of empowerment is believed to be an important factor in the persistent prevalence of malnutrition. In India, women's empowerment often varies by community, with tribes sometimes being the most progressive. OBJECTIVE: To explore the relationship between women's empowerment, maternal nutritional status, and the nutritional status of their children aged 6 to 24 months in rural and tribal communities. METHODS: This study in rural Karnataka, India, included tribal and rural subjects and used both qualitative and quantitative methods of data collection. Structured interviews with mothers were performed and anthropometric measurements were obtained for 820 mother-child pairs. The data were analyzed by multivariate and logistic regression. RESULTS: Some degree of malnutrition was seen in 83.5% of children and 72.4% of mothers in the sample. Biological variables explained most of the variance in nutritional status, followed by health-care seeking and women's empowerment variables; socioeconomic variables explained the least amount of variance. Women's empowerment variables were significantly associated with child nutrition and explained 5.6% of the variance in the sample. Maternal experience of psychological abuse and sexual coercion increased the risk of malnutrition in mothers and children. Domestic violence was experienced by 34% of mothers in the sample. CONCLUSIONS: In addition to the known investments needed to reduce malnutrition, improving women's nutrition, promoting gender equality, empowering women, and ending violence against women could further reduce the prevalence of malnutrition in this segment of the Indian population.     

2013-2020年郑州市二七区碘缺乏病监测结果统计分析

目的 统计分析2013-2020年郑州市二七区碘缺乏病(IDD)监测结果.方法 2013-2020年按照《全国碘缺乏病监测方案》在郑州市二七区开展盐碘监测,同时收集同期新婚育龄妇女、孕妇、哺乳期女性、0～2岁婴幼儿、8～10岁儿童5类人群的尿样,测定尿碘含量.结果 2013-2020年,郑州市二七区居民盐碘含量中位数与...     

Morinda revisited: changes in nutritional well-being and gender differences after 30 years of rapid economic growth in rural Punjab, India

A follow-up study of malnutrition and its determinants among children 6 to 24 months of age was carried out in rural areas of Punjab State in India 30 years after the original study, and following a period of rapid economic growth. The original 1971 study had found a high prevalence of mortality and malnutrition and the worst gender difference in nutritional status ever recorded in an Indian study. The 2001 follow-up study found dramatic reductions in child mortality, child malnutrition, gender-based imbalances in child well-being and care, and family size, the result of participatory economic growth coupled with broad-based educational, health, and family-planning services. Despite overall improvements in caloric intake, however, 40% of lower-class children in 2001 were still consuming less than 50% of their caloric allowance. With minimal gender-based abortion and significantly reduced neglect and mortality offemale children, gender balance among children in this area of rural Punjab improved markedly over the 30-year period.     

Thirty years of a ban on the sale of noniodized salt: impact on iodine nutrition in children in Himachal Pradesh, India

BACKGROUND: A survey conducted by the central iodine-deficiency disorders team in Himachal Pradesh, a state in the goiter-endemic belt of India, revealed that 10 of its 12 districts have an endemic prevalence of goiter. The survey was conducted to provide health program managers data to determine whether it would be necessary to initiate intervention measures. OBJECTIVE: To assess the status of urinary iodine excretion and household salt iodization levels after three decades of a complete ban on the sale of noniodized salt in this goiter-endemic state in India as measured by assessment of urinary iodine excretion levels and iodine content of salt at the household level. METHODS: The guidelines recommended by WHO/ UNICEF/ICCIDD for a rapid assessment of salt iodization were adopted. In each of the 12 studied districts, all senior secondary schools were enlisted and one school was selected by using a random sampling procedure. Two hundred fifty children 11 to 18 years of age were included in the study. Urine samples were collected from a minimum of 170 children and analyzed using the wet digestion method. Salt samples were also collected from a minimum of 170 children and analyzed using the spot testing kit. RESULTS: All districts had a median urinary iodine excretion level > 200 microg/L and 82% of the families were consuming salt with an iodine content of 15 ppm or higher. CONCLUSIONS: The results of the present study high-light the successful implementation of the salt iodization program in the state of Himachal Pradesh. This positive impact may be due to the comprehensive strategy adopted by the state government to improve the quality of salt, development of an effective monitoring information system and effective information, education, and communication activities.     

