Brief Research Article

Anemia Control Program in India Needs to be More

Comprehensive
Priya Y. Kulkarni1, Jitendra S. Bhawalkar2, Archana A. Jadhav3
1
Research Scholar, MUHS and Associate Professor, Department of Community Medicine, Symbiosis Medical College for Women, SIU, Pune, 2Dean, 3Consultant and
Ex‑Professor, Dr. D. Y. Patil Medical College and Research Centre, Pune, Maharashtra, India

Summary
Iron‑deficiency anemia has continued to remain high in India. It is possibly due to relying on only iron–folic acid (IFA) supplementation
through Anemia Control Program (ACP) that is National Iron Plus Initiative (NIPI). Based on the WHO’s recommendations, we studied
different interventions that can help to increase the effectiveness of NIPI such as Vitamin C supplementation with IFA, low‑dose iron (LDI) with
intensified health education (IHE), LDI with Vitamin C, and iron‑rich food items to increase hemoglobin (Hb%) among adolescent girls through
public–private partnership named Rashtriya Kishor Swasthya Karyakram. Increments in Hb after 12 weeks of interventions were compared
with that of control groups one with NIPI and the other without any intervention. Highest increment in Hb% was observed in IFA under NIPI
plus Vitamin C group, followed by LDI plus IHE group which was comparable to Hb increment in only the NIPI group. It emphasizes the
need of making existing NIPI more stringent and comprehensive by integrating effective measures based on up‑to‑date scientific knowledge.

Key words: Adolescent girls, Anemia Control Program, iron‑deficiency anemia, National Iron Plus Initiative

Anemia is a major public health problem of global concern
as still a third of the world’s population is anemic. Majority
of anemia exists in the form of iron‑deficiency anemia (IDA).
Most of IDA sufferers belong to low‑and middle‑income
countries,[1] especially where nutritional deficiencies, worm
infestations, and infection/inflammation are more prevalent.
South East Asia Region (SEAR) including India contributes the
highest IDA burden. IDA affects preschool children and women
of reproductive age worst. It fuels maternal morbidity, and
mortality and is the world’s second leading cause of disability
causing nearly 4% of Gross Domestic Product (GDP) loss.[1]
As per WHO, India belongs to high anemia prevalent areas
where  ≥40% of menstruating adult women and adolescent
girls (AGs) are anemic. India ranked 170 out of 180 countries
for anemia among women during Global Nutrition Survey,
2016.[2]
Oral iron supplementation is a preventive strategy for anemia
control at the population level.
Based on it, India’s National Nutritional Anemia Control
Program (NNACP) was initiated in 1970. Its interventions were
to provide iron and folic acid (IFA) tablets to all vulnerable
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groups by paramedical staff.[3] Several policy revisions in
NNACP arrived at today’s National Iron Plus Initiative (NIPI)
with the decentralization of IFA supplies to states as per
requirements.
In spite of several revisions and modifications in NNAPP, in
fact, the prevalence of anemia among pregnant women (PW)
is increased from 49.7% to 52.2% and among women of
reproductive age group from 53.1% to 57.0% during NFHS
second to fifth rounds.[4] Several studies report it is still
higher as 84.9% among PW and 90.1% among AGs.[4] It
makes India far away from the attainment of Sustainable
Development Goals by 2030.[2,5] Combating IDA among
these groups is of utmost importance as it is a hidden cause
of major maternal morbidities and mortalities as well as
affect on their offspring.
Address for correspondence: Dr. Priya Y. Kulkarni,
Symbiosis Medical College for Women, Lavale, Pune, Maharashtra, India.
E‑mail: dr_pdkulkarni@yahoo.co.in
This is an open access journal, and articles are distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to
remix, tweak, and build upon the work non‑commercially, as long as appropriate credit
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For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com
Submitted: 12‑Oct‑2021 Revised: 03‑Aug‑2022
Accepted: 03‑Aug‑2022 Published: 22-Sep-2022

DOI: How to cite this article: Kulkarni PY, Bhawalkar JS, Jadhav AA. Anemia
10.4103/ijph.ijph_1918_21 control program in India needs to be more comprehensive. Indian J Public
Health 2022;66:358-61.

