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 Table of Contents  
Year : 2017  |  Volume : 4  |  Issue : 2  |  Page : 87-93

Compliance and patterns of iron-folic acid intake among adolescent girls and antenatal women in rural Tamil Nadu

1 Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
2 Primary Health Centre, Virudhunagar, Tamil Nadu, India

Date of Web Publication14-Mar-2017

Correspondence Address:
Dr. Kalaiselvi Selvaraj
Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry - 605 006
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/cjhr.cjhr_88_16

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Background: Anemia continues to be a major public health problem in India despite its long-recognized negative impact on health, especially of women. In a scenario where there is little increase in Hb levels even with implementation of various iron supplementation program apart from compliance, their dietary pattern also may play a role. Moreover, majority of the current literature assessed compliance to Iron Folic Acid (IFA) supplements in facility based settings. Objectives: This study aims to identify the compliance to Iron Folic Acid intake and dietary pattern which could influence the absorption of iron among anaemic pregnant women and adolescent girls in a rural area of Tamil Nadu. Methods: This community based cross sectional study was carried out in one of the primary health centres (PHC) in Tamil Nadu during the period of Feb-Mar 2013 among pregnant women and adolescent girls. From the eligible pregnant women and adolescent girls, information regarding socio economic characteristics, practices related to personal hygiene, dietary patterns, consumption of Iron Folic Acid tablets, and reason for non compliance were collected using structured questionnaires during house-to-house visit. Following this, Haemoglobin was estimated among all study participants. Results: Totally 147 (99.3%), 99 (56.6%) pregnant women, adolescent girls were found to be anemic respectively. Out of these, Iron folic acid tablets were consumed by 136 (91.9%), 60 (60.6%) of pregnant women and adolescent girls respectively. Around 90% of the anemic participants consumed IFA tablets during the night time, immediately after food in rice based diet. Pregnant women who were in their third trimester (OR 0.27, 95% CI: 0.10 to 0.69) and high socio economic status (OR 0.10, 95% CI: 0.02 to 0.55) had significant poor compliance compared to women in second trimester and low socio economic status respectively. Among the adolescent girls, increasing age and current school going status had facilitated the consumption of more number of IFA tablets. Conclusion: In this backward district, prevalence of anemia among pregnant women and adolescent girls were extremely high. Compliance to IFA tablets among pregnant women is favourable whereas among adolescent girls is extremely poor. Some of the dietary practices followed in this region could impair the iron absorption level and treatment effect.

Keywords: Adherence, adolescent female, anemia, compliance, iron compounds, pregnant women

How to cite this article:
Selvaraj K, Arumugasamy P, Sarkar S. Compliance and patterns of iron-folic acid intake among adolescent girls and antenatal women in rural Tamil Nadu. CHRISMED J Health Res 2017;4:87-93

How to cite this URL:
Selvaraj K, Arumugasamy P, Sarkar S. Compliance and patterns of iron-folic acid intake among adolescent girls and antenatal women in rural Tamil Nadu. CHRISMED J Health Res [serial online] 2017 [cited 2021 Jan 17];4:87-93. Available from: https://www.cjhr.org/text.asp?2017/4/2/87/201996

  Introduction Top

Iron deficiency anemia accounts for 85% of all cases of anemia and negatively impacts on national productivity with losses of up to 2% of the gross domestic product.[1],[2] Severe anemia during pregnancy significantly contributes to maternal mortality and morbidity.[3],[4] Severe anemia also increases perinatal morbidity and mortality by causing intrauterine growth retardation and preterm delivery.[5]

Similarly, adolescent girls are also at a higher risk for anemia and can have serious consequences throughout the reproductive years of life and beyond.[6] Anemia in adolescent girls affects their reproductive physiology as well as their physical work capacity and cognition.[7]

The prevalence of anemia among adolescent girls lives in India is reported as 55%.[8] In India, the prevalence of anemia in pregnant women has been reported to be in the range of 33%–89%.[9],[10],[11],[12] Under the Reproductive child health program, all pregnant women registered in any facility will receive 100–200 iron-folic acid (IFA) tablets.[13] Similarly, under weekly IFA supplementation program, all adolescent girls will receive a minimum of 52 tablets in a year.[14] However, the effectiveness of these programs still remains questionable.

