Indian Journal of Health Social Work
A STUDY ON THE IMPLEMENTATION STATUS OF WEEKLY IRON AND FOLIC ACID SUPPLEMENTATION’ (WIFS) IN THE SELECTED GOVERNMENT SCHOOLS OF WEST BENGAL
Kheyali Roy1 & Shaurya Prakash2
1,2Research Scholar, Department of Social Work, Visva-Bharati, Santiniketan, West Bengal
Correspondence: Shaurya Prakash, e-mail id: firstname.lastname@example.org
ABSTRACTBackground: Background: Anaemia has been acknowledged as a key public health issue in present scenario. The most common type of anaemia is Iron deficiency anaemia, and it occurs when your body doesn’t have enough of the mineral iron. Your body doesn’t have enough of the mineral iron. Your body needs iron to make haemoglobin. When there isn’t enough iron in our blood stream, the rest of the body can’t get the amount of oxygen it needs. Most cases of iron deficiency anaemia are mild and don’t cause complications. Aim: The study aims to assess the implementation status of ‘Weekly Iron and Folic Acid Supplementation’ (WIFS)’ component under Rashtriya Kishore Swastha Karyakram (RKSK) among the female students. Method: The study will be mainly qualitative in nature as it is primarily an exploratory study. This evaluation of the WIFS, for its efficacy, effectiveness and relevance clearly demonstrates that while the program is still relevant, implementation is not effective or efficient. Conclusion: The program was implemented nationwide in all schools without any exclusion criteria. Certain level has been achieved in WIFS programme in terms of compliance to IFA tablet consumption but there is a huge scope of improvement. Keywords:, IFA, Anaemia, Adolescent health.
Adolescence is marked by a rapid phase of growth and development during which the demand of nutrition and micronutrients is comparatively in peak of the list. Consequently, mainly the adolescent girls, are endangered to iron deficiency. The excessive pervasiveness is in the ages of 12-15 years when demands are at a highest level (Gopaldas, T. and Kale, M, 1985). Adolescence is a period of transition from childhood to adulthood. It is characterised by rapid physical, biological and hormonal changes resulting in psycho-social, behavioural and sexual maturity in an individual. It is the second growth spurt of life and both boys and girls undergo different experiences in this phase. During this period in life there is a significant increase in nutritional requirements, especially for iron. Anaemia, an exemplification of under-nutrition and deficient dietary intake of iron is a community health issue, the pregnant women, infants, young children and also the adolescents are the victims of that particular issue. Anaemia in India primarily occurs due to iron deficiency and is the most worldwide nutritional deficiency problems in the country now a days. The pervasiveness of anaemia in girls (Hb< 13g%) is very soaring as per the statement of NFHS-3 and the National Nutrition Monitoring Bureau Survey. According to NFHS 3 facts and figures, above 55 percentage of duo adolescent boys and girls are anaemic (Minister of Health and Welfare, 2012). Adolescent girls in specific are further endangered to anaemia because of fast widening of the body and dropping of blood in the time of menstruation cycle. According to NFHS-3 almost 56% of adolescent girls aged 15-19 years suffer from some form of anaemia. Above than 39% adolescent girls (15-19 years) are mildly anaemic while 15% and 2% experience from moderate and severe anaemia respectively while during NFHS-2 the prevalence was 41%, 18% and 2% for mild, moderate and severe anaemia among 15–19-year-olds indicating that there has not been much of change in the trends. In India, the largest frequency of anaemia is announced in the ages 12-13 years, which also corresponds with the mean age of menarche (Mukherjee, 2016).
Iron deficiency Anaemia adversely affects transport of oxygen to tissues and results in diminished work capacity and physical performance. Anaemic girls have lower pre-pregnancy stores of iron and pregnancy is too short a period to build iron stores to meet the requirements of the growing foetus. Anaemic adolescent girls have a higher risk of preterm delivery and having babies with low birth weight. Regular consumption of iron-folic acid supplements along with a diet rich in micronutrients is essential for prevention of iron deficiency anaemia in adolescent girls and boys.
