Menu ENN Search

Implications of inconsistent anaemia policies for children and adolescents in Africa

Summary of published study1

Location: Sub-Saharan Africa

What we know: There are many interdependent factors that cause anaemia (infectious and chronic disease, micronutrient deficiencies), which challenges the development of relevant clear, consistent policies and their adaptation to resource-poor settings.

What this article adds: A review to identify international anaemia policies relevant for children in Africa identified some agreement but many inconsistencies, including a wide variety of diagnostic methods, treatment approaches and prevention programmes; inconsistent definitions and target groups; and poor description of the evidence base. These factors limit harmonisation. Anaemia policy development is fragmented and evidence from resource poor settings is lacking. Contextual adaptations of global recommendations are necessary. A single body within WHO should be responsible for devising and implementing a coherent approach to anaemia policy development and access. 

In sub-Saharan Africa, the high prevalence of infectious diseases such as malaria, helminthiasis and HIV; chronic diseases including haemoglobinopathies and deficiencies of micronutrients such as iron, cobalamin, folate and vitamin A, are responsible for causing anaemia in an estimated 47% of children and adolescents. This array of interdependent factors is a major challenge for developing clear, cohesive and evidence-based policies for anaemia diagnosis, prevention and treatment. Adapting policies to apply to resource-poor settings in Africa presents an additional challenge. 

International anaemia policies relevant for children in Africa are produced by several agencies and by different units within single agencies, for example those dealing with malaria, HIV, nutrition and neglected tropical diseases including helminthiasis. The wide variety of diagnostic methods, treatment approaches and prevention programmes for anaemia in various risk groups that are practised in Africa suggest that the guidance offered by current policies may be inconsistent, or difficult to apply in the Africa setting. An additional complication is the fact that the definition of anaemia in countries varies with age and gender; for example, from Hb<94g/l in infants aged two months to Hb<130g/l in male adolescents. 

A recent study identified and compared international policies concerning anaemia diagnosis, treatment and prevention in children. It evaluated the quality of these policies and the extent to which they are based on evidence relevant to the African contexts making recommendations for improvements to the policy making process. The study used the WHO definition for ‘guidelines’ to identify relevant policies and therefore included documents that contain recommendations about health interventions, whether they be clinical, public health or policy interventions. Databases and websites of international policy-making organisations were searched for documents relevant for the diagnosis, treatment and prevention of anaemia in children and non-pregnant adolescents (i.e. less than 18 years old) in Africa. No restrictions on language or time period were applied. The search was completed in May 2013.

Results

Several areas of agreement between policies were noted especially in relation to iron supplements and transfusions and the need to treat co-morbidities. It was generally agreed that although there are continued concerns about potential increased risk of infections, iron supplements are generally beneficial for treating anaemia, especially in combination with other anaemia interventions. Iron given with foods was speculated to be safe, although safety when administered as a fortificant has been questioned. There was consensus that blood transfusions are indicated in children with severe anaemia who are clinically unstable. However, there were also examples of ambiguities within individual policies and inconsistencies between policies on key issues concerning anaemia diagnosis, treatment and prevention. For example, the definitions for categories of anaemia severity were inconsistent, many policies did not specify the age group for which the policy had been developed and where target age groups were specified, they varied between policies.  

As so few policies explicitly described the evidence on which they had been based, it was not possible to draw conclusions about whether publication of evidence was related to any revision of existing policies or to the development of new policies. Some of the contradictory findings in the evidence are likely to reflect differences in populations or population sub-groups and their environment, which may limit the generalisability of some policies. However, for others, particularly those concerning diagnostics, there is insufficient available evidence to inform recommendations. The anomalies within and between policies and in some cases their lack of generalisability, mean that information often cannot be pooled to harmonise the policies. Without more context specific research to fill current evidence gaps and to clarify any adaptations that are needed for specific contexts, clinicians will remain uncertain about selecting the best intervention for their own practice. The clear need to adapt global anaemia policies for each context highlights the importance of WHO headquarters restricting itself to making global anaemia policies and then WHO’s regional offices can support local adaptations depending on the local context.  