Reaching the goal of Universal Salt Iodization (USI): experience of Uttar Pradesh, India

BACKGROUND: In 2002, the percentage of households consuming iodized salt in the state of Uttar Pradesh (UP) in India dropped to as low as 6%. This implied that 3.5 million newborns in this non-salt producing state, with 180 million population, were at risk of brain damage unless universal accessibility and consumption of iodized salt was ensured and sustained. OBJECTIVES: Urgent measures were introduced in 3 phases in the statefor accelerating procurement, distribution and consumption of iodized salt. METHODS: In the first phase, a study on mapping of salt wholesalers and understanding the salt trading system--including understanding the knowledge, attitudes, and practices of salt traders was undertaken to accelerate efforts to influence availability, marketing, and accessibility of iodized salt. The study revealed that a total of only 344 primary wholesalers supplied salt to the entire state. Of these, 126 wholesalers marketed 80% of salt and were located in only 15 of the total 70 districts of the state. This finding became a very strong basis for the program in phase II, which focused on the critical group of wholesalers and set up a system to frequently interact with them. The salt wholesalers were equipped with Salt Testing Kits (STKs) to ensure adequate iodine content in the salt procured by them and adherence to the legal ban on the sale of non-iodized salt for human consumption. Simultaneously, a "child-to-community" approach was launched through involvement of middle and high school children to create demand and monitor consumption of iodized salt at the household level. Over 217,000 salt samples (about 26,000 samples per quarter) were brought in by school children and tested for iodine content. RESULTS: The school activities resulted not only in influencing consumption of iodized salt, but also galvanized the entire chain linking consumers, retailers, and wholesalers. In less than 2 years, salt procured with nil iodine decreased from 38% to 15.3%, and salt marketed with adequate iodine level increased from 28.6% to 64.9%. School data revealed an increase in consumption of iodized salt from 6% to 46.7%. In phase 3, additional standardized activities at the school level were included and the program was taken to scale in the state. CONCLUSION: The findings revealed that identification and inclusion of salt wholesalers-not only the salt manufacturers-was important for achieving a rapid positive shift in iodized salt marketing and consumption practices.     

Assessment of the sustainability of the iodine-deficiency disorders control program in Lesotho

BACKGROUND: Evaluation of the sustainability of iodine-deficiency disorders control programs guarantees successful and sustained virtual elimination of iodine deficiency. The Lesotho universal salt iodization legislation was enacted in 2000 as an iodine-deficiency disorders control program and has never been evaluated. OBJECTIVES: To assess the sustainability of the salt iodization program in Lesotho, 2 years after promulgation of the universal salt iodization legislation. METHODS: The proportion to population size method of sampling was used in 2002 to select 31 clusters in all ecological zones and districts of Lesotho. In each cluster, 30 women were selected to give urine and salt samples and 30 schoolchildren to give urine samples. The salt samples were analyzed by the iodometric titration method, and the ammonium persulfate method was used to analyze the urine samples. The chairperson of the iodine-deficiency disorders control program was interviewed on programmatic indicators of sustainability. SAS software was used for statistical analysis of the data. RESULTS: The urinary iodine concentrations of very few children (10.1% and 21.5%) and women (9.8% and 17.9%) were lower than 50 microg/L and 100 microg/L, respectively. At the household level, 86.9% of the households used adequately iodized salt. Only four indicators of sustainability have been attained by the salt iodization program in Lesotho. CONCLUSIONS; Iodine-deficiency disorders have been eliminated as a public health problem in Lesotho, but this elimination is not sustainable. Effective regular monitoring of salt iodine content at all levels, with special attention to iodization of coarse salt, is recommended, together with periodic evaluation of the iodization program.     

