Weekly iron and folic acid supplementation with
counseling reduces anemia in adolescent girls:
A large-scale effectiveness study in Uttar Pradesh,
India
Sheila C. Vir, Neelam Singh, Arun K. Nigam, and Ritu Jain
Abstract
Background. Weekly iron–folic acid supplementation in
small-scale research trials and as administered in institu-
tions has been demonstrated to be effective in reducing
anemia in adolescent girls.
Objective. To assess the effectiveness of weekly iron–
folic acid supplementation in a large-scale project in
reducing the prevalence of anemia in adolescent girls.
Methods. The project provided weekly iron–folic
acid tablets, family life education, and deworming
tablets every 6 months to 150,700 adolescent school
girls and non-schoolgirls of a total district population
of 3,647,834. Consumption of the iron–folic acid tablets
was supervised for schoolgirls but not for non-schoolgirls.
Hemoglobin levels were assessed in a random sample of
non-schoolgirls at 6 and 12 months and schoolgirls at 6
months. The effect of supplementation on the prevalence
of anemia and the compliance rate were assessed over a
4-year period.
Results. In 4 years, the overall prevalence of anemia
was reduced from 73.3% to 25.4%. Hemoglobin levels
and anemia prevalence were influenced significantly at
6 months. No difference in the impact on hemoglobin
or anemia prevalence was observed between supervised
and unsupervised girls. Counseling on the positive effects
of regular weekly iron–folic acid intake contributed to a
high compliance rate of over 85%. The cost of implemen-
tation was US$0.36 per beneficiary per year.
Conclusions. Weekly iron–folic acid supplementa-
tion combined with monthly education sessions and
Sheila C. Vir was affiliated with UNICEF and is currently
affiliated with the Public Health Nutrition and Development
Centre, New Delhi; Neelam Singh is affiliated with Vatsalya,
Lucknow, Uttar Pradesh, India; Arun K. Nigam is affiliated
with the Institute of Applied Statistics and Development Stud-
ies, Lucknow; Ritu Jain is affiliated with the Public Health
Nutrition and Development Centre, New Delhi.
Please address queries to the corresponding author: Sheila
C. Vir, B-4/141, Safdarjung Enclave, New Delhi-110029;
e-mail: sheila.vir@gmail.com.
186 Food and Nutrition Bulletin, vol. 29, no. 3 © 2008, The United Nations University.
deworming every 6 months is cost-effective in reducing
the prevalence of anemia in adolescent girls. Appropri-
ate counseling, irrespective of supervision, is critical for
achieving positive outcomes.
Key words: Adolescent, anemia, compliance, India,
weekly iron–folic acid supplementation
Introduction
Iron-deficiency anemia is the third leading cause of
loss of disability-adjusted life years (DALYs) among
girls and women 15 to 44 years of age worldwide [1].
The prevalence of anemia among pregnant women
and young children in India is high [2]. From 50% to
90% of adolescent girls in India are also anemic [3, 4].
Early marriage, early conception, and anemia during
adolescence reduce growth velocity and increase the
risk of maternal death, pregnancy complications,
obstructed labor, and low birth weight [5–9]. Moreover,
iron deficiency during adolescence is often aggravated
during pregnancy [10]. Recent data from India [11]
indicates that 55.8% of adolescent women in the age
group of 15–19 years were anaemic and the preva-
lence of anaemia continued to remain at about 58.7%
during pregnancy. Adolescent pregnancy and anemia
contribute to the high prevalence of low birth weight
and subsequent undernutrition among Indian children.
Iron deficiency during adolescence, with or without
anemia, results in poor physical work capacity, poor
concentration, and low school achievement [9]. The
prevention and control of iron-deficiency anemia and
iron deficiency during adolescence is critical for the
development of the nation. Targeting adolescent girls
will help prevent iron deficiency during pregnancy and
its consequences. It has been proposed that in countries
where the prevalence of anemia during pregnancy
exceeds 40%, universal supplementation of adolescent
girls with iron supplements is warranted [12].
