India has the largest number of micronutrient deficient persons in the world. Results of the 2006 DHS showed that anemia levels in particular have not declined even when other health indicators have shown steady improvement in a number of states.

 

Reduction of anemia among women has been the focus of several USAID-funded projects in Jharkhand State. Gumla District, a tribal area with a population of about 450,000, was the focus of initial pilot activities by the MOST Project (from October 2004 to August 2005) and then by Immunization BASICS and A2Z. (AED led the behavior change activities under MOST and provides overall management for A2Z activities.) The early program covered five blocks of Gumla District with an intention to scale-up the intervention across the state. A local NGO, Vikas Bharti Bishunpur, has acted as a bridge between communities and the government health system.

 

Focus interventions have included promotion of iron/folic acid supplements, malaria control and de-worming, and improving reproductive health for women. IFA is distributed to both pregnant women and adolescents at the village level by Anganwadi Workers (AWWs) who receive a government honorarium for providing child and maternal health outreach. Village Advocates, or volunteers, identify pregnant women and encourage them to attend antenatal care early. Vikas Bharti Workers (VBWs) mobilize communities and facilitate support groups. The project designed training for health workers and volunteers and created job aides and a calendar for pregnant women. 

 

One of the unique aspects of the intervention was an effort to assess and treat anemia in health workers and volunteers themselves, in addition to their "clients." The project believed that personalizing the experience of effective anemia treatment would motivate workers to become advocates for the activities.

 

An evaluation by A2Z staff of this first phase in August, 200, focused on results among the workers, and showed that anemia in health workers and volunteers dropped by 50 percent. (See figure 1)

 

The evaluation showed a significant decrease in the proportion of anemic cases among all three categories of workers. In the pre-project period, an overwhelming 83 percent of AWWs were found to be anemic, but that decreased to 51 percent six months after the project ended (significant at p<0.01). Similarly, in the pre-project period around three-quarters of village health workers were anemic, compared to 47 percent six months after project funding had ended (significant at p<0.01).

 

Further analysis of the hemoglobin levels of the functionaries showed that there had been a tremendous shift to better hemoglobin levels. In the pre-project period, only 23 percent of functionaries were observed to have hemoglobin levels of 11 g/dl or above, while in the post-project period this proportion more than doubled at 50 percent. Similarly, in the pre-project period, more than two-thirds (69 percent) of functionaries were observed to be moderately/mildly anemic (hg 7 to <11 g/dl), while in the post-project period this proportion was reduced to 49 percent. (See figure 2).

 

 

The evaluation also showed increased trust in health workers and peer-to-peer communication among women; and some “volunteer fatigue” and refresher trainings recommended. It also revealed that maintaining sufficient supplies in the face of increased demand was a challenge. The A2Z project followed up with state and national administrations as well as the USAID Mission to address the supply issue.

 

AED is currently working with the State Government to scale up this program in seven additional districts, to reach a population of approximately seven million. Eventually, the program will be implemented across the state.

 

Capsule-based programs to improve vitamin A status are now common throughout the developing world. Less common are programs that aim to improve vitamin A status through food-based strategies. Changes in dietary practices are challenging. Recommended behaviors must take into consideration agro-ecological and market conditions, economic constraints, cultural preferences, intrahousehold food distribution practices, beliefs about the appropriateness of foods at different times, and traditional cooking practices and tastes. Food-based strategies are feasible, however, even in resource-constrained settings.

 

AED supported several programs in sub-Saharan Africa more than a decade ago that brought about important changes in household dietary practices. Under USAID's Nutrition Communication Project, AED worked in Niger from 1991-94 to increase consumption of vitamin A-rich foods among vulnerable groups—in particular children between the age of 6 months and 6 years, and pregnant and nursing mothers.

 

AED worked with the Ministries of Health, Agriculture, and Education, and with Helen Keller International. At the time of the project, vitamin A deficiency was nearly universal. The program began with a pilot in the district of Birni N'Konni. 

 

Formative research looked at the social, economic, and market factors affecting nutrition status. Research included in-depth interviews, 24-hour food recall and food frequency lists, market surveys, observations, and ethnographies. 

 

Central to the strategy for improving vitamin A status was increased consumption of liver by vulnerable groups. Research found liver to be one of the most important vitamin A -rich foods consumed in the province. It is a highly prized grilled snack which men eat in the market and sometimes bring home for their wives and children. One 25g serving of liver every two weeks can provide enough vitamin A to meet 75 percent of a pre-school child's needs during that period. Research also showed that spending money was available primarily in the post-harvest months, so that consumption of liver could be affordably increased precisely during the months when other vitamin A-rich foods were scarce. 

 

The project developed a communication intervention with the underlying theme of "family responsibility" – encouraging husbands to ensure that their wives and children ate a varied diet and in sufficient quantities to assure their health. Specific messages encouraged men to increase the frequency with which they bought liver as a snack for their children and their wives.

 

Messages also encouraged women to ask their husbands to bring home liver snacks from the market; to buy liver themselves/and/or to share the liver of animals slaughtered for feats or other special occasions among themselves and their children. 

 

The pilot depended almost entirely on village drama as a channel for communication. In each village amateur drama teams were formed by government health workers, agricultural extension agents, and community members. Training consisted of five days of "classroom" instruction and practical training with a role play guide that allowed teams to develop their own skits. Teams were rewarded with diplomas and other non-cash incentives. Most of the dramas used humor to help change social norms regarding the husband's responsibility for the project's "special foods." Traditionally men are responsible for providing their families with staples.

 

An evaluation after the pilot phase showed significant positive change. The percent of women who reported that they ate liver in the past week rose from 52 percent to 69 percent. The percent of women who indicated they gave liver to their children in the past week rose from 51 percent to 65 percent.

 

Phase two of the project expanded activities to four districts. Taking advantage of a new FM radio station, Radio Tahoua, the project also recorded the dramas performed by village drama teams and broad case a total of 42 different ten-minute skits over a three-month period. The expanded intervention also relied on flip-chart sized counseling cards to support face-to-face counseling. In each village, government health workers, teachers, and agricultural extension agents were trained to serve as volunteer educators, and in some villages to work with drama groups. 

 

Overall, 60 percent of men and 40 percent of women heard or saw some element of the educational program. After 12 months, both knowledge and practices increased in the intervention area. (See figure 1.)