Prevention and Control of Anemia Amongst Children and Adolescents: Theory and Practice in India

Relationship between adolescent anemia and school attendance observed during a nationally representative survey in India

BACKGROUND

Anemia has been suggested to be related with schooling outcomes in India. Less is known, however, about whether the observed relationship persists after accounting for all household-level factors which may confound the association between anemia and schooling.

METHODS

Nationally representative data on adolescents aged 15-18 years with data on measured hemoglobin level and school attendance were extracted from India's National Family Health Surveys conducted between 2005 and 2021. We compared school attendance between adolescents living in the same household but with varying levels of hemoglobin concentration, while controlling for age and period effects. We assessed heterogeneity in the relationship between anemia and school attendance across anemia severity groups and socio-demographic characteristics.

RESULTS

The proportion of adolescents with any anemia is 55.2% (95% CI: 55.0-55.5) among young women and 31.0% (95% CI: 30.6-31.5) among young men. In conventional (between-household) regression models, having any anemia is associated with a 2.5 percentage point reduction (95% CI: 2.1-2.8) in school attendance; however, in household fixed-effects models, anemia has qualitatively small and non-significant effects on school attendance. Our results are consistent using alternative model specifications as well as across anemia severity groups, genders, types of relationship to the household head, household wealth quintiles, and states and union territories in India.

CONCLUSIONS

This within-household analysis finds little evidence that anemia is associated with school attendance among adolescents in India. Observational studies likely overstate the connection between anemia and school attendance due to household factors that have not been accounted for.

Indian adolescents' perceptions of anaemia and its preventive measures: Aqualitative study

High prevalence of anaemia is a severe public health problem in several low- and middle-income countries like India. A qualitative inquiry was designed to understand the perceptions of adolescents regarding anaemia and anaemia prevention measures. Convenience sampling was employed to recruit 39 adolescents (19 girls; 20 boys) from Tikari, India. Interviews were carried out in the local language, audio-recorded and transcribed verbatim. Hemoglobin concentration was also assessed from a single drop of capillary blood using the HemoCue, and the participants were asked to share their Science/Biology and Home Science textbooks. Interview data was analysed thematically. Descriptive statistics were used to examine the distributions of the hemoglobin data while textbooks were analysed using content analysis to verify the coverage of anaemia and anaemia-related matter. Seven themes were identified: (i) Poor understanding of the term anaemia; (ii) Minimal discussion about anaemia in classroom; (iii) Limited knowledge about symptoms of anaemia; (iv) Limited awareness about prevention and cure of anaemia; (v) Perception of iron folic acid and deworming tablets among students; (vi) Lack of contribution of health workers in the prevention of anaemia; (vii) No knowledge of 'Anemia free India' programme. More than half of the sample had anaemia (16.7% mild anaemia, 33.3% moderate anaemia, 2.8% severe anaemia). Content analysis revealed that there was limited discussion about anaemia in both Home Science and Science textbooks. Behavioural interventions should focus on inculcating healthy culinary and dietary practices and addressing the gaps in knowledge and understanding of anaemia and its prevention among adolescents.

Diagnostic Validation and Feasibility of a Non-invasive Haemoglobin Screening Device (EzeCheck) for 'Anaemia Mukt Bharat' in India

Anaemia remains a major public health issue in India despite several efforts. It is crucial to introduce technology-based innovations for the mass screening and early diagnosis of anaemia. Traditional anaemia screening requires drawing blood and laboratory analysis and can be logistically expensive in resource-constrained settings. A non-invasive haemoglobin test for mass screening in such settings is vital which can quickly and efficiently screen large populations. This study validated the haemoglobin estimation between the invasive haematology analyzer and the non-invasive EzeCheck (EzeRx Health Tech Pvt. Ltd., Bhubaneswar, Odisha, India) in the community setting. We conducted a cross-sectional study among 416 urban slum members in Bhubaneswar, India. We used inter-rater reliability (kappa statistic) of haemoglobin estimation between the haematology analyzer and EzeCheck devices. The finding showed a moderate agreement between both devices (kappa=0.4221). Between both devices, 91.59% of the results were with +/-1.5 difference; 43.51%, no difference; 33.65%, less than one difference; and 14.42%, +/-1 to +/-1.5 difference of haemoglobin estimation. There was no significant difference in overall anaemia status estimates between the devices. Mass screening in schools and communities with non-invasive haemoglobin tests can help identify anaemic people for early diagnosis and bring patients for timely treatment, which can be used in remote areas to support 'Anaemia Mukt Bharat'.