Iron and folic acid supplementation in India
Iron–folic acid supplementation of girls during
adolescence has been demonstrated to be effective
in meeting the increased iron requirements and in
building iron stores before the onset of pregnancy
[13]. School-based programs, with strong assurance of
supervision and compliance, have demonstrated that
weekly iron–folic acid supplementation of adolescent
girls is effective in reducing the prevalence of anemia
[14, 15]. Weekly iron folic acid is recommended for the
prevention of anemia [16]. Moreover, weekly iron–folic
acid supplementation has fewer side effects [17] and
lower costs [18] than daily supplementation and has
therefore been proposed to be more effective than daily
supplementation. Iron–folic acid administration, under
supervised conditions, has been shown to be feasible in
institutional environments such as schools [19]. How-
ever, a large percentage of adolescents in developing
countries do not go to school, and are often in a more
disadvantageous situation than those who do attend
school; they often are in a poor socioeconomic group,
and are not in an institutional environment where there
is contact with teachers and peers.
In developing countries such as India, the effective-
ness of iron–folic acid supplementation on a small scale
has been reported [14, 20]. The Government of India
[21] recommended the implementation of large-scale,
district-level projects to study the effectiveness of
weekly iron–folic acid supplementation for adolescent
girls. A district-level project for adolescent girls, includ-
ing both those who are in school and those who are
not in school, was planned and implemented in Uttar
Pradesh. Uttar Pradesh is a northern Indian state with
a population of 180 million, of whom about 20 mil-
lion are adolescents. The objective of the district-level
project was to develop an implementation strategy,
integrated with the ongoing development programs,
to reduce anemia in adolescent girls 10 to 19 years
of age. The project intervention consisted of weekly
iron–folic acid supplementation, deworming every 6
months, and family life education. The effectiveness
of the intervention was assessed in terms of changes
in hemoglobin concentration and the prevalence of
anemia as the implementation was expanded from a
small administrative unit to a large scale project.
TABLE 1. Coverage of non-schoolgirls and schoolgirls in one district
No. of blocks Age group
Phase (total population) (yr)
1 (Sep 2001–Dec 2002) 1 (85,383) 11–­18
2 (Jan 2003–Dec 2004) 2 (324,087) 11–­18
3 (Jan 2005–Dec 2006) 10 in rural and 10­–19
urban areas
(3,647,834)
a. ICDS (Integrated Child Development Services) centers are established by the government for each population of about 1000.
b There were 95 centers in one block and 170 in the other.
187
Methods
A comprehensive project entitled UMANG (Uplifting
Marriage Age, Nutrition, and Growth)—the acronym
UMANG in local language meaning “joy with an ele-
ment of hope”—was launched in Lucknow, a central
district of Uttar Pradesh. The district has 10 admin-
istrative rural and urban blocks, with a population of
3,647,834.
The project was launched in three phases. Phase 1
was conducted from September 2001 to December
2002 in one administrative block among girls 11 to 18
years of age who were not in school (non-schoolgirls).
Phase 2 was conducted from January 2003 to December
2004 in two administrative blocks among girls 11 to 18
years of age, including both girls who were in school
(schoolgirls) and non-schoolgirls. Phase 3 was con-
ducted from January 2005 to December 2006 in all 10
administrative blocks of the district among schoolgirls
and non-schoolgirls 10 to 19 years of age (table 1).
The intervention for all schoolgirls and non-school-
girls consisted of weekly iron–folic acid tablets (con-
taining 100 mg of elemental iron as ferrous sulfate
and 500 µg of folic acid), deworming tablets (400 mg
of albendazole) at 6-month intervals, and family life
education. Tetanus toxoid injections were administered
to some girls by the health department. A state-based
nongovernmental organization supported implementa-
tion of the UMANG project in coordination with the
three primary government agencies: Health, Education,
and Integrated Child Development Services (ICDS).
The elected rural development representatives, who
were members of Panchayati Raj Institutions, the “grass
root” units of self government, were fully involved.
