Iron and folic acid supplementation for the control of anemia among adolescent girls: Schools as delivery platforms Open Access

Abstract

Anemia remains a problem of moderate public health significance among adolescent girls in Ghana. In response, the Girls’ Iron-Folic acid Tablet Supplementation (GIFTS) program was implemented in October 2017. We aimed to identify predictors of anemia among adolescents in Ghanaian schools, evaluate the effectiveness of school-based weekly iron-folic acid (IFA) supplementation after one school year, and examine the barriers and facilitators to the program during its first two years.

Among 2,948 girls and 609 boys (10-19 years) randomly selected from 115 schools within 8 regions of Ghana, the prevalence of anemia was 24% and 13% respectively. Predictors of anemia and hemoglobin concentration (Hb) among girls included age, geophagy, malaria, diet, and body mass index (BMI). Predictors of anemia among boys included age, malaria, diet, and BMI. Age and BMI each had opposite associations with anemia among boys and girls.

Our longitudinal, cohort study with 1,387 adolescent girls from 60 secondary schools found that anemia declined from 25.1% to 19.6% after 8 months. Cumulative weekly IFA tablets consumed (mean 16.4, range: 0-36) was positively associated Hb and negatively associated with anemia. IFA supplementation had a curvilinear dose-response relationship with Hb. Next, we derived a cut-point for the minimum effective number of tablets over one school year reflective of adequacy of Hb: 26.3 tablets.

While 90% of schoolgirls received at least one IFA tablet over the first school year, 76% had not consumed the minimum effective number of tablets. School-level represented 75% of the variance in IFA consumption. The ability to make up missed doses, school level, educators’ program-related training and experiences, and educator perceptions on difficulty of implementation and time burden were associated with cumulative IFA consumption.

Finally, at 16 schools, we conducted 77 semi-structured key informant interviews with educators and parent leaders. The results indicated that, after two years of implementation, schools had adapted the program, and widespread changes in attitudes and beliefs about the IFA tablets had improved their acceptability. However, limitations remained including supply chain, program ownership, communication, training, motivation, and resources. These results may be used to improve Ghana’s IFA program and have applications for similar programs.

Table of Contents

Contents

Acknowledgements .................................................................................................................................. vi

List of Figures ........................................................................................................................................... ix

List of Tables ............................................................................................................................................. x

Research in Context ................................................................................................................................. xi

Chapter 1: Introduction ................................................................................................................................ 1

Chapter 2: Overview of Methods .................................................................................................................. 4

2.1: Setting ................................................................................................................................................ 4

2.2: Program, Training, and Oversight ...................................................................................................... 4

2.3: Program Evaluation Study Design and Sampling Frame .................................................................... 6

2.4: Data Collection and Data Management ............................................................................................. 8

2.5: Statistical Methods and Data Analysis ............................................................................................. 10

2.6: Alternate Study Designs and Analytic Strategies ............................................................................. 13

References (Chapters 1 and 2) ................................................................................................................ 18

Chapter 3: Predictors of Anemia among Adolescent Schoolchildren of Ghana ......................................... 20

3.1: Introduction ..................................................................................................................................... 22

3.2: Methods ........................................................................................................................................... 23

3.3: Results .............................................................................................................................................. 27

3.4: Discussion ........................................................................................................................................ 29

3.5: Figures and Tables ........................................................................................................................... 34

References (Chapter 3) ........................................................................................................................... 41

Chapter 4: A School-Based Weekly Iron and Folic Acid Supplementation Program is Effective at Reducing Anemia in a Prospective Cohort of Ghanaian Adolescent Girls .................................................................. 43

4.1: Background ...................................................................................................................................... 45

4.2: Methods ........................................................................................................................................... 47

4.3: Results .............................................................................................................................................. 51

4.4: Discussion ........................................................................................................................................ 54

4.5: Conclusion ........................................................................................................................................ 56

4.6: Figures and Tables ........................................................................................................................... 58

References (Chapter 4) ........................................................................................................................... 66

Chapter 5: Barriers and Facilitators of Iron and Folic Acid Supplementation within a School-based Integrated Nutrition and Health Promotion Program among Ghanaian Adolescent Girls ......................... 68

5.1: Background ...................................................................................................................................... 70

viii

5.2: Methods ........................................................................................................................................... 72

5.3: Results .............................................................................................................................................. 75

5.4: Discussion ........................................................................................................................................ 79

5.5: Figures and Tables ........................................................................................................................... 84

References (Chapter 5) ........................................................................................................................... 95

Chapter 6: A Qualitative Analysis of Program Fidelity, Innovation, and Perspectives of Educators and Parents after Two Years of the Girls’ Iron-Folic acid Tablet Supplementation (GIFTS) Program ............... 97

6.1: Introduction ..................................................................................................................................... 99

6.2: Methods ......................................................................................................................................... 101

6.3: Results ............................................................................................................................................ 104

6.4: Discussion ...................................................................................................................................... 123

6.5: Figures and Tables ......................................................................................................................... 127

References (Chapter 6) ......................................................................................................................... 135

Chapter 7: Expanded Discussion ............................................................................................................... 136

7.1: Summary of Findings...................................................................................................................... 136

7.2: Comparison of Findings to Similar Studies .................................................................................... 137

7.3: Study Strengths and Limitations .................................................................................................... 141

7.4: Remaining Research Gaps and Next Steps .................................................................................... 144

7.5: Conclusions .................................................................................................................................... 145

References (Chapter 7) ......................................................................................................................... 147

Appendices ................................................................................................................................................ 149

Appendix 1: Key Informant Interview Guides ....................................................................................... 149

Appendix 2: Distribution of Hemoglobin Concentration at the Baseline and Follow-on Surveys of the Phase I Evaluation of the GIFTS Program .............................................................................................. 158

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School	Laney Graduate School
Department	Nutrition and Health Sciences
Degree	Ph.D.
Submission	Dissertation
Language	English
Research Field	Health Sciences, Nutrition Health Sciences, Public Health
Keyword	iron folic acid anemia implementation science adolescent
Committee Chair / Thesis Advisor	O. Yaw Addo, Emory University Reynaldo Martorell, Emory University
Committee Members	Andrea J. Sharma, Centers for Disease Control and Prevention Usha Ramakrishnan, Emory University Maria Elena Jefferds, Centers for Disease Control and Prevention

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