Iodine content in bread,milk and the retention of inherent iodine in commonly used Indian recipes

Iodine deficiency disorders (IDD) is still a major public health problem and iodized salt remains the most effective means to control IDD in India. Few reports indicate that vegans have inadequate iodine intake while at the same time concerns are being raised on the implementation of universal salt iodization in the country. Therefore, we investigated the iodine content in bread, milk and commonly used Indian recipes prepared without iodized salt and the retention of inherent iodine therein. Results showed considerable iodine content in bread (25 μg/100 g) and milk (303 μg/L) as a positive fallout of universal salt iodization. Iodine content in 38 vegetarian recipes prepared without iodized salt was very low (2.9 ± 2.4 μg/100 g). Retention of inherent iodine (65.6 ± 15.4%) and iodine from iodized salt (76.7 ± 10.3%) in the same recipes was comparable. Thus, universal salt iodization programme remains the single most important source of dietary iodine for the Indian population.     

Stability of iodine in salt fortified with iodine and iron

BACKGROUND: Determining the stability of iodine in fortified salt can be difficult under certain conditions. Current methods are sometimes unreliable in the presence of iron. OBJECTIVE: To test the new method to more accurately estimate iodine content in double-fortified salt (DFS) fortified with iodine and iron by using orthophosphoric acid instead of sulfuric acid in the titration procedure. METHODS: A double-blind, placebo-controlled study was carried out on DFS and iodized salt produced by the dry-mixing method. DFS and iodized salt were packed and sealed in color-coded, 0.5-kg, low-density polyethylene pouches, and 25 of these pouches were further packed and sealed in color-coded, double-lined, high-density polyethylene bags and transported by road in closed, light-protected containers to the International Council for the Control of Iodine Deficiency Disorders (ICCIDD), Delhi; the National Institute of Nutrition (NIN), Hyderabad; and the Orissa Unit of the National Nutrition Monitoring Bureau (NNMB), Bhubaneswar. The iodine content of DFS and iodized salt stored under normal room conditions in these places was measured by the modified method every month on the same prescribed dates during the first 6 months and also after 15 months. The iodine content of DFS and iodized salt stored under simulated household conditions was also measured in the first 3 months. RESULTS: After the color code was broken at the end of the study, it was found that the DFS and iodized salt stored at Bhubaneswar, Delhi, and Hyderabad retained more or less the same initial iodine content (30-40 ppm) during the first 6 months, and the stability was not affected after 15 months. The proportion of salt samples having more than 30 ppm iodine was 100% in DFS and iodized salt throughout the study period. Daily opening and closing of salt pouches under simulated household conditions did not result in any iodine loss. CONCLUSIONS: The DFS and iodized salt prepared by the dry-mixing method and stored at normal room conditions had excellent iodine stability for more than 1 year.     

Time trends in the intrafamily distribution of dietary energy in rural India

The intrafamily distribution of dietary energy in 5,458 households from seven states in India was assessed from 24-hour dietary recall data collected by the National Nutrition Monitoring Bureau during 1996-97. The energy consumption, expressed as percentage of recommended dietary intake (%RDI), of preschool children, schoolchildren, and adolescents was compared with that of adult men and women in the same households. Time trends in the intrafamily distribution of dietary energy were assessed by comparing the data with those collected in 1975-80 using the same procedures in the same villages. About one-third of the preschool children had an inadequate intake of energy, even when their adult counterparts had an adequate intake, whereas only about 7% of the preschoolers and their parents were consuming inadequate amounts of energy. The extent of energy inadequacy was much less in adolescents and school-age children than in preschool children. This was true even when the adults in the same households had an adequate energy intake. In 1996-97, there was a significant increase in the proportion of households with preschool children consuming inadequate energy, although both adult men and women were consuming energy-adequate diets as compared with the dietary data collected in the same villages in 1975-80. The results indicate the need to provide effective nutrition education for parents regarding the nutritional needs of their children.     