The project proposal was presented to the Direc-
torate of Family Welfare of the state government and
was approved by the ethical division of the govern-
ment. Oral permission for participation in the study
was obtained from the parents of non-schoolgirls in
the community by the village-based front-line work-
ers of the ICDS (anganwadi workers). For schoolgirls,
permission was obtained from the district education
program officers and principals of the schools. Parents
of schoolgirls were briefed by the school principals
No. of ICDS
centersa No. of schools Girls covered
 95 — 3,800 non-schoolgirls
265b 100 22,695 (12,695 non-schoolgirls
and 10,000 schoolgirls)
1,275 351 150,700 (73,700 non-schoolgirls
and 77,000 schoolgirls
188
and oral consent was obtained from them for their
children’s participation in the project. Details of the
methods for non-schoolgirls and schoolgirls are pre-
sented below.
Non-School Going Girls (Non-schoolgirls)
The project was implemented for non-schoolgirls by
linking and building on the Reproductive Child Health
Program under the primary health and family welfare
services as well as the ongoing Adolescent Girls Scheme
of the ICDS. Under the routine ICDS program, only
three adolescent girls from the most deprived section of
the community are selected from a population of about
1,000. Under the UMANG project, three girls who were
part of the Adolescent Girls Scheme were trained to
mobilize and form a group of 20 to 25 adolescent girls,
referred as the UMANG group. These girls were also
trained to provide support to ICDS workers in keeping
records of supplies of iron–folic acid and in recording
compliance. The UMANG group members, by a “girl-
to-girl” approach, reached an additional 20 to 50 girls
in the community who did not directly participate in
the regular UMANG group meetings.
For the non-schoolgirl group, the fourth Saturday
of the month was fixed for reaching the group of
adolescent girls (UMANG group) for the provision of
iron–folic acid supplements and for conducting family
life education sessions. Each girl in the UMANG group
was provided with four or five iron–folic acid tablets
per month from a blister pack of 30 tablets. The red,
non-sugar-coated tablets contained 100 mg of elemen-
tal iron and 500 µg of folic acid. The composition of
the tablets was identical to that of tablets prescribed
for daily consumption by pregnant women under the
National Anemia Control Program of the Government
of India. The consumption of iron–folic acid tablets by
the non-schoolgirl group was not supervised. Deworm-
ing tablets (albendazole, 400 mg) were administered to
girls along with the first dose of iron–folic acid and at
6-month intervals thereafter. Family life education was
provided by ICDS anganwadi workers with the support
of the nongovernmental organizations. The benefits of
regular consumption of iron–folic acid tablets and the
importance of adhering to the preventive dose were
discussed. The girls were encouraged to note positive
outcomes of consumption of iron–folic acid. Special
emphasis was placed on relating the consumption of
iron–folic acid to increasing energy levels for daily
work, reducing lethargy, increasing concentration at
work, improving skin glow and appearance and regu-
larizing menstruation. To prevent adverse effects such
as abdominal pain, nausea, or other gastrointestinal
problems, the girls were advised to consume the tablets
after dinner or the last large meal of the day, prior to
sleep.
The family life education sessions focused on a
S.C. Vir et al.
different theme each month. The topics varied from
development and care during adolescence to young
child and family care. Family life education aimed at
value education, positive thinking, physical and psy-
chological changes, and health and nutrition informa-
tion, including details on the importance of iron–folic
acid consumption, the right age for marriage and
conception, and sexually transmitted diseases, includ-
ing HIV/AIDS. To encourage the girls to participate in
the sessions, they were asked to write questions (which
they were often not comfortable asking in the presence
of peers) on pieces of paper and put them in a question
box to be discussed in the sessions.
The monitoring system initially was limited to
maintaining a register to record the supply of iron–folic
acid tablets and their weekly consumption at the ICDS
center. However, these were not routinely recorded. A
small study on compliance with iron–folic acid sup-
plementation and its perceived effects on well-being
was conducted on a group of 150 girls selected at
random in the district (15 girls per block of the district)
from among non-schoolgirls who had been receiving
iron–folic acid for a minimum of 24 months. The girls
were interviewed to assess the rate of compliance, the
reasons for poor compliance, and specific practices fol-
lowed while they were consuming the tablets.
