TABLE 4.
Approaches to implementation of interventions to address anemia
| Intervention | Efficacy | Effectiveness | Scalability | Interactions | Social and behavior change considerations |
|---|---|---|---|---|---|
| Nondietary interventions | |||||
| Malaria preventive chemoprophylaxis | Proven | Proven | Already scaled up | In areas with poor coverage of malaria prevention and treatment, iron supplementation may increase morbidity and mortality | Usage of insecticide nets, fear of side effects from chemoprophylaxis, and lack of adherence when moving from treatment to prevention |
| Antihelminth treatment | Proven | Effectiveness confounded by interactions with malnutrition, poverty, low educational levels, and socioeconomic status. Proven at the community level in combination with water, sanitation, and hygiene and iron and vitamin A supplementation programs | Programs are scaled up | Programmatically, used in conjunction with prenatal iron supplementation (in sub-Saharan Africa and Latin America) and vitamin A and/or folic acid supplementation (in Asia) | Need to address provider and caregiver behaviors |
| Treatment of anemia of inflammation caused by tuberculosis and HIV | Proven—when addressing underlying cause | Proven—anemia improves with the treatment of tuberculosis and HIV | Programs are scaled up | Additional supplementation with iron, folic acid, and vitamin B12 | Related to tuberculosis and HIV programs |
| Management of acute blood loss | Proven—when addressing underlying cause | Implementation challenges in health facilities | Even with facility resources, the uptake is low | Blood transfusions | Relates to provider training and preparation |
| Management of chronic blood loss | Evidence quality is low | Implementation challenges | Even with facility resources, the uptake is low | Iron supplementation | Relates to provider training and preparation |
| Delayed cord clamping | Proven | Proven and used widely | Scaled up | Alongside other interventions for a positive pregnancy experience | Need to address provider behaviors, training, and preparation |
| Management of inherited blood disorders | Supportive and palliative care | More research needed | More research needed | Interactions with iron supplementation and malaria programs | |
| Dietary enhancement and diversification | |||||
| Addition of animal sources of iron to foods and improving dietary diversity to enhance iron intake and absorption | Mixed effects, not conclusive Systematic review shows benefit of dietary diversity and animal source food consumption More evidence needed on dose–response relationship Larger randomized trials needed |
Not yet | More research needed | Food–food /nutrient–nutrient interactions Infections Iron status Public health interventions such as antenatal and postnatal care, and supplementation with other nutrients (vitamin A, folic acid, ascorbic acid, etc.) |
|
| Food processing to improve iron bioavailability | Limited information from small studies Mixed effects Greatest potential shown in dehulling, phytase enzyme, and extrusion cooking |
Not yet | Limited scalability Opportunity cost because of labor intensive traditional processing techniques More research needed |
Processing method, time, temperature, pressure Food matrix: dietary fiber, antinutrients Nutrient–nutrient interactions (vitamin A, ascorbic acid, B6, B12, vitamin E, riboflavin, folic acid; minerals such as calcium, copper, zinc, selenium, etc.) Infections Iron status |
|
| Food-based fortification approaches | |||||
| Mass food fortification | Proven | Proven | Scaled up | In conjunction with other context- and need-based interventions that supply micronutrients | Effective mass fortification builds on, rather than changes, the normal eating habits of the population; social marketing is therefore often not necessary |
| Targeted food fortification | Proven | Proven in specific contexts | Not used widely (mainly used in select population groups) | Selective use of this intervention, based on context | |
| Biofortification | Proven | Increasing | Integration into agricultural value chains and food systems | Potential synergy with dietary diversification approaches | Needed for vitamin A biofortification, because beta-carotene content turns crops yellow or orange |
| Supplementation | |||||
| Iron supplementation (oral) | Proven | Proven | Already scaled up | May have reduced impact in areas with high amounts of inflammation/infection; may increase morbidity and mortality in areas with high malaria burden and poor health infrastructure | |
| Iron supplementation (IV therapy) | Proven in the clinical setting | Not yet used on a population basis | Not scaled up | Safety not yet widely evaluated in low-resource settings | |
| Micronutrient powders | Proven | Local sustainability is still questionable in many settings | Already scaled up | May cause dysbiosis, gut inflammation, and diarrhea in low-hygiene areas | MNPs are not likely cost-effective interventions in terms of costs per disability-adjusted life years, especially where anemia is less prevalent or the severity of anemia is not high |
| Other micronutrients supplementation | Mostly unproven; limited evidence for folic acid and vitamin A | Unproven | Folic acid scaled up in some countries for prophylaxis of neglected tropical diseases | Uncertain | |