Lessons from successful micronutrient programs. Part III: program impact

Micronutrient-deficiency control programs have been greatly extended at the national level in the last 10 to 15 years. However, rigorous evaluations of these are scarce, so that conclusions on impact are tentative and based mainly on indirect evidence. The coverage of vitamin A capsule distribution programs has exceeded 70% in most study countries. In countries implementing national iodized salt programs, the coverage reaches 60% to 90% of households with adequately iodized salt. Of the three micronutrients, coverage of iron tablet supplementation is the least well documented due to inadequate program monitoring systems and population survey data. Supplementation of preschool children 6 to 59 months of age with vitamin A capsules has plausibly contributed to the reduction in clinical vitamin A deficiency and its near-elimination in many countries. The impact of vitamin A capsule supplementation on children's biochemical vitamin A status (serum retinol) in national programs may be less. National data on salt iodization show a consistent relation to reduced prevalence of iodine-deficiency disorder symptoms (goiter); the rates of cretinism and other results of iodine deficiency are almost certainly falling too. The evaluation of the impact of salt iodization programs on biochemical iodine status is limited by a lack of data. Although trials have demonstrated the efficacy of iron supplementation in reducing the prevalence of anemia, the interpretation of national-level data is not so clear. Given the substantial financial and technical commitment required to implement national micronutrient-deficiency control programs, it is vital that investment enable the evaluation of the impact of these programs. It is becoming increasingly important to collect data on subclinical deficiency (e.g., biochemical data) to assess program impact.     

A multicenter community study on the efficacy of double-fortified salt

BACKGROUND: Iron and iodine deficiencies affect more than 30% of the world's population. Typical Indian diets contain adequate amounts of iron, but the bioavailability is poor. This serious limiting factor is caused by low intake of meat products rich in heme iron and intake of phytates in staple foods in the Indian diet, which inhibits iron absorption. OBJECTIVE: To test the stability of double-fortified salt (DFS) during storage and to assess its efficacy in improving the iron and iodine status of the communities. METHODS: The stability of both iodized salt and DFS during storage for a 2-year period was determined. The bioefficacy of DFS was assessed in communities covering three states of the country for a period of 1 year. This was a multicenter, single-blind trial covering seven clusters. The experimental group used DFS and the control group used iodized salt. The salts were used in all meals prepared for family members, but determination of hemoglobin by the cyanmethemoglobin method was performed in only two or three members per family, and not in children under 10 years of age (n = 393 and 436 in the experimental and control groups, respectively). The family size was usually four or five, with a male: female ratio of 1:1, consisting of two parents with two or three children. Hemoglobin was measured at baseline, 6 months (midpoint), and 12 months (endpoint). Urinary iodine was measured in only one cluster at baseline and endpoint. All the participants were dewormed at baseline, 6 months, and 12 months. RESULTS: The iron and iodine in the DFS were stable during storage for 2 years. Over a period of 1 year, there was an increase of 1.98 g/dL of hemoglobin in the experimental group and 0.77 g/dL of hemoglobin in the control group; the latter increase may have been due to deworming. The median urinary iodine changed from 200 microg/dL at baseline to 205 microg/dL at the end of the study in the experimental group and from 225 microg/dL to 220 microg/dL in the control group. There was a statistically significant (p < .05) improvement in the median urinary iodine status of subjects who were iodine deficient (urinary iodine < 100 microg/L) in both the experimental and the control groups, a result showing that DFS was as efficient as iodized salt in increasing urinary iodine from a deficient to sufficient status. There was a statistically significant increase (p < .05) in hemoglobin in all seven clusters in the experimental group compared with the control. CONCLUSIONS: The iron and iodine in the DFS are stable in storage for 2 years. The DFS has proved beneficial in the delivery of bioavailable iron and iodine.     