A “girl-to-girl” approach was introduced in the non-
schoolgirl group. Girls enrolled in the UMANG group
were trained in this approach and were encouraged to
contact one or two adolescent girls in their neighbor-
hood to provide them with iron–folic acid tablets and
to disseminate information acquired by them during
the family life education sessions. These girls were
supplied with four or five iron–folic acid tablets per
month for their own use and an additional four or five
tablets for the one or two girls reached by the girl-to-
girl approach.
School Going Girls (Schoolgirls)
For the schoolgirls, the intervention package was
introduced through the school system. The middle
and senior schools of a district, enrolling girls 10 to
19 years of age, were mapped. The designated non-
governmental organization trained two teachers per
school, using a specific training manual developed for
the project. Posters with culturally relevant informa-
tion were provided to each classroom. A fixed day of
the week (Saturday) was designated as “UMANG Day.”
Iron–folic acid tablets were provided and consumed by
most of the girls under the direct supervision of teach-
ers and class monitors. A few girls who complained of
gastrointestinal problems were advised to consume the
tablets after dinner and were therefore not supervised.
Family life education sessions were held twice a month
on Saturdays, as described for the non-schoolgirl
group. Deworming tablets were administered every 6
Iron and folic acid supplementation in India
months in February and August. Information materi-
als consisted of an illustrated training manual for the
teachers and posters for the classrooms. Compliance
was recorded in individual cards by the girls themselves
and this information was further transferred to class
registers by the nodal teachers of schools. The data
compiled at school level was shared every month with
the nodal nongovernmental organization. Compliance
records were reviewed periodically by the teachers and
the nodal nongovernmental organization.
In both the schoolgirl and the non-schoolgirl groups,
girls were selected (nonpaired) for blood samples in the
first and second blocks. For estimation of hemoglobin,
fingerprick blood samples were collected for analysis
by a hospital-supported laboratory. The laboratory
staff was informed about the project and its objectives.
Hemoglobin levels were estimated by the cyanmeth-
emoglobin method [22] before intervention (baseline)
and after 6 and 12 months of intervention. Quality
control measures were taken to ensure accuracy of
the readings and by counter checking periodically at
laboratory level. To study the trend in the prevalence of
anemia, non-schoolgirls and schoolgirls were selected
from both blocks in 2003 and 2004 and from the 10
blocks of the entire district in 2006. Girls with hemo-
globin levels below 12.0 g/dL were considered anemic,
in accordance with the World Health Organization
(WHO) criteria [23].
The cost of the project per girl was calculated by
dividing the total additional cost of the project by
the number of girls covered. Additional costs include
the cost of the baseline survey, training, education,
monitoring, and iron–folic acid tablets and excludes
the cost of ongoing routine health, ICDS, and education
programs, as well as the cost of deworming medication
and tetanus toxoid injections.
TABLE 2. Knowledge of anemia among non-schoolgirls at baseline and after 6 months
of family life education (percentage of girls)
Age 11–14 yr
Type of knowledge Baseline
Awareness of anemia 44.0
Preventive measures
Iron–folic acid tablets 4.2
Improved diet 12.5
Both diet and tablets 1.5
Medicines and tonics 26.0
Other 0.8
DNK (Do Not Know) 56.6
a. t = 11.026 (p < .01).
b. t = 8.244 (p < .01).
189
Results
Between September 2001 and December 2006, a total
of 150,700 girls (73,700 non-schoolgirls and 77,000
schoolgirls) were covered in the entire district, which
has a population of 3,647,834 (table 1).
