The impact of information, education and communication (IEC) activities on the control of iron deficiency

One of the strategies for combating iron defi­ ciency anaemia is nutrition education of the com­ munity, with special reference to iron deficiency. A study was therefore conducted to assess the effectiveness of training and information, edu­ cation and communication (IEC) activities on reducing the prevalence of iron deficiency anaemia during pregnancy. The specific objec­ tives of the study included identifying the major training institutions that conduct training of community level public health workers on the control of anaemia, to determine the effective­ ness of the training, to develop a standardized monitoring system to track the effectiveness of the training and to identify the major institutions that develop IEC material for the control and prevention of anaemia.


Introduction
One of the strategies for combating iron defi ciency anaemia is nutrition education of the com munity, with special reference to iron deficiency. A study was therefore conducted to assess the effectiveness of training and information, edu cation and communication (IEC) activities on reducing the prevalence of iron deficiency anaemia during pregnancy. The specific objec tives of the study included identifying the major training institutions that conduct training of community level public health workers on the control of anaemia, to determine the effective ness of the training, to develop a standardized monitoring system to track the effectiveness of the training and to identify the major institutions that develop IEC material for the control and prevention of anaemia. This presentation will deal with the effectiveness of training of the Public Health Staff by assessing the knowledge, service efficiency and manage ment capabilities of Medical Officers of Health and Public Health Midwives to control iron defi ciency anaemia.

Due to limitation of time and funds, it was de cided to study Public Health Midwives (PHM), Medical Officers of Health (MOH) and the Public
Health Nursing Sisters (PHNS) and the mothers in their care, in the three sectors, urban, rural and estate, in three of the nine provinces, the Western representing the urban sector, the North Central the rural sector and the Central Prov ince representing the estate sector. From these provinces 3 districts were selected, namely, Colombo, Anuradhapura and Nuwara Eliya.

Lot Quality Assurance Sampling (LQ AS) Method
The Lot Quality Assurance Sampling (LQAS) method (1) was used in the study because of its simplicity, accuracy, the short time required for implementation and the ease of analysis.
LQAS uses in an imaginative way one of the most basic and powerful statistics, namely binomials, which indicates the likelihood of an event occur ring. The particular event studied was whether a health worker has been effectively educating mothers in the community on the control and prevention of iron deficiency anaemia. The pro duction unit identified was thus the community. The next step was to choose the performance expectations for the health worker, i.e. thresh olds. It was decided to use 80% as the upper threshold and 50% as the lower threshold. The upper threshold is what the investigator (or MOH) expects of the health worker, the PHM. The lower threshold represents the community's risk. Identifying the PHM who does well (reac hes the 80% mark) and those whose performance is poor (below 50%) helps to direct scarce time and resources to understanding why a PHM is below standard and to improve her performance.
In step 3, a decision has to be made as to the level of accuracy desired. To keep the error to about 10%, one has to identify at least 90% of good workers and 90% of the problematic ones. The risk to the community (risk to the consumer) is minimised by identifying accurately as many of the PHMs as possible who are not working well, and the risk to the investigator or MOH (the pro ducer risk) by identifying correctly the PHMs who are working well. Because both types of risk are important, it was decided to select a The last step in the LQAS method relates to the interpretation of the LQAS result. For each ques tion a mother can be correct or incorrect. A zero mark is given if the answer is correct and one if answer is incorrect. To interpret the total scored by a mother: for a sample of 19, the number of failures permitted in the LQAS method is 6. A community has adequate coverage if 6 (or less) mothers in the sample fail to answer correctly. If 7 or more fail to respond correctly the com munity has not reached the standard.
Using these probability tables, it was decided that the 19:6 LQAS decision rule was appropriate for the study. In other words, 19 antenatal clinics per district would be visited and 6 defects would be the cut off level to define adequacy of service in that district. Under this rule a component ei ther functions adequately or it does not. A PHM fails when more than one of six observations in dicates poor performance. A component fails in a province when more than 6 out of 19 clinics fail the component.

Instruments for data collecting
Four instruments were designed and pre-tested. ii. Check list to interview pregnant women at tending the clinic?
Six pregnant women were interviewed at each clinic, randomly selected, and their knowledge on anaemia assessed by asking a few selected questions which would cover most facts a preg nant woman should know regarding prevention and control of anaemia.

iii. Questionnaire for MOH/DDHS
This was to assess the MOH's management role in anaemia control. One MOH per clinic was in terviewed. Taking the service, educational and management function of the MOH/DDHS into consideration, 18 components were identified as representative of all his/her responsibilities.

iv. Checklist and observation guide for PHNS
The purpose of this assessment was to determine the PHN's knowledge and activities related to anaemia control.
All 4 instruments were reviewed and discussed with experienced and qualified programme man agers, including officers of the Health Education Bureau, Family Health Bureau and the Univer sity of Colombo. The instruments were pre-tested in an ante-natal clinic in the City of Colombo.
One supervisor and two field investigators formed a team responsible for data collection from 19 clinics in each province. The MOH's ques tionnaire was self-administered. One PHM in each clinic was observed when attending to 6 mothers. The PHMs and mothers were selected randomly. PHNs were not interviewed as there were no PHNs in the estate sector and less than 50% in the other two sectors.