Prevalence and Risk Factors of Iron Deficiency Anemia among the Tribal Residential Adolescent School Students of Odisha: A Cross-Sectional Study

Background

Globally, anemia is one of the biggest public health challenges. The highest prevalence of anemia is seen among adolescents. Tribal communities are especially at a disadvantage, with several studies documenting a high prevalence of anemia among tribal adolescents. We investigated the prevalence of anemia and its associated risk factors among the tribal residential adolescent school students in Odisha.

Material and Methods

In a cross-sectional survey, the prevalence of anemia was estimated by spectrophotometry among adolescents of residential schools in three predominantly tribal districts of Odisha. The severity of anemia was defined as per the World Health Organization classification for adolescents.

Results

The mean age of 953 subjects was 13.07 ± 1.48 years. The prevalence of anemia was found to be 37.3%. As per the World Health Organization classification, 19.9% had mild anemia, 16.3% had moderate, and 1% had severe anemia. Consumption of Iron Folic Acid (IFA) was associated with the level of hemoglobin at a statistically significant level.

Conclusion

We found that the prevalence of anemia was lower than in similar studies conducted in other parts of the country. Despite poor coverage of beneficiaries with iron and folic acid at the national level, our study showed better compliance and was associated with a significantly higher level of hemoglobin among those who consumed IFA.

Predictors of Incidence and Remission of Anemia among Never-Married Adolescents Aged 10-19 Years: A Population-Based Prospective Longitudinal Study in India

Background

Dynamics of the anemia burden among Indian adolescents are poorly understood because of a lack of population-based longitudinal data.

Objectives

To examine the burden of anemia among never-married adolescents aged 10-19 y from the states of Bihar and Uttar Pradesh, India, and a wide range of predictors of its incidence and remission.

Methods

A sample of 3279 adolescents (male: 1787 and female: 1492) aged 10-19 y were included from baseline (2015-2016) and follow-up (2018-2019) surveys of the UDAYA (Understanding the Lives of Adolescents and Young Adults) project in India. In 2018-2019, all new cases of anemia were considered as incidence, whereas a return to the nonanemic status from being anemic in 2015-2016 was considered remission. Univariate and multivariable modified Poisson regression models with robust error variance were deployed to attain the study objective.

Results

The crude prevalence of anemia among males decreased from 33.9% (95% CI: 30.7%-37.3%) in 2015-2016 to 31.6% (95% CI: 28.6%-34.7%) in 2018-2019 but increased among females from 57.7% (95% CI: 53.5%-61.7%) in 2015-2016 to 63.8% (95% CI: 59.9%-67.5%) in 2018-2019. Anemia incidence was estimated to be 33.7% (95% CI: 30.3%-37.2%), whereas nearly 38.5% (95% CI: 35.1%-42.1%) of adolescents experienced remission of anemia. Older adolescents (aged 15-19 y) were less likely to experience anemia incidence. Consumption of eggs daily or weekly was negatively associated with anemia incidence compared with occasional or never consumption. Females had a higher risk of experiencing an incidence of anemia and decreased risk of experiencing anemia remission. The likelihood of adolescents experiencing anemia increased with an increased patient health questionnaire score. Household size was also associated with an increased risk of anemia incidence.

Conclusions

Interventions that are sensitive to socio-demographic factors and encouraging access to mental health services and nutritious food consumption could be helpful in further anemia mitigation.

Eye screening can be used to perform anemia screening and treatment in adolescent girls using ToucHb

Purpose

Anemia is common in adolescent girls. Apprehension while drawing blood to estimate hemoglobin concentration is a barrier for confirming anemia. ToucHb, a noninvasive instrument that estimates the hemoglobin by taking an image of the exposed conjunctiva, was used during eye screening to help diagnose and treat anemia.