Effect of iodine status and other nutritional factors on psychomotor and cognitive performance of Filipino schoolchildren

BACKGROUND: Until 1998, iodine deficiency was a public health problem in the Philippines. A law entitled "An Act Promoting Salt Iodization Nationwide" (ASIN) has been passed and implemented by the government to eliminate iodine deficiency. The contribution of salt iodization, as well as dietary, health, and environmental factors, to improving the intellectual performance of Filipino schoolchildren remains to be determined. OBJECTIVE: The objectives of the study were to determine the relationship between iodine status and levels of psychomotor and cognitive performance in first-grade children aged 6 to 10 years, and to examine the extent to which dietary, biochemical, health, and environmental factors contribute to children's mental performance. METHODS: Two hundred ninety children in six classroom sections from a public school in Manila were examined by measurement of urinary iodine excretion (UIE) and thyroid palpation. The median UIE level for each section was determined. Sixty-five children classified as iodine deficient (UIE < 90 microg/L with grade 1 goiter, n = 34) and non-iodine deficient (UIE > 100 microg/L without goiter, n = 31) were given psychomotor and cognitive function tests (Bender-Gestalt and Raven's Colored Progressive Matrices). Scores from the two tests were used to determine each child's general ability percentile rank. Other variables examined were dietary intake (% RDA of nutrients ingested based on two nonconsecutive 24-hour recalls); deficiencies in iron, vitamin A, and selenium; parasitic infection; coliform contamination of drinking water; household use of iodized salt; illness in the past 2 weeks; and wasting and stunting. RESULTS: Children whose general ability scores were at or above the 50th percentile had higher UIE levels, but the relationship was not significant. Children from sections with higher median UIE levels had higher percentile ranks for general ability (p = .002). Backward logistic regression showed that the variance in deficient and adequate mental performance was explained by dietary intakes that met > or = 80% of the RDA for energy, protein, thiamin, and riboflavin; the use of iodized salt; child's iodine status; and stunting (R2 = .520, p = .0016). Higher class median UIE was associated with better psychomotor and cognitive performance in children who were tested. Factors that contributed to better performance include higher intakes of energy, protein, thiamin, and riboflavin; household use of iodized salt; normal iodine status; and absence of stunting or chronic malnutrition. CONCLUSIONS: Salt iodization, accompanied by adequate intakes of energy, protein, and foods rich in thiamin and riboflavin, can contribute to improved mental performance in Filipino schoolchildren. Longer-term factors that can contribute to improved performance are achievement of normal iodine status and elimination of protein-energy malnutrition.     

Difference in goiter rates between regular and occasional users of iodized salt in Mongolia

In Mongolia many households use iodized salt only occasionally. We investigated whether the occasional use of iodized salt had an impact on the reduction of goiter size. We examined 685 children (8-11 years old) in five groups of households that (1) used iodized salt regularly, (2) used more than 10 kg of iodized salt annually, (3) used 6 to 10 kg annually, (4) used less than 6 kg annually, (5) and regularly used noniodized salt. The prevalence of goiter as determined by ultrasound in these five groups was 31.1%, 30.3%, 40.6%, 52.1%, 56.6%, respectively. There was no difference between goiter rates among the first three groups, but these groups had significantly lower rates than the last two groups. We concluded that annual use of more than 6 kg of iodized salt, preferably more than 10 kg, by a household had a beneficial effect on the rate of goiter. In addition, the possibility was suggested that households that consumed only iodized salt consumed less salt than other households.     

Undernutrition among adult Dhimals of Naxalbari, West Bengal: comparison with other tribes of eastern India