Observations on activities of PHM
The performance of the PHMs is indicated in Table 1. In this Table, component one refers to what the PHM should have been observed do ing; weighing mother and noting weight on chart, measuring height at first visit of mother, testing urine, health education and issue of iron tablets. In components 2,3 and 4, whether mother was told of importance of weight gain, signs of iron deficiency and the high risk groups in anaemia. Component 5 dealt with feeding colos trum and breast feeding, component 6, explain ing importance of iron and components 7 and 8, examinations of eye lids and tongue. Table 2 indicates the quality of the mother's knowledge on anaemia. In the Western Prov ince (urban sector) services are adequate only in respect of 2 components: frequency of visits to clinic by pregnant women and adequacy of tablets given to them. Mothers had received in adequate service in examination of tongue and eye lids, knowledge on anaemia, its prevention, ifoods rich in iron, kind of tablets to be taken and three diseases resulting in anaemia.

Observations on mothers
In the rural sector (NCP), 5 components were (adequately serviced, the deficiencies being in talks on anaemia and its prevention, disease con ditions causing anaemia and kind of tablets to be taken. The estate sector (Central Province) appears to be better than the other two. Out of 19 clinics observed, the knowledge component was ad equate in 7 out of 9 components, inadequacies being in kinds of tablets given to prevent anaemia and diseases causing anaemia.
In all three sectors, in general, the components in which pregnant women are inadequately in formed were diseases causing anaemia and kind of tablets needed for prevention.

Effectiveness of MOH's management role in anaemia control
In the urban sector (Colombo District) all MOH's consided themselves competent to handle all components assigned to them. They considered that, on the whole, the ante-natal services pro vided to mothers is adequate, and that their own knowledge on the specified components is also adequate. Nine DDHS/MOHs have had a train ing in the control and prevention of anaemia during the last 3 yrs. All of them accept that anaemia is a priority health problem in Sri Lanka and state that they have adequate knowledge on iron deficiency anaemia and its control.

In the rural sector (Anuradhapura District) 19
MOHs answered the questionnaire. As in the urban sector, out of 18 components in the check list used to assess knowledge and management capability of the MOH, all were found to be ad equate, in all clinics.

Discussion and Conclusions
This study on the effectiveness of the training of public health staff in the prevention and control of iron deficiency anaemia was directed at 3 com ponents of the anaemia control programme implemented by the Ministry of Health through the peripheral services, in the urban, rural and estate sectors.
The study included, i. observation of services provided to an ante natal mother by the PHM during the mother's attendance at a clinic, ii assessment of knowledge of the mother on essential aspects of anaemia, and iii assessment of the managerial function of the DDHS/MOH in anaemia control.
The assessment of the quality of the services was judged using the LQAS method In all three sectors the PHMs attended to their basic functions adequately. These functions in cluded weighing and maintaining the mother's card, testing urine, issuing iron tablets and health education. However, there were variations be tween the sectors with regard to the other com ponents observed. In the urban and rural sectors all seven other components were inadequately delivered. In the estate sector, on the other hand, six out of eight components were adequately delivered.
Two components that need attention in all 3 sec tors are the ability to detect signs of iron defi ciency and knowledge of foods rich in iron. It is therefore imperative that PHMs receive regular in-service training.
As far as the knowledge of mothers is concerned, knowledge was adequate only in 2 components, in the urban sector. The mothers in the rural sec tor fared better than in the other two, being in adequate only in 2 components.
Where knowledge and management functions of the MOH is concerned, the position is differ ent. Although the PHMs attached to estates are provided with the same training as those in the urban and rural sectors, the place of the MOH is taken by EMAs who are not fully qualified doc tors, although they are provided with regular inservice training by the PHSWT whenever new programmes are introduced. The EMAs said they had insufficient time to devote to iron deficiency control activities. In 12 clinics the EMAs said they were unaware of measures that should be taken to meet iron requirements during pregnancy.
The MOHs in the urban and rural sectors assessed themselves as being aware of measures to prevent and control and treat iron deficiency anaemia. All 18 components in the checklist were found to be adequate in all clinics.
The question arises: if this position be correct, that MOHs are more adequately equipped than the EMAs to manage anaemia control pro grammes, how is it that the mothers attending clinics run by MOHs fared poorly when com pared with mothers in the estate sector. Both mothers and PHMs in the Western Province are more exposed to health education and other programmes in the electronic media, in spite of which the less educated and more deprived women on the estates are cared for better.