Methods

ToucHb was used during secondary school eye screening and during house-to-house eye screening to estimate the hemoglobin concentration in the body. Each of the girls was distributed a packet of 60 tablets of ferrous and folate and a tablet of albendazole. They were followed up after 3 months.

Results

Exactly 1511 municipal school girls aged 10-19 years (mean 12.9; standard deviation [SD] 1.64) were examined. Of them, 949 (62.8%) had hemoglobin of ≤9 mg%. Among those girls with hemoglobin ≤9 mg%, the mean (SD) during the initial and follow-up examinations was 6.1 (1.4) and 9.6 (1.03), respectively, by paired t-test (P < 0.001). Another 588 girls (average age 14.4 years, SD 1.2) had their eyes examined and hemoglobin estimated during a house-to-house eye screening. Of them, 116 (19.7%) had hemoglobin level of ≤9 mg%. Their pre-Hb was 7.9 (SD 1.05) on average and after 3 months, it was 9.6 (SD 1.02). Among those girls with hemoglobin ≤9 mg%, the mean (SD) during the initial and follow-up examinations was 6.2 (1.4) and 7.9 (1.1), respectively, by paired t-test (P < 0.001).

Conclusion

ToucHb was useful to diagnose anemia while doing eye screening and to ensure its treatment. Anemia diagnosis and management would enhance the health of adolescent girls.

Iron-and-folic-acid supplementation among adolescents (aged 10-19 years) in two North Indian States, 2015-2016: a sex-stratified analysis

OBJECTIVE

This study assessed the prevalence and predictors of receiving iron-and-folic-acid (IFA) supplement by male and female adolescents in two north Indian states.

DESIGN

The UDAYA (Understanding the lives of adolescents and young adults in Bihar and Uttar Pradesh) survey dataset was used. Conducted during 2015-2016, UDAYA was a state representative cross-sectional survey. To recruit sample, UDAYA adopted a multi-stage systematic sampling method with a household selection probability proportional to size. Weighted bivariate and multivariate logistic regression analyses were deployed. The variance inflation factor was estimated to check the presence of multicollinearity among variables included in regression model.

SETTING

The state of Bihar and Uttar Pradesh, India.

PARTICIPANTS

A total of 10 433 individuals from Bihar and 10 161 individuals from Uttar Pradesh were included, totalling 20 594 individuals (male: 5969, female: 14 625) aged 10-19 years.

RESULTS

Overall, 3·6 % (95 % CI: 2·7, 4·7) of males and 4·8 % (95 % CI: 4·0, 5·7) of female adolescents received IFA supplement in preceding 1 year of survey date. Multivariate results indicate that IFA receipt varied with age, and state of residence among males, whereas religion and mother's education were associated with IFA receipt among females. Irrespective of sex, adolescents living in rural areas had higher odds of receiving IFA supplement than adolescents in urban setting.

CONCLUSIONS

Low coverage in receiving IFA supplement among adolescents is a serious concern for the success of anaemia reduction programme. While designing interventions for overall increase in IFA distribution, the socio-economic factors influencing IFA receipt must be considered.

Prevalence and Triggering Factors of Childhood Anemia: An Application of Ordinal Logistic Regression Model

INTRODUCTION

Anemia is indeed a significant risk factor for children's health as it affects growth retardation and has severe short and prolonged effects that follow in morbidity and death. Notwithstanding such ways to tackle anemia, the prevalence remains high in India and poses a severe public health concern.

OBJECTIVES

The primary focus of this study was to find the prevalence and to determine the factors associated with the anemia of children under five years of age in India. Problem Statement. The increasing prevalence of childhood anemia and the life-threatening consequences for millions of children in India are a major concern. Knowing the relevant associated factors with childhood anemia is essential to reduce the frequency and severity level. Study design. For analysis purposes, this study utilized a cross-sectional study design. Methodology. Using the Indian Demographic and Health Survey 2015-16 data, we used chi-squared and gamma tests to find the association. Then, we utilized multinomial logistic regression and ordinal logistic regression to find the better model and the influencing factors of anemia in India.