The ever increasing prevalence of anemia even after many strategies brought to focus, the life course approach. The main aim of life course approach is to ensure adequate hemoglobin at preconceptional level. Hence, adolescent girls are targeted in many nutritional programs such as anemia prophylaxis program for adolescent girls, 12 × 12 initiative, Kishori Shakthi Yojana. Despite these programs, anemia prevalence still remains static. Introducing various nutritional programs ensures solution from supply side or provider's side. Hence, it is high time to focus on barriers from the beneficiaries' perspective.

Various evaluation programs on adherence to IFA supplementation had reported 40%–60% compliance among adolescent girls and pregnant women, respectively.[15],[16] During the treatment phase, hemoglobin levels are highly influenced by various factors such as consumption of IFA tablets before or after food, type of cereals consumed in the diet, dietary preference to vegetarian/mixed diet, and frequency of fruits intake especially citrus fruits.[17],[18],[19],[20] Although evidence are available in these aspects majority of them were conducted in controlled settings. In actual practice, what is the pattern prevalently followed by the people is not well explored. Any faulty practices followed in these dietary behaviors can have a profound effect on the hemoglobin level.

Thus, any effort to improve the compliance of IFA needs to explore these patterns to ensure optimum compliance. We, therefore, tried to find out the compliance and pattern of IFA intake among pregnant women and adolescent girls in a rural area of Tamil Nadu.

  Materials and Methods Top

Study design

This study is a community-based cross-sectional study carried out during February–March 2013 in the service area of Narikudi Primary Health Centre (PHC) in Virudhunagar district of Tamil Nadu. The total population of Narikudi PHC during the study period was 17,904 and birth rate was 17.8/1000 midyear population.

Sample size and sampling technique

The particular study PHC area was selected conveniently as this comes under workplace of the first author. Based on the assumed prevalence of anemia among pregnant women as 58%, 5% alpha error, estimated sample size was arrived at 145. To fulfill this sample size, all pregnant women registered in Narikudi PHC were included in the study. Similarly, based on the expected prevalence of 56% among adolescent girls, 5% alpha error sample size estimated was 140. Adolescent girls (10–19 years) from one of the randomly selected sub-centres (Panaiyur sub-centre within the Narikudi PHC had 182 adolescent girls) were included in the study.

Data collection procedure

Pregnant women who had registered for antenatal care in Narikudi PHC area and residing in that PHC area for at least 6 months were considered as eligible participants. Pregnant women who stay in their mother's house after bangle ceremony (usually celebrated around the 7th/9th month of gestation) were excluded from the study. From the eligible pregnant women and adolescent girls, information regarding socioeconomic characteristics, practices related to personal hygiene, dietary patterns, consumption of IFA tablets, and reason for noncompliance were collected using structured pretested questionnaires during house-to-house visit. Following this, hemoglobin was estimated among all study participants.

Hemoglobin estimation

Hemoglobin estimation was done using Sahli's method (Sahli's Haemoglobinometer, Model: HB-10) by trained laboratory technician.

Ethical issues

This study was approved from Jawaharlal Institute of Postgraduate Medical Education and Research scientific and ethics committee. Informed consent was obtained from all pregnant women, adolescent's girls 18 years and above and parents of all adolescent girls. Assent was obtained from adolescent girls of <18 years.

Statistical analysis

Data were entered into MS Excel 2007 and analyzed using SPSS version 17.0 (SPSS Statistics for Windows, Version 17.0. Chicago: SPSS Inc). Sociodemographic characteristics were presented either as mean ± standard deviation or proportions (%). Anemia was defined as <11 g/dl, <12 g/dl among pregnant women and adolescent girls, respectively. Patterns of IFA intake in relation to diet were reported in percentages. Compliance to IFA intake among pregnant women was defined as follows: Based on the Reproductive and Child Health program guidelines following assumptions were made to define compliance. If the pregnant woman had consumed at least 30, 60 tablets, 90 tablets at the end of 5–7th month of gestation they were considered as compliant to IFA tablets. For remaining months also the similar assumptions were followed. Association of compliance to IFA tablets and other sociodemographic profile, dietary practices were analyzed using Chi-square test. Determinants of compliance to IFA tablets were identified from multivariate logistic regression analysis. Results of this multivariate analysis were reported as ORadj with 95% confidence interval. For adolescent girls factors were identified from multiple linear regression. In this number of tablets consumed by the adolescent girls was considered as a dependent variable and other socioeconomic characteristics were entered under independent variables.