BACKGROUND: The tribes of India comprise approximately 8% of the total population of the country, which probably has the largest number of tribal communities in the world. In general, the tribal populations are among the most underprivileged and undernourished people in India. OBJECTIVES: To determine the anthropometric characteristics and prevalence of undernutrition, based on body mass index (BMI), of adult Dhimals, a tribal population of Naxalbari, West Bengal, India, and to compare these results with those from four other tribes of Eastern India: the Bathudis, Kora Mudis, Santals, and Savars. METHODS: A total of 305 adult (18 years or older) Dhimals (159 men and 146 women) from three villages (Maniram, Hatighisa, and Buraganj) in the Mallabari area of Naxalbari were studied. These villages are located 5 km from Siliguri town, which is approximately 580 km from Kolkata, the provincial capital of West Bengal. Anthropometric measurements included height and weight. BMI was calculated by the standard equation. Undernutrition was evaluated according to World Health Organization (WHO) cutoff points. RESULTS: The overall prevalence of undernutrition (BMI < 18.5) was very high (36.4%). The prevalence was significantly higher in women than in men (46.4% vs. 27.0%; chi2 = 12.54; p < .001; odds ratio, 2.35). According to the WHO criterion, the prevalence of undernutrition was high and the situation was serious in men. Among women, the prevalence of undernutrition was very high and the situation was critical. However, in general, compared with other tribal people of eastern India except the Santals, adult Dhimals had better anthropometric and nutritional profiles. CONCLUSIONS: This study provides evidence that although the anthropometric and nutritional profiles of adult Dhimals are better than those of some of the other tribal populations of eastern India, immediate appropriate nutritional intervention programs are needed for implementation among this ethnic group.     

Serum copper levels among a tribal population in Jharkhand State, India: a pilot survey

BACKGROUND: Copper is an essential trace element that plays a pivotal role in cell physiology. Dietary intake of copper by a population of low-income groups in India has been found to be low, and hence the possibility of dietary copper deficiency exists. OBJECTIVE: To determine serum copper levels among tribal populations in India, an area in which data are limited. METHODS: The study was conducted among tribal populations 18 to 75 years of age residing in Sahibganj, Jharkhand. Two blocks in the district were selected (from a total of eight) for the detailed study. A semistructured pretested questionnaire was used to collect demographic and socioeconomic information about subjects. A total of 995 subjects were enrolled for the present study. Blood was drawn from the antecubital vein and collected in previously labeled polypropylene tubes. Serum copper was determined by the atomic absorption spectrophotometry method and serum samples with copper levels less than 80 microg/dL were considered to have low serum copper levels. RESULTS: The mean serum copper concentration of the study subjects was 91.18 +/- 35.48 microg/dL. Thirty-four percent of the study subjects had low serum copper levels (< 80 microg/dL). Nearly 35% of males and 34.4% of females had low serum copper levels. CONCLUSIONS: This study documented a high prevalence of low serum copper levels among the studied tribal population. Further multicenter studies with larger sample sizes are needed to assess the biological implications of copper deficiency among the tribal populations in India.     

Urinary iodine concentration of pregnant women and female adolescents as an indicator of excessive iodine intake in Sri Lanka

BACKGROUND: Mild deficiencies and excesses of iodine have deleterious effects in both females and males. The iodine status of the population after implementation of the universal salt iodization program in Sri Lanka is not known. OBJECTIVE: This cross-sectional study was carried out to assess the iodine status of pregnant women and female adolescents, with urinary iodine concentration used as the measure of outcome. METHODS: The participants were 100 women in the first trimester of pregnancy and 99 female adolescents in Kuliyapitiya, Kurunegala District, North-Western Province, Sri Lanka. The urinary iodine concentration was measured in a casual urine sample from each subject. The iodate contents of salt samples collected from households of the adolescents participating in the study were also measured. RESULTS: The median urinary iodine concentration of 185.0 microg/L and the prevalence of values under 50 microg/L of only 1% among the pregnant women indicate adequate iodine intake and optimal iodine nutrition. The median urinary iodine concentration (213.1 microg/L) among female adolescents indicates a more than adequate iodine intake and a risk of iodine-induced hyperthyroidism. Approximately 8% and 4% of the adolescents and pregnant women, respectively, had urinary iodine concentrations in the range of mild iodine deficiency (51 to 100 microg/L). More than half of the adolescents (56%) and 39% of the pregnant women had urinary iodine concentrations higher than optimal. The median iodine content in salt samples was 12.7 ppm. Only 20.2% of the samples were adequately iodized, and 10.1% of the samples had very high iodine levels. CONCLUSIONS: Female adolescents and pregnant women had no iodine deficiency, but a considerable proportion of them, especially female adolescents, were at risk for iodine-induced hyperthyroidism. There is thus a need for proper monitoring of the salt iodization program to achieve acceptable iodine status.     