RESULTS

In our study, we have found that children with highly educated mothers were 36.7% less likely (OR = 0.633, P ≤ 0.001, 95% CI: 0.608, 0.658) to be higher anemic than the children with not educated mother. Children with moderate and severe anemic mothers were 163.3% (OR = 2.633, P ≤ 0.001, 95% CI: 2.565, 7.704) more likely to be higher anemic than the children with not anemic mother. Not stunting children were 21.9% (OR = 0.781, P ≤ 0.001, 95% CI: 0 .764, 0.797) less likely to be higher anemic than the stunting children. Children aged 36-59 months were 73.9% (OR = 0.361, P ≤ 0.001, 95% CI: 0.353, 0.369) less likely to be higher anemic than the children aged 6-24 months. Again, the ACI value revealed that ordinal logistic regression was a better-fitted model for these data.

CONCLUSION

and contribution. The variables such as stunting, underweight, wasting, child age, size of the child, and source of drinking water were the most critical indicators for child anemia in India. In summary, our study result indicated the major socioeconomic and demographic factors associated with childhood anemia in India, which can help the policymaker to take quick decision to reduce the severity level.

Anemia Among Children Under 5 Years in India: A District-Level Spatial Analysis Using NFHS-5 Data

The 2015/2016 National Family Health Survey (NFHS-4) revealed that the prevalence of anemia among children under 5 years is 58% in India. Lack of nutritional supplementation and lack of health care facilities are found to be important influential factors of anemia among children. We aimed to examine district-level spatial heterogeneity and clustering of associated factors with childhood anemia in India. Geographically weighted regression was applied on the NFHS-5 data for 335 districts. Factors such as prevalence of nutritional supplementation in children and mothers, birth order, antenatal care, diarrhea in children, and stunting were found to be significantly associated. Spatial scan statistics technique identified 3 significant local spatial clusters of anemia. This study provides findings based on the latest available data which can further assist in the design and execution of tailor-made policies.

Anemia and nutritional aspects in adolescent athletes: a cross-sectional study in a reference sport organization

OBJECTIVE

To assess the association between anemia and nutritional aspects in adolescent athletes from a large sport club.

METHODS

This is a cross-sectional study, involving 298 athletes aged between 10 and 17 years, submitted to measurement of skin folds, weight and height, and collection of capillary blood in duplicate to determine hemoglobin values. It was carried out in a random sample composed of athletes from eight sport modalities.

RESULTS

Regarding nutritional status, 10.1% of athletes were overweight based on body mass index and 70 (23.5%) athletes had a percentage of body fat classified as high or very high. The prevalence of anemia was 16.4%, being more prevalent in judo (37.1%), basketball (34%) and futsal (20.5%) athletes. Low hemoglobin levels were significantly associated with shorter stature (p=0.006).

CONCLUSIONS

There was a significant association between anemia and short stature, suggesting that the athlete's height-weight development may be affected in suboptimal conditions of oxygen distribution.

Pediatric lichen planus: a systematic review of 985 published cases

BACKGROUND

Lichen planus (LP) is a chronic inflammatory disorder usually occurring in middle-aged adults. Data are scarce in the pediatric population.

OBJECTIVE

To describe the patients' characteristics, clinical presentation, and management of pediatric LP.

METHODS

A systematic literature review of pediatric LP was performed in the Medline and Cochrane databases up to February 1, 2020. Demographic and clinical data were extracted for analysis, in addition to laboratory and histology findings, treatments used, and response to treatment. LP pemphigoides (LPP) was further pooled for a subcategory analysis.

RESULTS

One hundred and sixty-four articles were included representing 985 patients. The most common country of origin was India. The most common clinical signs were flat-topped papules (51%); the linear variant was present in 9%. Oral involvement was present in 22%. The most commonly used treatment was topical corticosteroids followed by systemic corticosteroids. The mean duration of treatment was 124.4 days. LPP patients had a short disease duration before diagnosis (4.1 months, P < 0.001) and failed previous treatment more frequently (P < 0.001). Systemic corticosteroids were more often prescribed in this subgroup (75%, P < 0.001) with more recurrence after treatment (31%, P = 0.048).