The response to this high level of anaemia was however limited to pregnant women with the implementation of daily iron folic acid supplementation throughout pregnancy. Without any program for other population groups, it was not surprising that the next two iron surveys in the year 2001 and 2002 reported that exceedingly excessive pervasiveness of anaemia is 81 percent in the children between the ages of 6-60 months. The prevalence was 55% among the non-pregnant women and in male section it was 28%. The cause for this high prevalence of anaemia among women and children was attributed to iron deficiency as both the population groups have high demand for iron compared to men. Government will plan the strategy with the development of several documents (information pamphlets for schools, training manuals for teachers and Monitoring and evaluation booklets) and training of school health coordinators, principals and DEO’s.
The program was implemented throughout the country in all schools with WIFS for both girls and boys till the VIII standard and for girls only in higher secondary schools. The main stakeholders were Ministry of Health and Ministry of Education. Every Thursday during the school calendar year was declared as “Iron Day”, and every student would be provided with IFA supplement and schools would practice supervised consumption of the tablet. The health centres were to support the schools with supply of tablets and to treat any side effects if reported. The schools were to send in term reports twice a year to the Nutrition Program in the department of Public Health. Four districts, one in each region of the country including the south were selected as sentinel sites and 796 students were followed up twice a year with haemoglobin estimations. A program review was planned in 2007.
The program was implemented from 2004 and continues to be implemented in all schools. The government has always considered anaemia as a major public health concern and the WIFS continues to benefit Bhutanese children in schools. The program in the department of public health recognized several implementation problems over the years and decided to evaluate the program in 2013. The Ministry of Health & Family Welfare has launched a health programme for adolescents, in the age group of 10-19 years, which would target their nutrition, reproductive health and substance abuse, among other issues.
Previously we discussed about WIFS, RKSK and general guidelines about the topic. Now we will discuss about the past studies related to topic of the study. There are many literatures about the health status of adolescents’ school-going children but to fulfil our purpose of study we have considered topics related to our research topic i.e., Implementation status of ‘Weekly Iron and Folic Acid Supplementation’ (WIFS)’ component under Rashtriya Kishore Swastha Karyakram (RKSK). Rawat, Garg, & Singh (1986) in their study found that anaemia is a rapidly grown problem due to nutritional deficiencies. According to Gopalan (1989), anaemic girls are at risk of compromised physical and mental functions, and they may also be at increased obstetric risk, once pregnant. In India, to combat the pervasive problem of anaemia, initiation of iron supplementation early in the adolescent years has been recommended, but is not yet being implemented. According to Brabin and Brabin (1992), Iron needs are high in the period of adolescence, in the time of menarche the adolescent girl needed it most as this period is the beginning of menstrual cycle. It causes iron loss and so the body needs iron maximum in this time. If any adolescent girl has low status of iron in their body it hampers their growth or development. According to WHO (1999) the adolescents’ girls are a section of vulnerable group in most of the developing countries. There is a huge problem of early marriage and among the adolescents’ girls the anaemia tendency is high due to social circumstances. According to Wadhwa, (2008), in the study the author found that many policies are designed for Adolescent health. As adolescent is the period of growth and development it should be done. According to Sheila (2008), the programme called WIFS mainly designed for reducing the anaemia condition among the adolescent population. For positive outcomes of this programme is possible only when appropriate counselling, good supervision will be done.
Though a lot of research has been conducted in the various aspects of the adolescent girl’s health as dealt with in the Review of Literature, there are still some gaps that have been identified. There is many research about the health status of women but very less research in adolescent’s girl health status mainly of the age of school going children and there is many research in the area of maternal health and so on but very less research in India about how IFA implementation influences the growing age of the school going children.
The aim of the study is to assess the implementation status of ‘Weekly Iron and Folic Acid Supplementation’ (WIFS) component under Rashtriya Kishore Swastha Karyakram (RKSK) among the students. In order to carry out the research the researchers have formulated some research objectives which includes to know the structure of the WIFS programme, to know the implementation scenario of WIFS programme and to know the social acceptance among students and family about this programme.
As it is indicated in the title, this section includes the research methodology of the study. In more details, in this part the author outlines the research strategy, the research method, the research approach, the methods of data collection, the selection of the sample, the research process, the type of data analysis, the ethical considerations and the research limitations of the project.
