Anaemia, or iron deficiency, is a severe public health problem among adolescent girls and women in Uttar Pradesh (UP) where every second woman is anaemic. Slightly more than 52 per cent women in the age group of 15-49 years in rural UP are anaemic, pointed out the National Family Health Survey-4 (2015-16) of the Union health ministry.
Seventeen-year old Khushbu Sonkar, a resident of Songwan village in Jaunpur district, is an unusual footsoldier in the state administration’s fight against anaemia, which not only affects the present generation women but also has serious consequences for the next generation as anaemic mothers often deliver weak and anaemic babies, who are susceptible to several other diseases.
In the COVID19 pandemic, the challenge of addressing anaemia among rural women increased manifold as a large number of health services came to a grinding halt, including the programme to administer IFA (iron and folic acid) tablets to adolescent girls and women.
And that is where Khushbu, and several other rural adolescent girls, stepped in.
“When I was told by the ASHA bahu in my village that girls were not consuming their weekly iron ki goli, I got worried. Even those who had these tablets at home were not consuming them. So, with my face mask on, I started visiting families in my village along with the anganwadi didi (sister),” the 17-year-old, whose village is over 200 kilometres from the state capital Lucknow, told Gaon Connection. “I informed my friends and other girls in my neighbourhood about the importance of iron ki goli. A number of adolescent girls in my village soon became regular with their weekly tablet,” she added.
To eradicate and prevent anaemia among out-of-school adolescent girls (including married girls) in the age group 10-19 years are given a tablet of iron and folic acid, commonly known as ‘iron ki goli’ or IFA tablet, once a week under the Integrated Child Development Scheme (ICDS) of the central government. Health agencies, along with the state government, have roped in adolescent girls like Khushbu to inform and educate their peers about the importance of IFA tablets in order to fight anaemia and malnutrition in India’s most populous state.
Nutrition International, a non-profit, is working with the district administration of Jaunpur to ensure minimal disruption to the folic acid supplementation programme, and is also supporting health systems to improve anaemia indicators among adolescents through the weekly iron and folic acid supplementation programme.
“Considering the high prevalence of anaemia in Uttar Pradesh, it is critical to implement this intervention that directly addresses this public health issue. Currently, we are working with the state government to expand this peer support model to enhance the weekly iron and folic acid supplementation programme and ensure IFA consumption,” Sangeeta Karmakar, Uttar Pradesh State Programme Representative, Nutrition International, told Gaon Connection.
Poor nutrition, leading to iron deficiency, is the leading cause of anaemia. In addition to increased morbidity and negative effects on physical well-being (weakness or fatigue), anaemia is associated with delayed mental and psychomotor development and an increased risk of maternal mortality, according to the World Health Organization.
“Every second adolescent girl has anaemia. Every second woman of reproductive age is anaemic”
When COVID19 disrupted health services
Since last year, as the focus shifted to curb the spread of coronavirus in the country, an unintended but serious impact was borne by adolescent girls and women who missed out on various health services administered through the anganwadi centres, which were shut down due to the lockdown.
Studies and reports show supplementary nutrition, immunisation and health education have been affected during the COVID19 pandemic. Last year, during the pandemic, Gaon Connection conducted three rural surveys which documented how immunisation and other nutrition services were disrupted.
Amid this, an intervention in Jaunpur district of Uttar Pradesh has ensured the health of adolescent girls in villages is not compromised.
“I used my own example to inform other adolescent girls in my village about the benefits of iron ki goli. Initially, I would also avoid the tablet fearing it might harm me. But when I was told about its significance, I started consuming it regularly. In just two-three months, I started observing changes,” said Khushbu.
“Earlier, I would feel weak during periods (menstruation). Now I do not keep lying in bed all day during my periods,” said the 17-year-old. Now, when she meets both in-school and out-of-school girls in her village, she shares her personal experiences of irregular periods and bouts of weakness, which has been successfully addressed by consuming IFA tablets regularly.
“I explain to other girls how weekly iron and folic acid supplementation helps improve one’s haemoglobin and reduces susceptibility to anaemia and helps in having healthy babies,” said the young rural footsoldier.
Adolescent girls like Khushbu are providing a big support to anganwadi workers in rural areas of the state in continuing with the weekly iron and folic acid supplementation programme in the pandemic.
In pre-COVID19 days, beneficiaries used to come to anganwadi centres to consume the weekly IFA tablet. However, due to the pandemic, the strategy for distribution of IFA supplements changed from anganwadi centres to house visits. This new modality was a challenge for anganwadi workers as well as rural families. There was also an inherent inhibition to consume the IFA tablet, which was not considered an important tablet by the rural population.
Support to anganwadi workers
Sujata Devi, an anganwadi worker in Bishunpur Majhawara village of Sirkoni block in Jaunpur, had a difficult time convincing women and adolescent girls to consume one IFA tablet a week.