  Results Top

Sociodemographic characteristics

Totally, 148 antenatal women participated in this study [Figure 1].
Figure 1: Distribution of study participants in relation to anemic status and iron-folic acid intake

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Out of these 148 women 103 (69.6%) belonged to 20–24 years of age. There were 126 (85.1%) antenatal women who received school education beyond primary level. Totally, 142 (96%) women were homemakers. All women except two were from above poverty line and belonged to lower middle (41.2%) and lower (38.5%) socioeconomic classes [Table 1].
Table 1: Compliance to iron-folic acid intake and associated sociodemographic factors among anemic pregnant from Narikudi Primary Health Centre area - multivariate analysis

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The mean age of adolescent girls who participated in this study was 14.2 ± 2.7 years. Among 175 adolescent girls, 32 (18.3%) were currently not going to school or college, and 20, 5 and 7 of them were doing mill work, tailoring, and household chores respectively. Totally, 61.7% of them completed at least middle school of education.

Obstetric related parameters of study participants

Primigravida, second, third, and higher gravid women were 48.6%, 35.8%, and 15.6% respectively among the study population of pregnant women. Of the 148 antenatal women, 48% were in second, 38.5% in third, and 13.5% in the first trimester of gestation at the time of the study [Table 1].

Dietary behavior of study participants

Antenatal mothers

The majority of them (91.9%) were nonvegetarians and preferred mainly chicken or fish. Of the 136 nonvegetarians, 61 (45%) and 75 (55%) had taken nonvegetarian food monthly once and weekly once, respectively. Totally, 140 (94.6%) women had the habit of consuming fruits regularly and mainly preferred apple (91.2%) and orange (75.7%). Among women who had a regular consumption of fruits, (79.3%) of them had consumed fruits weekly once including 21 (15%) of them who had fruits in their diet daily.

Adolescent girls

Similar to antenatal women, the majority of adolescent girls (89.1%) also nonvegetarians with preference toward chicken and egg (81.1%). Thirty-eight (24.3%) and 31 (19%) of adolescent girls had consumed nonvegetarian food and fruits respectively at least weekly once in the previous month. The majority of anemic pregnant (92.5%) women had consumed IFA tablets though all of them had not taken regularly.

Out of 148 pregnant women, 114 (77%) had consumed their IFA tablets as per the advice received from their health-care providers. Women had their IFA tablets during the night time immediately after rice-based diet. Among 34 women who did not consume IFA tablets regularly, major reasons were: dislike the taste (70.6), late registration (14.7%), and side effects (14.7%) [Table 2].
Table 2: Patterns of iron-folic acid intake among pregnant and adolescent girls of Narikudi Primary Health Centre area

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Factors like age of the pregnant women, gestational age at the time of recruitment to the study, education, income, frequency of consuming nonvegetarian items and fruits, anemic status were compared against the compliance to IFA status [Table 2]. Among all these factors, gestational age and income status were found to be significant for IFA compliance. Pregnant women who were in their third trimester and high socioeconomic status had significant poor compliance compared to women in the second trimester and low socioeconomic status, respectively. These two factors remained significant even after adjusted for other confounders [Table 1].

Adolescents iron-folic acid intake

On bivariate analysis, adolescent girls who were more than 14-year-old had significantly consumed more number of IFA tablets compared to adolescent girls of <14-year-old. Similarly, girls who completed more than primary education consumed more iron tablets compared to those who had below primary level of education. When the compliance to IFA tablets were operationally defined as at least weekly one IFA tablets in the past 1 year (total of 52 tablets in the past 1 year) none of the adolescent girls consumed adequate number of tablets. But still, among the girls who consume IFA tablets, factors associated with consumption of more number of IFA tablets were analyzed using linear regression analysis. In this analysis, number of IFA tablets was considered as dependent variable and factors such as age, education, current school going status, and dietary preferences were entered as an independent variable using enter method [Table 3].
Table 3: Linear regression analysis on factors associated with increasing iron-folic acid tablets among adolescent girls from Narikudi Primary Health Centre

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  Discussion Top

This study conducted from rural area of Virudhunagar district Tamil Nadu shows the prevalence of 99% anemia among pregnant women and 66.7% anemia among adolescent girls. This prevalence is extremely high compared to national average and state specific anemia prevalence.[8],[21]

In this study area, around 90% pregnant and adolescent girls consume nonvegetarian diet. Yet, the frequency of nonvegetarian intake (55% vs. 24.3%) and fruits intake (79.3 vs. 19.0%) were more among pregnant women compared to adolescent girls. The common fruit consumed was orange (a citrus rich fruit). This could be due to the prevailing practice of giving privilege to pregnant women in their diet during conception. The frequency of fruits intake among adolescent girls was lower than the National Family Health Survey III results.[8]