The research held with respect to this study was an applied one, but not new. Rather, numerous pieces of previous academic research exist regarding the Implementation status of ‘Weekly Iron and Folic Acid Supplementation’ (WIFS)’ component under Rashtriya Kishore Swastha Karyakram (RKSK), not only for Bolpur in specific, but also for other places in India and other places of the world. As such, the proposed research took the form of a new research but on an existing research subject.
In order to satisfy the objectives of the research, a qualitative research was held. The main characteristic of qualitative research is that it is mostly appropriate for small samples, while its outcomes are not measurable and quantifiable. Its basic advantage, which also constitutes its basic difference with quantitative research, is that it offers a complete description and analysis of a research subject, without limiting the scope of the research and the nature of participant’s responses (Collis & Hussey,2003). However, the effectiveness of qualitative research is heavily based on the skills and abilities of researchers, while the outcomes may not be perceived as reliable, because they mostly come from researcher’s personal judgments and interpretations. Because it is more appropriate for small samples, it is also risky for the results of qualitative research to be perceived as reflecting the opinions of a wider population. (Bell, 2005).
The study has been conducted using qualitative research methodology. The study design used was in line with answering the questions and fulfils the objectives of the research. The study design provided in-depth information. Also, the research study is exploratory in nature, and therefore there is no hypothesis formulated.
Purposive sampling method was used to select the sample. In Bolpur Sub-Division the researcher chooses 3 urban and 3 rural higher secondary schools, and contacted them for taking the samples for her research.
The sample size considered for the current study are 3 rural higher secondary school, 3 urban higher secondary school, number of students participants per school is taken as 10, number of teachers participants per school is taken as 2-3 and number of parents involved in the study is 10.
Tools for data collection
The researcher decided to undertake a qualitative study method for this research study because she wanted to explore the experiences about the WIFS program under RKSK. Focussed Group Discussion and interview schedule was introduced to the respondents for the research purpose.
One teacher commented that her job was just to collect the IFA tablet and give to the individual call teacher for distribution. She did not know when and how the program had begun and said that there was no follow up, record keeping or reporting. It is imperative that for programs such as IFA supplementation to be successful, teachers
One of the important impacts of the WIFS envisioned was to instil knowledge on iron deficiency anaemia (IDA) among the students who would then serve as agents of change for improving nutritional outcomes in the family. These received significant attention in the first few years but over the passage of time, the booklets have disappeared from the schools and very few teachers discuss about anaemia and iron with the students. Only one school had a poster on IDA and the importance of WIFS in the school. It is therefore not surprising to find that the level of knowledge among students was quite poor. The reason for poor knowledge among students is apparent with 61% of the students saying that topics on anaemia and iron were not discussed in school. Majority (77%) of the students said that girls required iron more than boys and attributed this to menstruation and blood loss. 13 % felt that both sexes required equally while 7 % did not.
One of the important outcomes expected from the WIFS program was to increase the level of knowledge on anaemia among students and who would then go out to “mobilize awareness in the community and to their mothers and peers not attending schools”. From the current poor level of knowledge among students, this objective is unlikely to have been achieved. This is a result of poor knowledge among teachers and the absence of any discussion or teaching on anaemia and iron supplementation. Teachers in turn have not been provided any training and neither have they been provided with any updates.
Outcome from the Focussed Group Discussion
Parent’s view: The parents initially believed that weekly supplements were contraceptives because iron tablets were strongly associated with pregnancy and antenatal care. This probably explains why, almost without exception, interviewees insisted they never discussed taking part in the trial with anyone – family or friends. Allowing “young girls” to join a trial providing contraception would be controversial so individuals did not readily admit to participation.
Students view: One of the important impacts of the WIFS envisioned was to instil knowledge on iron deficiency anaemia (IDA) among the students who would then serve as agents of change for improving nutritional outcomes in the family. The nutritional information booklet for schools incorporated knowledge on IDA and recommended that this be included in the curriculum and that teachers discuss enquire about the program during school health activities. These received significant attention in the first few years but over the passage of time, the booklets have disappeared from the schools and very few teachers discuss about anaemia and iron with the students. Only one school had a poster on IDA and the importance of WIFS in the school. It is therefore not surprising to find that the level of knowledge among students was quite poor. Majority of the students said that girls required iron more than boys and attributed this to menstruation and blood loss. 13 % felt that both sexes required equally while 7 % did not know who required more. Many did not know that iron was required for growing children. Majority of the students responded to the cause of anaemia as menstruation, blood loss and poor diet. Almost 88% of the students also said that IFA tablet should be taken after food.