Although WHO recommend that its guidelines should specify the duration of their validity, when they should be reviewed and which department will be responsible for initiating the review, most of the policies identified in the study did not have any indication of their duration of validity, and few have undergone any documented process of updating. By analysing the strengths and weaknesses of international policies concerning anaemia in children and adolescents in Africa, the authors have been able to identify and prioritise areas for further work. The authors advise that in order to address the weakest aspects of existing anaemia policies, attention should be focussed on constituting appropriate guideline development and peer review groups and on more rigorous methods for updating and developing policies and incorporating evidence. Furthermore, a comprehensive review of existing research evidence concerning anaemia in African children is urgently needed so that knowledge gaps can be identified and prioritised and research commissioned to fill the gaps. Almost none of the current policies are specifically tailored to Africa, which raises concerns about the appropriateness of these policies in the Africa context. Research located in Africa and involvement of national stakeholders is essential to be able to answer context-specific questions concerning, for example, the risks and benefits of iron supplementation where other infections are prevalent or in groups at high risk of anaemia, such as those with HIV infection or sickle cell disease and young infants.  

Although the lack of policies concerning anaemia diagnosis is particularly worrying since effective anaemia screening and diagnosis is a critical entry point for many children into the health-care system, currently anaemia policy development is fragmented and those concerning iron requirements are based largely on estimates of nutritional requirements from food intake studies in healthy Western children. In areas with high infection exposure, there is a need to identify specific iron biomarkers which are not affected by concurrent inflammation. Hepcidin, an essential hormone which regulates iron metabolism, may be useful for differentiating anaemia due to iron deficiency from other causes. 

Although the review focuses on children, it is likely that a similar lack of harmonisation applies to policies concerning anaemia in other population subgroups, such as pregnant women and the elderly. A critical step towards reducing the high burden of anaemia in African children should be the establishment of a single body within WHO responsible for devising and implementing a coherent approach to revising and developing anaemia policies and for making these policies easily accessible.

Show footnotes

1 Hamdan M, Brabin B and Bates I (2014). Implications of inconsistent anaemia policies for children and adolescents in Africa. Public Health Nutrition 17 (11) pp2587-2594.

More like this

FEX: Current evidence on anaemia and micronutrient supplementation strategies in school-age children and adolescents

View this article as a pdf By Elena Hemler, Wafaie Fawzi and Stephanie Wrottesley Elena Hemler is senior project coordinator for the Nutrition and Global Health Program in...

Resource: Adolescent nutrition mapping study: A global stakeholder survey of policies, research, interventions and data gaps

Executive summary Nutrition in school-aged children and adolescents can significantly impact lifelong health and wellbeing as well as national economic growth and the health...

FEX: Adolescent Nutrition: Policy and programming in SUN+ countries

Summary of report1 This summary was prepared by Emily Mates (ENN) who undertook the review as an independent consultant together with Tanya Khara (independent), with the...

FEX: Adolescent nutrition mapping study: A global stakeholder survey of policies, research, interventions and data gaps

View this article as a pdf Summary of research1 Nutrition in school-aged children and adolescents can significantly impact lifelong health and wellbeing as well as the...

FEX: Weekly iron and folic acid supplementation and nutrition education for adolescent girls in Africa and Asia

View this article as a pdf By Anjali Bhardwaj, Lucy Murage, Shibani Sharma, Dhian Dipo, Christine Makena, Marion Roche and Mandana Arabi Anjali Bhardwaj is the Regional...

FEX: Results and lessons learned from WFP’s efforts to support adolescent girls in Niger

By Alexandra Pirola, Benedict Tabiojong Mbeng and Mica Jenkins View this article as a pdf Lisez cet article en français ici Benedict Tabiojong Mbeng is Head of...

FEX: Iron and vitamin A deficiency in African refugees

Summary of published research1 Haemacue survey in Tanzania Five cross-sectional surveys were conducted in refugee camps in north and east Africa between 2000-2002 to assess...