Toward better compliance with iron-folic acid supplements: understanding the behavior of poor urban pregnant women through ethnographic decision models in Vadodara, India

This study made an attempt to develop ethnographic decision models to understand and improve iron-folic acid supplement procurement and compliance-related behaviors of poor urban pregnant women in Vadodara, India, based on data obtained through the use of qualitative research tools. Open-ended, in-depth interviews were conducted with 36 pregnant women (17-32 weeks of gestation) purposively selected from four urban slums. Fortnightly home visits were made to the houses of 20 pregnant women-family member pairs to elicit behaviors related to iron-folic acid supplement procurement and compliance at the household level, from which the ethnographic decision models were developed. The hemoglobin levels of these women were also assessed. Regular counseling until delivery, based on the ethnographic data, helped to improve compliance, which resulted in 95% of the women consuming over 90% of the required dose. The mean hemoglobin level also improved from 9.6 to 11.08 g/dl until the end of the last trimester. This study highlighted the need for qualitative ethnographic data to develop such models that would help in the understanding of specific behaviors that influence program acceptance. Such data would have policy-level implications, for example, developing appropriate information-education-communication material and counseling strategies.     

An analysis of the etiology of anemia and iron deficiency in young women of low socioeconomic status in Bangalore, India

BACKGROUND: Anemia and iron deficiency are significant public health problems in India, particularly among women and children. Recent figures suggest that nearly 50% of young Indian women are anemic. OBJECTIVES: Few studies have comprehensively assessed etiologic factors contributing to anemia and iron deficiency in India. Hence, this study assessed the relative importance of various factors contributing to these problems in young women of low socioeconomic status in Bangalore, India. METHODS: A random sample of 100 nonpregnant, nonlactating women 18 to 35 years of age, selected from among 511 women living in a poor urban settlement, participated in this study. Data were obtained on demography, socioeconomic status, anthropometry, three-day dietary intake, blood hemoglobin, hemoglobinopathies, serum ferritin, serum C-reactive protein, and stool parasites. RESULTS: The prevalence rates of anemia and iron deficiency were 39% and 62%, respectively; 95% of the anemic women were iron deficient. The mean dietary iron intake was 9.5 mg per day, predominantly from the consumption of cereals, pulses, and vegetables (77%). The estimated bioavailability of nonheme iron in this diet was 2.8%. Dietary intakes were suboptimal for several nutrients. Blood hemoglobin was significantly correlated with dietary intake of fat, riboflavin, milk and yogurt, and coffee. Serum ferritin was significantly correlated with intake of niacin, vitamin B12, and selenium. Parasitic infestation was low. CONCLUSIONS: An inadequate intake of dietary iron, its poor bioavailability, and concurrent inadequate intake of dietary micronutrients appear to be the primary factors responsible for the high prevalence of anemia and iron deficiency in this population.     

Empowering a tea-plantation community to improve its micronutrient health

This project was designed to convince and empower management and plantation workers to improve their own nutritional health status and productivity. Plantations are generally bypassed by the government's primary health-care system. A nine-month intervention with iron (60 mg of elemental iron) and vitamin A supplementation and iodized salt was performed on the Balanoor Plantations in India. Of the women tea pickers, 99% (n = 334) received the supplements and bought the iodized salt from the plantation ration shop. Their mean hemoglobin level rose significantly from 11.0 to 11.9 g/dl. The women pickers gave the supplements to their families as well as themselves. The results were the same whether iron was given once or twice a week. The mean hemoglobin level of the women pickers rose significantly from 11.1 to 12.0 g/dl with the twice-weekly dose and from 10.9 to 11.8 g/dl with the weekly dose. The prevalence of clinical signs of vitamin A deficiency in the entire plantation population (about 2,500) was reduced significantly (from 19% to 4%), as was iodine deficiency (from 17% to 7%). Common health problems decreased from 88% to 54%. The number of patients referred to larger hospitals decreased significantly from 116 to 86. Absenteeism was not affected.