Teachers view: More than ninety percent teachers reported that they have thoroughly counselled their pupil for this iron folic acid tablet to consume weekly as per the instruction of the health department. Forty nine percent of the teachers reported that they had consumed the tablet before the adolescents to make sure that they are also will follow the instruction given by the teachers. The teachers reported that they monthly examine the student’s haemoglobin status. The schools are getting regularly the iron tablets from the government officials. Most of the teachers supported the WIFS programme also positively opined that this programme is very useful for the adolescent population. They also have said that many of the students have misbeliefs and so they are not taking the tablets. The parents also sometime discourage their children to take the tablets in school.
The lesson learnt from the study are:
• Program review and performance assessment must be done continuously according to a plan.
• Monitoring should be an important component of the program and must be implemented as planned.
• Public health program such as the WIFS must be supported with adequate IEC materials which is widely distributed.
• In the school setting, the same information should be incorporated and adapted into the health activities of the school. This is especially relevant when providing health product for public health intervention. Correct information about the health product including potential side effects must be informed to both implementers and recipients and strategies to deal with them must be instituted. Mechanisms to report adverse effects and related events should also be in place and must be aligned to the national adverse reaction reporting mechanism.
• When a program continuous indefinitely for such long periods, there must be opportunity for more training including refresher training for all implementers from program personnel to school health teachers. Implementers must be regularly updated on the program and feedback sought on the progress at the field level. Those at the program level should take every opportunity during field visits to enquire on the program and identify issues such as need for training.
• All school-based health programs should have the support from parents by engaging them by including them in the decision making. Schools should ensure that school health is one of the discussion points at the annual Parent – Teacher meeting (PTM). Awareness among parent will ensure better implementation and in the long run, sustainability of the program.
The program was implemented nationwide in all schools without any exclusion criteria. Certain level has been achieved in WIFS programme in terms of compliance to IFA tablet consumption but there is a huge scope of improvement. Fears of Harm/ Unpleasant side effects have significant association with non-compliance to IFA tablet. Proper IEC (Information Education and Communication) and Behavioural Change Communication (BCC) to eliminate the fear of harm/unpleasant side effects will help to increase the compliance. Teachers may play an important role in this matter. There is need of regular orientation to the teachers for behaviour change communication to the parents. Periodic monitoring of the supplies, stocks and records of WIFS programme is needed. The importance of the IFA tablets in the prevention of iron deficiency anaemia is needed to be educated by information, education and communication by social media. Encouraging the children to grow kitchen garden and explaining them the importance of nutrition is important. Resistance from the parents can be overcome by explaining the parents and children the importance of the programme and beforehand explanation of the side effects. The importance of taking tablets after food and under supervision should be strictly followed. Most of the school students consume IFA tablets under WIFS programme although irregularly and inadequately. Barriers of IFA tablet consumption such as side effects, lack of awareness among students, and irregular supply of tablets should be considered. Iron fortification of foods and/or changing composition of iron preparation to avoid side effects may also be considered in future. This study indicates that that weekly IFA under the supervision of trained peer educators may reduce the severity of anaemia.
Brabin & Brabin. (1992). Focusing on anaemia: Towards an integrated approach for effective anaemia control. Joint statement.
Gopalan, C., & Kaur, S. (Eds.) (1989). Women and nutrition in India. New Delhi: Nutrition Foundation of India. Women and nutrition in India: general considerations; p. 378.
Gopaldas, T., & Kale, M. (1985). Prophylactic iron supplementation for underprivileged schoolboys. Indian Pediatrics, 22: 731– 743.
Memorandum of understanding on anaemia control (draft) between Ministry of Health and Ministry of Education.
Ministry of Health and Family Welfare, Government of India (2012). Operational Framework: Weekly Iron Folic Acid Supplementation Programme for Adolescents: 1-3.
Mukherjee, S. B. (2016). Growth, nutritional status and anaemia in Indian adolescents. Indian Pediatrics. 53:905-60.
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World Health Organization. (1999). Programming for adolescent health and development.
Conflict of interest: None
Role of funding source: None