358 © 2022 Indian Journal of Public Health | Published by Wolters Kluwer - Medknow
 Kulkarni, et al.: Anemia control program in India needs to be more comprehensive
There are many contexts specific issues behind the scene of
IDA in India like scarce resources at family level, lack of
knowledge and awareness, personal likes and dislikes, faulty
cooking and food consumption practices, worm infestations,
noncompliance to IFA supplementation with other lacunae
under NIPI, and many more. NIPI needs to be strengthened
to address these issues to combat IDA.
WHO recommends interventional research on iron
supplementation by dose, frequency, duration, and additional
nutrient/micronutrient, especially nonPW and AGs to help in
decision‑making regarding further policies to be incorporated
in existing ACPs.[5]
We carried out an interventional follow‑up study with
the main objective to assess the effectiveness of Vitamin
C supplementation with IFA under NIPI to improve
hemoglobin (Hb) as it increases the bioavailability of available
iron. Three secondary schools were randomly selected from
one of the Municipal Corporations in Western Maharashtra.
AGs studying in 7th–9th standard in these schools were recruited
after seeking Ethical Committee Approval, due permissions,
consent, and assent.
The primary outcome variable was the mean difference between
Hb2 (post-intervention) and Hb1 (pre-intervention). For main
intervention group (IG) of NIPI + Vitamin C, sample size for
mean difference was calculated using formula:  (σ12 + σ22)
(Z1 − α/2 + Z1 − β)2/Δ2 where, σ1 = 0.95, σ2 = 0.91, Z 1‑α/2 = 96.
For CI 95%, Z 1‑β =1.28 at power = β =90%, Δ = mean
difference (Hb2‑Hb1) =1.05 g%. Calculated sample size was
17, but we recruited one whole division for one intervention
as students and teachers emphasized. Similarly, for all other
IGs, actual Hb2 estimations exceeded the required sample size.
Hb1 and Hb2 estimations were carried out by Sahali’s method
by trained technicians. After Hb1 assessment, deworming
was done by tablet Albendazole 400 mg under supervision.
It was followed by 12 weeks (wk) of interventions, as shown
in Table 1.
Hb2 assessment was done by the same technicians and
procedures but they were blinded about control and different
IGs. Anemia was graded as per the WHO Scale as severe,
moderate, mild, and normal as Hb in g%: <7, 7–9.9, 10–11.9,
and >12 g/dL, respectively.[6]
Mean Hb1 was 9.9 (+1.272, 6.5–12.0) g%, with quite a higher
proportion,[7] (96.5%) of anemic AGs with moderate anemia
in majority (65%). Underlying reasons in the study population
can be from their lower socioeconomic background to lack
of awareness of hazards of IDA, knowledge of its preventive
measures, the importance of IFA consumption, etc., One
percentage were severely anemic and referred to a higher
center for further management.
After 12 weeks of interventions, mean Hb increased from 9.9
g% to 11.81 g%. Proportion of anemic AGs was significantly
decreased from 96.5% to 56.6% (P < 0.001), the majority of
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them had mild anemia after the intervention. Moderate anemia
decreased from 65% to 0.6%.
Paired t‑test showed a significant rise in Hb% in all
IGs (P < 0.001) except IG6, the control group (P = 0.3536)
which did not receive IFA for the last 2 years and showed a
slight decrease in Hb.
As shown in Figure 1, IG2 which received IFA as per NIPI
with Vitamin C 500  mg tablets showed the highest rise of
3.1 g% in Hb. IG1 and IG2 were significantly more to report
side effects such as abdominal discomfort, nausea than IG3,
and IG4 which received low‑dose iron  (LDI)  (P  <  0.001).
However, there was no difference pertaining to side effects
between IG1 and IG2 (P = 0.941) that is IFA with and without
Vitamin C.
IG3 (LDI plus Vitamin C) showed lowest rise of 1.62 g% in
Hb with lowest compliance as its weekly frequency was more.
School teachers of IG3 could not assure compliance as they
handed over both weekly doses to AGs in scarcity of time.
IG4  (LDI plus intensified health education  [IHE]) ranked
second in increasing Hb (2.6 g%), while IG1 (NIPI without
Vitamin C) and IG5  (IHE plus Rashtriya Kishor Swasthya
Karyakram [RKSK]) group showed a comparable increase in
Hb after 12 weeks of interventions.
One‑way ANOVA for post hoc multiple comparisons using
Tukey’s HSD test at a 0.05 level of significance showed: Rise
in Hb was significantly (P < 0.001): (1) higher in all IGs as
compared to the control group, (2) higher in NIPI + Vitamin
C group,  (3) lower than others, except control group, in
LDI + Vitamin C group (1.62%), and (4) lower in NIPI than
NIPI + Vitamin C and LDI + IHE groups.
Thus, the addition of Vitamin C to weekly IFA under NIPI was
the most effective intervention in a shorter period of 12 weeks
than only IFA supplementation. Similar findings are being
pointed out by the number of studies since decades ago, still
awaiting required modification in the existing program.[8‑10]
As per the NIPI strategy, AGs are supposed to get once weekly
IFA for 52 weeks a year.[2] We identified lacunae in logistic
supplies in existing NIPI that lead to nonconsumption of IFA
supplementation by AGs for a long duration of 2 years. That
was the reason behind the slight decrease in Hb in the control
Figure 1: Difference between pre‑ and postintervention Hb%.
359
 Kulkarni, et al.: Anemia control program in India needs to be more comprehensive