FEX: Lack of progress in reducing anaemia among women

Summary of article1 Location: Global What we know: Anaemia is a persistent condition amongst women and children under 5 years of age and prevalent worldwide. What this...

en-net: Upto what extend iron flour fortification can increase the Hb level of anemic adolescent women if iron fortified wheat flour is feed to these anemic adolescent women for 3 months?

i am doing my Mphil research on iron wheat flour fortification for anemic adolescent women. can any one have any information or relevant site or paper that how much it will...

FEX: WHO Guideline: Nutritional care and support for patients with TB

Undernutrition increases the risk of tuberculosis (TB) and in turn TB can lead to malnutrition. Undernutrition is therefore highly prevalent among people with TB. It has been...

FEX: Consumption of iron-rich foods among adolescent girls in Nepal: Identifying behavioural determinants

By Ajay Acharya, Pooja Pandey Rana, Bhim Kumari Pun and Basant Thapa View this article as a pdf Ajay Acharya is a Family Planning Specialist for the USAID-funded Suaahara II...

FEX: Improving maternal nutrition in South Asia: Implications for child wasting prevention efforts

View this article as a pdf Lisez cet article en français ici By Zivai Murira and Harriet Torlesse Zivai Murira is Nutrition Specialist at United Nations Children's...

FEX: Diet and nutrition status among school-age children and adolescents in Tanzania

View this article as a pdf By Sauli John, Geofrey Mchau, Heavenlight Ayubu, Stanslaus Mafung'a, Samafilan Ainan, Wiggins Kyatikila, Elizabeth Lyimo, Frank Chacky, Fatoumata...

FEX: Improving the nutritional well-being of school-age children through the Nutrition-Friendly Schools Initiative (NFSI) in the State of Palestine

View this article as a pdf By Selena Bajraktarevic, Kanar Qadi, Amani Badwan, Younis Awadallah and Rania Abueita This Field Exchange report is a summary of the cumulative...

FEX: Adolescent nutrition in Mozambique: putting policy into practice

Research By Erin Homiak Erin Homiak MPH is seconded to SETSAN Manica as Nutrition Advisor. Her role is funded by UKaid/DFID. She has been working for Concern Worldwide since...

FEX: Non-nutrition interventions to prevent anaemia in school-age children and adolescents

View this article as a pdf By Natalie Roschnik, Andrew Hall, Moussa Sacko and Sian Clarke Natalie Roschnik is Senior Nutrition Advisor with Save the Children UK, with over 20...

FEX: Acceptability and perceived usability of a non-invasive haemoglobin monitor among community members and health workers in Tanzania

By Rebecca Smyth, Dr Asrat Dibaba, Abena Thomas, Mwivano Malimbwi, Dr Frank Mtimbwa and Dr Nelson Bukuru Rebecca Smyth is the Research and Publication Coordinator of Enhancing...

Resource: Accelerating improvements in nutritional and health status of young children in the Sahel region of Sub-Saharan Africa: review of international guidelines on infant and young child feeding and nutrition

Abstract The United Nations Convention on the Rights of the Child holds governments responsible to ensure children's right to the highest attainable standard of health by...

FEX: Development of a SAM photo diagnosis app

Summary of presentation1 View this article as a pdf By Laura Medialdea Marcos, Iván Molina Allende and Antonio Vargas Brizuela Laura Medialdea Marcos is Principal...

FEX: Independent and combined effects of improved WASH and improved complementary feeding on child stunting and anaemia in rural Zimbabwe

Summary of research1 Location: Zimbabwe What we know: Stunting and anaemia remain prevalent in children; plausible interventions have shown limited or inconsistent...

Close

Reference this page

Implications of inconsistent anaemia policies for children and adolescents in Africa. Field Exchange 49, March 2015. p33. www.ennonline.net/fex/49/africa

(ENN_4864)

Close

Download to a citation manager

The below files can be imported into your preferred reference management tool, most tools will allow you to manually import the RIS file. Endnote may required a specific filter file to be used.