LIMITATIONS

Lack of randomized controlled studies, in addition to publication bias.

CONCLUSION

In children, LP had a wide polymorphous clinical presentation, and the reported cases were mostly from India. The linear variant was more common and the oral mucosa was less affected in children. LPP, a rare subtype in children, was treated with systemic corticosteroids and recurred more frequently.

Community-level women's education and undernutrition among Indian adolescents: A multilevel analysis of a national survey

Background

Little research has explored the influence of social context on health of Indian adolescents. We conceptualized community-level women’s education (proxy for value placed on women’s wellbeing) as exerting contextual influence on adolescent hemoglobin level and body mass index (BMI).

Methods

We derived our sample of more than 62,000 adolescent aged 15 through 17 years from the Indian National Family Health Survey 2015–16. The sample consisted of a total of 62648 adolescents (54232 girls and 8416 boys) for the hemoglobin, and 62846 adolescents (54383 girls and 8463 boys) for the BMI analysis. We fitted multilevel random intercepts linear regression models to test the association of village- and urban-ward-level-women’s education with hemoglobin level and BMI of adolescents, accounting for their own and their mother’s education; as well as relevant covariates.

Findings

Our fully adjusted model estimated that if the 52% of communities with less than 20 percent of women having a tenth-grade education in our sample were to achieve 100 percent tenth-grade completion in women, hemoglobin would be 0·2 g/dl higher (p<0·001) and BMI would be 0·62 kg/m² higher on average among all adolescents in such communities. Unexplained variance estimates at the contextual level remained statistically significant, indicating the importance of context on adolescent undernutrition.

Interpretations

Adolescents are deeply embedded in their context, influenced by contextual factors affecting health. Promoting adolescent health therefore implies altering social norms related to adolescent health and health behaviors; along with structural changes creating a health-promoting environment. Integrating our empirical findings with theoretically plausible pathways connecting community-level women’s education with adolescent undernutrition, we suggest that enhancing community-level women’s education beyond high school is necessary to facilitate these processes.

Implications

Addressing contextual determinants of adolescent undernutrition might be the missing link in India’s adolescent anemia and undernutrition prevention efforts, which are currently focused heavily on individual-level biomedical determinants of the problem.

Agreement between dried blood spots and HemoCue in Tamil Nadu, India

India retains the world's largest burden of anemia despite decades of economic growth and anemia prevention programming. Accurate screening and estimates of anemia prevalence are critical for successful anemia control. Evidence is mixed on the performance of HemoCue, a point-of-care testing device most widely used for large-scale surveys. The use of dried blood spots (DBS) to assess hemoglobin (Hb) concentration is a potential alternative, particularly in field settings. The objective of this study is to assess Hb measurement agreement between capillary HemoCue and DBS among two age groups, children 6-59 months and females age 12-40 years. We analyzed data from the baseline round of a cluster randomized rice fortification intervention in Cuddalore district of Tamil Nadu, India. Capillary blood was collected from a subset of participants for Hb assessment by HemoCue 301 and DBS methods. We calculated Lin's concordance correlation coefficient, and tested bias by conducting paired t-tests of Hb concentration. Independence of the bias and Hb magnitude was examined visually using Bland-Altman plots and statistically tested by Pearson's correlation. We assessed differences in anemia classification using McNemar's test of marginal homogeneity. Concordance between HemoCue and DBS Hb measures was moderate for both children 6-59 months (ρc = 0.67; 95% CI 0.65, 0.71) and females 12-40 years (ρc = 0.67: 95% CI 0.64, 0.69). HemoCue measures were on average 0.06 g/dL higher than DBS for children (95% CI 0.002, 0.12; p = 0.043) and 0.29 g/dL lower than DBS for females (95% CI - 0.34, - 0.23; p < 0.0001). 50% and 56% of children were classified as anemic according to HemoCue and DBS, respectively (p < 0.0001). 55% and 47% of females were classified as anemic according to HemoCue and DBS, respectively (p < 0.0001). There is moderate statistical agreement of Hb concentration between HemoCue and DBS for both age groups. The choice of Hb assessment method has important implications for individual anemia diagnosis and population prevalence estimates. Further research is required to understand factors that influence the accuracy and reliability of DBS as a methodology for Hb assessment.