Table 1: Intervention groups and interventions

Abbreviation of intervention Intervention received HB 1 (n1) HB 2 (n2)
Group (IG)
IG1: NIPI IFA as per NIPI program 45 40
Tab IFA (100 mg elemental iron +500 μg FA)/week×12 weeks
under class teacher’s supervision
IG2: NIPI + Vitamin C IFA as per NIPI plus Vitamin C to be consumed with 48 46
Tab IFA as in NIPI + Vitamin C 500 mg×once a week for
12 weeks under class teacher’s supervision
IG3: LDI + Vitamin C LDI + Vitamin C 38 37
LDI (LDI, 45 mg EI +400 μg FA) + Vitamin C 250 mg×twice/
week for 12 weeks under class teacher’s supervision
IG4: LDI + IHE LDI as IG3 + (IHE) 42 42
Interactive IHE sessions were carried out with the use of all
possible A‑V aids followed by question answer sessions
IG5: IHE + RKSK RKSK + IHE × 12 weeks 50 48
RKSK was through PPP under which AGs in one selected
division received iron rich, 1 kg chikki prepared with jaggery
per week to be consumed in school during study period
IG6: Control Control 43 40
Not received IFA through NIPI since last 2 years and for study
period. Informed to medical officer of health
Total 265 252
RKSK: Rashtriya Kishor Swasthya Karyakram, PPP: Public-private partnership, IHE: Intensified health education, LDI: Low‑dose iron, NIPI: National
Iron Plus Initiative, FA: Folic acid, IFA: Iron FA, AGs: Adolescent girls, IG: Intervention group

group, IG6. It shows the need of optimal use of resources and
assurance of adequate, timely logistic supplies.
Study emphasized ongoing NIPI can improve and maintain Hb
at a satisfactory level provided IFA supply and consumption is
regular and adequate as for IG1. Weekly iron supplementation
is the most appropriate, suitable, and feasible strategy which
is followed under NIPI, as intestinal mucosal removal time
is 5–6  days. Beneficiaries with side effects to higher doses
can be given LDI which increases the frequency of IFA
consumption per week and will need to ensure compliance. It
can be combined with IHE.
IHE helps to improve the perception about need and mandate
of IFA consumption. IHE regarding nutrition and importance
of iron supplements primed well to AGs in IG4. It received
LDI + IHE and ranked second to increase Hb, although it
had more frequency per week and less supervision by school
teachers. Barriers to compliance to IFA can be addressed
through IHE and behavior change communication.[6] In the
absence of IHE, LDI + Vitamin C (IG3) was the least effective
regimen with lower compliance.
It shows the importance of strengthening and intensifying
health and nutrition educational activities under NIPI by trained
health personnel to facilitate desirable behavior change to
overcome IDA. Existing human resources implementing NIPI
were overburdened to pay attention to NIPI and to health and
nutrition educational activities.
IHE can be integrated in school activities with delegation
of its responsibility to medical and nursing colleges in the
vicinity for more sustainable outcomes. Supplying iron‑rich
food items through public–private partnership  (PPP) such
as RKSK would also add synergy to the already existing
program.
Thus, iron supplementation should only be one of the
components of comprehensive, integrated ACP. Existing
ACP, NIPI needs to be strengthened urgently by integrating
well‑researched measures which are proven to be effective such
as Vitamin C supplementation with IFA, LDI to AGs getting
side effects to higher dose, IHE by trained health personnel, and
distributing iron‑rich food items through schools through PPPs.
Multiple micronutrient supplements and iron fortification of
some food items can also be considered.[10]
There is hardly any study reporting effectiveness of multiple
interventions for rise in Hb among AGs as in the present study,
e.g., NIPI + Vitamin C, LDI + Vitamin C, LDI + IHE, and
IHE + RKSK as well as only NIPI. Novelty of the study is that
it brings out the number of ways in which the effectiveness
of existing NIPI can be enhanced. For example: If IFA
supplementation is not at all acceptable at the beneficiary
level, other measures can be made available through different
stakeholders like in the present study, we included for
IHE + RKSK.
NIPI will hardly succeed by relying on already fatigued human
resources. Instead of relying on school teachers, NIPI needs a
dedicated task force to work for the program which can take
care of screening and referral for other diseases also through
schools. There is a need of an hour to incorporate some
activities in existing NIPI like periodic screening of anemia;
record keeping of Hb%, IFA consumption and reasons behind
non-consumption by use of up‑to‑date technology; treatment

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 Kulkarni, et al.: Anemia control program in India needs to be more comprehensive

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