Egypt: Preventing and Treating Anemia in School Children

A survey of adolescence in Egypt (Adolescents and Social Changes in Egypt: 1997) estimated that 50 percent of adolescent girls and boys are anemic. By age 19, around 65 percent of girls are anemic. This affects their growth, general health and the health of their future children. Poor eating habits are the main reason for the high rates of anemia among adolescents in Egypt. Their daily iron requirements are not met by the typical diet because of an inadequate intake of iron-rich foods and foods that enhance iron absorption, and/or excess intake of inhibitors of iron absorption, such as tea and whole wheat bread.

To address these high anemia rates, the Egyptian government and the Student Health Insurance Program (SHIP) began a targeted program to lower those rates through a dynamic school-based program. The Healthy Mother/Healthy Child Program (HM/HC) of the Ministry of Health was a collaborator. The goal of HM/HC was to reduce maternal and infant mortality in Upper Egypt. Under the HM/HC Results Package, the United States Agency for International Development (USAID) supported the work of John Snow Inc. (JSI) and the Manoff Group to implement the program to achieve the goal of reducing mortality. The task of improving the health and nutrition of adolescents by strengthening the preventive health program of SHIP was part of this work and was called the Adolescent Anemia Prevention Program. The goal of this program was to reduce and prevent anemia in preparatory and secondary schools (including public, private, religious, government and technical schools) in five governorates of Egypt (Aswan, Beni Suef, Fayoum, Luxor, and Qena).

The program adopted a two-pronged strategic approach—supplementation and nutrition education. This approach addressed the immediate situation of iron deficiency anemia and lack of adequate iron stores through weekly in-school provision of iron supplements. The long-term situation of poor dietary habits was addressed through targeted communications activities to improve specific practices related to dietary intake of iron-rich foods.

The work was implemented in phases and built on a formative research base and periodic operational research studies. Methods for supplementation and nutrition education were tested, logistical problems and cultural issues were resolved to ensure success and sustainability. Most students willingly took their weekly iron tablet. As they learned more about anemia through the nutrition communications activities. many of the students who previously would not take the tablets became regular pill takers The main reason for student avoidance of taking the tablet was their fear that it would reduce their fertility (the inclusion of boys in the iron supplementation effort helped dispel the rumors the iron tablets were birth control pills).

The pilot in Aswan showed the health education activities in the schools and the community nutrition communications efforts (including a TV spot about the program) were helpful for the students' understanding of the importance of the iron tablets and the effect of anemia on student health, clearly linking the communications efforts with improving compliance.

From the formative research, four dietary "behavior problems" were identified and, along with dietary changes, considered possible to implement:
  • Eat/serve breakfast everyday
  • Eat/serve iron-rich food for each meal and for snacks
  • Eat/serve fruits and vegetables rich in vitamin C with each meal
  • Delay tea drinking until at least 1 hour after a meal
The school-based education program focused on these four behaviors. The media aired radio and television spots (free on local government channels) to inform the community, parents and students about the program. These spots started a month before the program began in the school and continued all year. Formal educational materials were distributed to the students and the parents of preparatory students. Posters were hung in the schools. Pill distributors conveyed brief nutrition messages (reminders of the four behaviors to change) to students during the weekly distribution of pills.

A number of materials were developed and produced by JSI and Manoff in Egypt for use by the nutrition educators in the school system. For preparatory and secondary students, a colorful booklet was designed containing interactive stories, word games, and puzzles based on information about anemia and the key behaviors to prevent it.

The posters described and encouraged the four key behaviors and featured the students, teachers and parents who also appeared in the television spot. The popular posters were hung in the classroom during the health education campaign. They were changed to coincide with the different messages the activities focused on.

The Health Educator Guide provided guidance on implementing the nutrition education program in the schools including liaising with school administrators and staff, promoting the four messages and how to implement the students' activities. Activities were developed that required no materials or teaching aides—for example, playing games based on information about anemia or creating a soap opera (about the tragedy of the star having anemia and how it affects her life).

Using interactive methods of teaching nutrition information and relating it to students' daily life and school skills has proven very effective. When the activities are fun, the information being conveyed is much easier to remember and more effectively processed by the students. Group interaction also helped create a common knowledge about anemia and a sense of belonging to a special group so they were motivated to achieve the behaviors.

Results showed a decline of 20% in anemia in the tested students.