In the first phase, 3,800 non-schoolgirls were cov-
ered. A baseline survey on knowledge, attitudes, and
practices (KAP) was conducted in 273 girls during
phase 1. For each of the 95 ICDS centers, the three girls
from the community who were attached to the center
for 6 months during phase 1 under the Adolescent
Girls Scheme were selected for the KAP survey and
the hemoglobin study. Of the 285 girls selected, 273
girls participated in the KAP study (table 2), whereas
only 194 girls agreed to give blood for hemoglobin
testing. This was well above the sample size of 170 girls
considered adequate for the study, with an estimated
prevalence of anemia among adolescent girls of 70%
for a 10% relative margin of error. The average age of
onset of menstruation for the 273 girls studied was 13.1
years. The KAP study was repeated after the girls had
been enrolled in the study for 6 months, with participa-
tion in family life education sessions and consumption
of weekly iron–folic acid supplements. The findings
are presented in table 2. The family life education
sessions resulted in significant increases in awareness
of anemia and knowledge of methods of preventing
anemia especially regarding the role of iron folic acid
tablets.
Data on hemoglobin levels were available for 194 girls
in phase 1. An additional 243 girls who joined the ICDS
program after 6 months as new entrants under the
ICDS Adolescent Girls Scheme were included in phase
2. Since the two samples of phases 1 and 2 were inde-
pendent, their hemoglobin data were pooled. Figure 1
presents hemoglobin levels according to age for the 437
girls of the two phases. Of these 437 girls, 413 and 216
girls agreed to participate in the hemoglobin estimation
study after 6 and 12 months of weekly iron-folic acid
Age 15–18 yr
6 mo Baseline 6 mo
94.7a 64.1 98.9b
38.0 10.3 37.3
16.8 21.8 31.4
35.3 3.6 22.8
6.5 27.9 4.6
0.5 1.2 0.3
7.3 39.1 4.4
190 S.C. Vir et al.

TABLE 3. Mean hemoglobin levels (g/dL) in schoolgirls at

supplementation, respectively (fig. 1).
baseline and after 6 months of intervention according to age
After 6 months of weekly iron–folic acid supplemen-
tation, the mean hemoglobin value in non-schoolgirls Baseline 6 mo
improved significantly from 11 to 11.8 g/dL (t = 6.234, Age (yr) (n = 596) (n = 573)
p < .01), and the percentage of girls with anemia 11 10.7 11.7
(hemoglobin < 12 g/dL) decreased from 55.0% to 39.8% 12 10.8 11.8
(fig. 1). The prevalence of severe anemia (hemoglobin 13 10.9 11.8
< 7 g/dL) decreased from 2.3% to 1.0%, the prevalence 14 11.0 11.8
of moderate anemia (hemoglobin 7 to 9.9 g/dL) from 15 11.0 11.9
15.3% to 4.9%, and the prevalence of mild anemia 16 11.0 11.9
(hemoglobin 10 to 11.9 g/dL) from 37.4% to 33.9%. 17 10.3 12.1
Twelve months of intervention resulted in further 18 11.0 11.6
improvement in hemoglobin levels and a reduction of
Mean 10.8 11.8
the prevalence of anemia (fig. 1).
Hemoglobin levels were also measured in 596 school-
girls selected at random from both blocks of phase 2.
Out of 100 schools in the two blocks, 79 schools were schoolgirls, who were supervised, and the non-school-
selected at random, and from these schools a sample girls, who were unsupervised (table 4). In accordance
with size matching that of the non-schoolgirl group with the intervention strategy, supervision of non-
was selected. The sample size required for an anemia schoolgirls was planned but could not be undertaken in
prevalence of 70% among both schoolgirls and non- the large-scale project, whereas supervision was feasible
schoolgirls with a 10% margin of error was 170. Of the and was carried out for the schoolgirls in an institu-
selected 596 girls, a total of 573 girls could be followed tional setting. During 6 months of intervention, hemo-
for hemoglobin levels after 6 months of weekly iron– globin levels increased from 10.5 to 11.7 g/dL (t = 8.36,
folic acid supplementation. Hemoglobin levels after 12 p < .01) in schoolgirls and from 11.3 to 12.0 g/dL
months of intervention were not measured. The mean (t = 8.35, p < .01) in non-schoolgirls. There was no
hemoglobin levels improved from 10.8 to 11.8 g/dL (t = significant difference between supervised schoolgirls
9.756, p < .01) (table 3). Figure 2 presents the change and unsupervised non-schoolgirls in the effect of 6
in anemia status at 6 months; the prevalence of anemia months of supplementation on hemoglobin levels. The
decreased from 73.8% to 46.3% (t = 7.378, p < .01), percentage of girls with any anemia after 6 months of
the prevalence of moderate anemia from 19.4% to weekly iron–folic acid supplementation decreased from
1.4%, and the prevalence of mild anemia from 53.7% 92.6% to 58.0% among supervised schoolgirls and from
to 44.9%. 73.3% to 39.0% among unsupervised non-schoolgirls.