“Rural families do not hesitate in giving the same tablet [IFA tablet] to pregnant women, but would not let girls take these. We need to understand that aaj ki balika hi kal ki mahila hogi (the girl today will become a woman tomorrow),” said Devi.
“If girls are healthy today, they will be healthy mothers tomorrow and give birth to healthy babies too,” said the anganwadi worker at whose centre 12 out-of-school girls were registered. At present, only eight are registered, as three got married and one is out of town.
As per the ICDS’s operational guidelines on IFA, each girl is given one tablet per week. These IFA tablets contain 100mg elemental iron and 500 microgram folic acid. These are given to an adolescent girl for 52 weeks in a year, on a fixed day preferably Monday.
“These tablets are to be consumed with khatta pani (lime water) or normal drinking water. Once started, the tablets are to be taken for at least six months regularly. But these can be taken till the girl is eighteen years,” informed Devi, who goes door-to-door for the tablet distribution.
Even for adolescent girls like Khushbu, it has not been easy to convince families in villages to let their adolescent girls have IFA tablets. “Even if girls would get ready, their families would refuse and prohibit them from taking IFA tablets. At times, I was told tum kha rahi ho hamari ladki ko mat khilao (You eat but don’t ask our girls to do the same),” narrated Khushbu. “Aunts in my neighbourhood would even scold me, and complain about this to my mother. They would say tumhari bitiya sabko samjhane nikali hai (Your daughter is visiting households telling people what to do),” she added.
“However, I kept on visiting them. When people started seeing that I am doing well after taking IFA tablets, they started letting their girls have these golis,” said the 17-year-old.
As per the Comprehensive National Nutrition Survey, 2016-18, 17.2 per cent of adolescents aged 10–19 years in Uttar Pradesh are classified as having iron deficiency.
Focus on iron rich foods
Apart from IFA supplementation, the district is stressing on increasing the consumption of iron rich foods. “We have a special focus on health, particularly anaemia among adolescent girls. We encourage them to eat iron rich foods such as chana (chickpea), green vegetables, sahjan (drumsticks), dal (pulses),” Manoj Kumar Verma, Chief Development Project Officer of Sirkoni block, told Gaon Connection.
“We ensure that all girls get iron goli (tablets) through anganwadis. There are 220 anganwadis in our block who work on iron supplementation apart from routine work of ration distribution. We have also given the title of ‘iron yoddha’ (iron warriors) to those who are working very efficiently in this,” Verma added.
The initiative is bringing hope as anganwadi workers observe positive changes in the health of young girls. “Now that girls are taking tablets there is a change in their health. They are more active, even during their periods,” anganwadi worker Sujata Devi, said.
Is iron supplementation enough to address anaemia?
A large number of public health experts believe that anaemia cannot be addressed only by consuming IFA tablets for six months. Creating nutri gardens and introducing more green leafy vegetables are emerging as ways to improve nutrition for adolescent girls.
“We need to understand that with IFA, carbohydrates and proteins are also required in the diet to absorb iron. This is something girls and families are usually not told about,” Lucknow-based Sunita Singh, who is working with the state government to improve health outcomes in adolescent girls, and pregnant and lactating women, told Gaon Connection. She is also a member of the Jan Swasthya Abhiyan, a non-profit working on public health issues.
In Uttar Pradesh, out-of-school girls between 11-14 years of age are given meetha daliya, namkeen daliya, and laddu premix as part of take home ration.
However, Sujata Devi alleged that since October last year, only rice, wheat, pulses, and refined oil was being given as part of the take home ration. “The quality of poshan ahar was of poor quality. People would not use it so we complained about this. But the supply was stopped in October. It’s been almost a year now. In March this year, only desi ghee (clarified butter) and milk was given for distribution,” said the anganwadi worker.
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Singh also acknowledged the disruption of take home ration services due to the pandemic. “The whole concept of supplementary nutrition is that if beneficiaries do not get sufficient nutrition from daily food it would be provided by supplementary nutrition. But, owing to the disruption in services, only dal and wheat or rice (under PDS) was given to beneficiaries. Besides, there has been an irregular supply of oil, pulses, and wheat,” she said.
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Gaon Connection tried to contact Sarika Mohan, Director of Bal Vikas Seva Evam Pushtahar Vibhag (Department of Child Development Services and Nutrition), Uttar Pradesh; Additional Director Vibha Chahal, and Jaunpur District Magistrate Manish Kumar Verma for their comments. But they were unavailable to comment.
Meanwhile, seeing the outcomes of the peer support model, the Nutrition International along with the state government is planning to encourage and train more adolescent girls like Khushbu Sonkar in other districts to take forward the message of the state’s fight against anaemia.