An Analysis of Maternal, Social and Household Factors Associated with Childhood Anemia

Anemia is highly prevalent in all strata of populations in India, with established evidence of intergenerational anemia. The state of Madhya Pradesh was selected to study childhood anemia as the population is mostly rural, with many tribal districts, and has the highest infant mortality rate in India. This study aims to understand the maternal, social and household factors that affect anemia among children aged 6 months to 5 years by analyzing the the National Family Health Survey (NFHS) conducted in 2015-2016. Children aged 6-59 months with estimated hemoglobin levels were included in this study. Bivariate and multivariable analyses were conducted to understand associations between childhood anemia and various socioeconomic factors. Two models to understand the presence of anemia and the levels of anemia were computed. Higher likelihood of having severe childhood anemia was observed among children of younger mothers (15- to 19-year-old mothers (adjusted odds ratio (aOR) 2.08, 95% confidence interval (CI): 1.06, 4.06, less educated (uneducated mothers aOR 2.25, 95% CI 1.13, 4.48) and belonged to a scheduled tribe (aOR 1.88, 95% CI 1.07, 3.29). Strong associations between anemia in mothers and their children suggest intergenerational anemia which has long-term effects. Malnourished children (severe stunting aOR 3.19, 95% CI 2.36, 4.31) and children born with very low birth weight (aOR 4.28, 95% CI 2.67, 6.87) were more likely to have anemia. These findings strongly suggest more proactive interventions including prenatal healthcare for women and monitoring of the nutrition children at the community level to combat childhood anemia. Evaluations of existing programs should be conducted to understand the gaps in reducing anemia and malnutrition in children.

Receipt of Weekly Iron Supplementation among Indian Children, 2005-2016

BACKGROUND

In response to India's unacceptably high burden of anemia among children aged 6-59 mo, the central government introduced the National Iron Plus Initiative program which recommends an intervention of iron supplementation to mitigate anemia, especially iron deficiency anemia.

OBJECTIVE

The objective of this study was to examine the trend (between 2005-2006 and 2015-2016) in receiving weekly iron supplementation (WIS) among children aged 6-59 mo, and factors associated with receiving WIS during 2015-2016.

METHODS

Two waves of the nationally representative cross-sectional National Family Health Survey (NFHS) data collected during 2005-2006 (NFHS-3) and 2015-2016 (NFHS-4) were used. The trend was measured using both rounds of datasets, whereas factors associated with WIS receipt were assessed from NFHS-4. The trend was assessed using a sample of 35,650 children from NFHS-3 and 202,227 children from NFHS-4. After exclusion of 8978 cases, a total of 199,110 children were included to analyze the factors associated with receiving WIS. Using appropriate sample weighting, unadjusted and adjusted (multivariate) logistic regression analyses were deployed. Application of the chi-squared test and checking for multicollinearity were also part of the analysis. The possibility of sample selection bias was tested.

RESULTS

An increase of WIS receipt (from 4.6% in 2005-2006 to 26% in 2015-2016) was observed. Older children, children living in rural areas, children belonging to Scheduled Tribes, children of mothers with secondary education or higher, and children whose mothers had some mass media exposure had higher odds of receiving WIS. Children of fifth or higher birth order, children who were followers of Islam and Christianity, children from the richest economic group, noninstitutional birth of children, and children from high-focus group states were negatively associated with WIS receipt.

CONCLUSIONS

Despite improvement (between 2005-2006 and 2015-2016) in receiving WIS, coverage remains unacceptably low (in absolute terms). The suboptimum performance of WIS intervention demands further investigation.