To study the impact of supervised and unsupervised Similarly, there was no significant difference between
weekly iron–folic acid supplementation, hemoglobin these two groups in the percentage decrease in the
levels were measured in one block of phase 2 after prevalence of anemia.
6 months of iron–folic acid supplementation in the The effectiveness of weekly iron–folic acid supple-

13
80 Baseline 6 mo
Mean hemoglobin (g/dL)

12 mo (N=216)
70

12 Cutoff 60
point
50
6 mo (N= 413)
% 40
11
30

Baseline (N= 437) 20

10
10
11 12 13 14 15 16 17 18 Overall
0
Age (yr) Anemic Moderate Mild No
anemia anemia anemia
FIG. 1. Hemoglobin levels in non-schoolgirls after 6 and 12
months of weekly iron–folic acid supplementation. Hemo- FIG. 2. Anemia status of non-schoolgirls after 6 months of
globin levels ≥ 12 g/dL indicate no anemia, < 7 g/dL severe weekly iron–folic acid supplementation. Hemoglobin levels
anemia, 7 to 9.9 g/dL moderate anemia, and 10 to 11.9 g/dL < 12 g/dL indicate anemia, 7 to 9.9 g/dL moderate anemia, 10
mild anemia to 11.9 g/dL mild anemia, and ≥ 12 g/dL no anemia
Iron and folic acid supplementation in India 191

TABLE 4. Mean hemoglobin levels and prevalence of anemia (hemoglobin < 12 g/dL) among supervised schoolgirls and
unsupervised non-schoolgirls at baseline and after 6 months of intervention according to age
Schoolgirls Non-schoolgirls
Baseline (n = 299) 6 mo (n = 276) Baseline (n = 300) 6 mo (n = 297)
Age Hemoglobin Anemia Hemoglobin Anemia Hemoglobin Anemia Hemoglobin Anemia
(yr) (g/dL) (%) (g/dL) (%) (g/dL) (%) (g/dL) (%)
11 9.7 100.0 11.5 77.8 9.5 100.0 — —
12 10.3 93.1 11.5 64.7 11.2 76.9 11.8 61.5
13 10.3 93.0 11.7 53.1 11.2 81.8 11.8 44.8
14 10.6 89.5 11.7 58.8 11.3 67.8 12.0 39.0
15 10.7 92.3 11.8 47.3 11.4 74.2 11.9 43.7
16 10.7 88.5 11.6 65.5 11.4 65.2 12.1 28.8
17 10.3 100.0 11.8 70.0 11.4 76.0 12.1 26.9
18 11.0 100.0 11.7 57.1 11.3 80.0 12.0 44.0
Overall 10.5 92.6 11.7a 58.0b 11.3 73.3 12.0c 39.0d
a. t = 8.36 (p < .01), baseline vs. 6 mo.
b. t = 8.54 (p < .01), baseline vs. 6 mo.
c. t = 8.35 (p < .01), baseline vs. 6 mo.
d. t = 6.37 (p < .01), baseline vs. 6 mo.

TABLE 5. Anemia status of combined non-schoolgirls and schoolgirls in 2003, 2004, and 2006
Anemic (hemoglobin < 12 g/dL)
Severe Moderate Mild Nonanemic
(hemoglobin (hemoglobin (hemoglobin (hemoglobin
Year N Total < 7 g/dL) 7–9.9g/dL) 10­–11.9 g/dL) > 12 g/dL)
2003 1,173 73.3 0 7.9 65.4 26.7
2004 870 39.0 0 1.1 37.9 61.0
2006 301 25.4 1.6 6.5 17.3 74.6

mentation in reducing anemia was studied. Table 5
presents data on hemoglobin status in schoolgirls and
non-schoolgirls selected at random in 2003, 2004,
and 2006. In 2003, only 26.7% of girls were non-
anemic. After 4 years, the percentage of girls who were
nonanemic increased remarkably to 74.6%.
Routine monitoring information was available only
for schoolgirls and indicates that the compliance rate
with weekly supplementation remained high in all three
phases of implementation. During the first year (2003)
as well as in 2006, more than 90% of schoolgirls had a
compliance rate of over 90%. The individual monitor-
ing card maintained by the girls not only facilitated
recording compliance but also served as a reminder for
weekly consumption of the tablets.
Analysis of data from 150 non-schoolgirls after
at least 2 years of intervention showed that 86.0% of
girls regularly consumed the tablets weekly (table 6).
Twenty-eight girls (18.7%) reported side effects, such
as vomiting, nausea, diarrhea, and black stool. Twenty-
one girls (14.0%) did not consume the tablets regularly.
The primary reported reason for poor compliance was
“forgot to take” (52.4%); 28.6% gave “health problems”
as the reason. Eighty-three percent consumed the tab-
lets after dinner, which may have contributed to the
low percentage of girls with adverse effects. Almost all
the girls (99.3%) drank only water while consuming
the tablets.
The additional cost incurred by the project was
calculated to be US$0.36 per beneficiary (table 7). In
phase 1 the cost was rather high at Rs 119.62 (US$2.96)
per beneficiary. The cost was reduced remarkably to
Rs 14.60 (US$0.36) per beneficiary when the project
implementation moved from the pilot phase in one
block in 2001–02 to covering the entire district in
2006.
Discussion
The aim of the study was not to demonstrate the physi-
ological efficacy of iron–folic acid supplementation,
but to study its effectiveness when supplementation
was scaled up in a project setting. The project was
initially planned for only two blocks, but as a result of
the positive outcome and community demand in the
first two blocks, the project was further scaled up to
cover the entire administrative district. Evidence for the
effectiveness of weekly iron–folic acid supplementation
in a project situation was considered essential to influ-
192 S.C. Vir et al.

TABLE 6. Characteristics of consumption of iron–folic acid

dose (60 mg) of iron in a smaller supervised group of
tablets by 150 non-schoolgirls
adolescent girls or in a school-based supplementation
Characteristic % (no.) of girls project [14–16, 19, 24].
Weekly consumption A major factor responsible for the success of the
Yes 86.0 (129) large project was motivational strategy. Despite weak
No 14.0 (21) supervised conditions in non-schoolgirls, timely and
repeated counseling with emphasis on the positive
Reasons for not consuming
attributes of weekly iron–folic acid supplementation
Forgot 52.4 (11)
appeared to have contributed to the significant posi-
Health effects 28.6 (6)a tive outcome. The present findings confirm that even
Other 19.0 (4) in a large-scale project with weekly supplementation,
Perceived impact of tablets appropriate counseling can overcome poor compliance.
Positive 62.7 (94) Counseling on the benefits of iron supplements and on
Negative 18.7 (28) overcoming side effects has been reported to motivate
None 18.7 (28) pregnant women to complete the full dose of prescribed
Time of consumption supplements [25]. The importance of effective com-
Any time 16.7 (25)
munication to accompany the distribution of iron–folic
After dinner 82.7 (124)
acid supplements has been highlighted in other stud-
ies [19, 26]. The findings also show that motivational
On an empty stomach 0.6 (1)
strategies with a focus on positive attributes of weekly
Manner of consumption iron–folic acid supplementation appeared to be as
With tea or coffee 0.7 (1) effective as supervised intake of the tablets. The main
With water 99.3 (149) reported reason for noncompliance was forgetting to
a. 6 non-schoolgirls (4%) out of a total of 150 reported adverse effects take the tablets, whereas adverse effects were reported
on health by only 6% in non-schoolgirls. Similar results have
been reported from Sri Lanka [24], with less than 3% of
TABLE 7. Costa of the intervention girls reporting side effects such as constipation, sleepi-
ness, abdominal pain, rash, and nausea.
Yearly per Yearly per Weekly iron–folic acid supplementation of adolescent
No. of capita cost capita cost
girls should be made part of maternal and child nutri-
Year beneficiaries (Rs) (US$)
tion programs, because it contributes to building iron
2003 3,800 119.62 2.96 stores before pregnancy [13, 27], enhances adolescent
2004 22,695 58.60 1.45 growth [28] and cognitive development [19, 29], and
2006 150,700 14.60 0.36 reduces the incidence of low birth weight associated
a. Includes cost of IFA supplement, training, IEC, monitoring with adolescent pregnancy [9]. Large-scale projects to
combat anemia among adolescent girls, especially girls
from socially and economically disadvantaged groups
ence policy for addressing anemia in adolescent girls. who do not go to school, have not been systematically
Therefore, an effort was made to collect and analyze the implemented in developing countries such as India.
available data as the project was scaled up. The study The absence of any policy for addressing anemia for
was not designed as a long-term research study, and adolescent girls [30] is possibly due to perception of
this remains the primary limitation of this report. high cost associated with daily and not weekly dosage
The study showed that the prevalence of anemia of supplementation, poor compliance, and the extra
among adolescent girls was very high: 55.0% in non- managerial burden for the health sector. However, the
schoolgirls and 76.3% in schoolgirls. This finding present findings indicate that weekly iron–folic acid
concurs with the high prevalence rates of anemia, supplementation built on existing programs costs only
ranging from 58.2% to 100%, reported from various about one-third of a dollar per beneficiary annually.
parts of India. The present findings confirmed that The cost is significantly reduced when the imple-
in a large-scale project, weekly iron–folic acid sup- mentation is shifted from an experimental project to
plementation is feasible and is effective in reducing a program model and is linked to ongoing health or
anemia in both unsupervised non-schoolgirls and education programs.
supervised schoolgirls. The effect of supplementation In a developing country such as India, provision of
on hemoglobin levels was significant within 6 months, weekly iron–folic acid supplementation to adolescent
and a remarkable threefold decrease in the prevalence girls needs to be viewed as one of the most important
of anemia was seen after 4 years of intervention. Similar nutrition interventions, since it will increase work and
reductions in anemia prevalence were reported from school performance as well as contribute to reducing
weekly iron–folic acid supplementation with a lower the risk of anemia during pregnancy. The latter will
Iron and folic acid supplementation in India
significantly reduce the rates of maternal mortality,
fetal growth retardation, perinatal mortality, and low
birth weight. Weekly supplementation of adolescent
girls should be considered a critical component of the
Reproductive and Child Health program and accorded
a high priority in the control of nutritional anemia in
developing countries such as India [31]. The present
finding of a reduction in the prevalence of anemia in
adolescent girls should be viewed in the context of our
efforts to accelerate the achievement of the Millennium
Development Goals of improving child survival and
maternal health.
Conclusions
Adolescent girls are an important target group because
their high iron requirements lead to depleted iron
stores and a high prevalence of anemia. In adolescent
girls, iron requirements increase by twofold to meet the
loss of iron from the body with the onset of menstrua-
tion; the loss of iron in menstrual blood ranges from
12.5 to 15.0 mg per month or 0.4 to 0.5 mg per day.
In girls and women after the growth spurt, the risk of
iron deficiency and anemia is high throughout their
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