Among the anemic pregnant women, 7.5% did not take IFA tablets. Among adolescent girls this proportion was even higher (39.4%). The reason for low compliance among adolescent girls could be due to lack of knowledge regarding their hemoglobin status and accidental detection of anemia among them. Unless the program screens periodically for anemia among adolescent girls, they would not know their anemic status. Except one adolescent girl, all the pregnant women and adolescent girls consumed their iron tablets immediately after food mainly during the night. Since the staple food is rice, majority of them had taken their tablets along with rice-based diets. Studies have reported fractional absorption of iron from rice-, wheat-, millets-based diets as 8.3%, 11.2%, 4.6% respectively.[17]

Compliance was defined in many studies in different ways like regular intake of IFA tablets from the date of registration, not missing more than 2–3 tablets consecutively, etc.[15],[16] Since this study did not record any information on which day the IFA tablets were started defining compliance in those lines would not be possible. Moreover, this study attempts to identify the compliance to IFA intake along the lines of program implementation guidelines rather than the optimal one.

This study showed 77% compliance among pregnant women. Among adolescent girls, none were compliant according to program guidelines. Studies conducted among pregnant women from other Indian settings (Calcutta: 62%, Mangalore: 64.7%) also reported similar compliance rate.[15],[16] Compared to Indian settings studies reported from Africa had shown poor compliance among pregnant women.[22],[23] A study conducted among adolescent tribal girls of Madhya Pradesh had shown 89% compliance, but this was an interventional study conducted under trial design.[24]

Among the pregnant women, those who were in their third trimester of gestation and high socioeconomic status had poor compliance compared to women who belong to the second trimester and low socioeconomic status, respectively. Probable reason for poor compliance among third-trimester pregnant women could be due to late registration which subsequently leads to lesser number of cumulative IFA tablets. Reason for poor compliance among pregnant women from high socioeconomic status needs further exploration. A study conducted among pregnant women from Calcutta also reported poor compliance among women from high socioeconomic status (low: High; 100% vs. 0% economic status).[15] This study from West Bengal also reported better compliance among women living in joint families, belonging to scheduled caste and tribes and made aware of anemia by the health worker.[15]

In a study conducted from Mangalore region of Karnataka, better compliance was noted among people from low socioeconomic status (low: High economic status; 73.8% vs. 38.8%).[16] This difference could be due to differing study setting and definition used for defining compliance. The earlier two studies were done from representative areas of rural region whereas this study from Karnataka was a facility based one. This study further added increasing age of the mother, number of children, preference to nonvegetarian diet and access to free availability of IFA tablets as associated with better compliance to IFA tablets. Although the current study also had shown the results on the similar line in terms of age, preference to Nonvegetarian diet, statistically these findings were not found to be significant. The present study did not focus on the compliance to IFA tablets among women attending a different type of health facilities. Among the adolescent girls, increasing age and current school going status had facilitated the consumption of more number of IFA tablets.

Apart from the determinants mentioned in this study, factors like awareness on anemia, time of registration during antenatal period and health seeking behavior of women can significantly influence the IFA consumption pattern.

Strengths and limitations

This study reports a result based on the representative samples studied from rural area of one of the backward districts in Tamil Nadu. This study also adds to the compliance pattern to IFA tablets among adolescent girls in a field setting. The response rate among pregnant women and adolescent girls in the present study were 95.4%, 96.2%, respectively. This high response rate was possible due to participation of field ANMs in the area. Compliance was measured as per the self-report; we did not do any pill counting or other objective methods for checking the compliance. Since the sample size was calculated based on the prevalence of anemia, interpretations from statistical tests of significance needs to be further explored. The definition of compliance varies across different studies, therefore, comparability was difficult. The results can be applicable to countries with diet pattern similar to South Indian population, which are basically rice eating population. During analysis clustering (more than one pregnant woman/more than one adolescent girl participant from the same family) were not adjusted. Yet, the results may not vary as no family had more than one pregnant woman and only five families had more than one adolescent girl from the same family.

  Conclusion Top

In this backward districts of rural area from Tamil Nadu prevalence of anemia among pregnant women and adolescent girls were extremely high. Compliance to IFA tablets among pregnant women is favorable whereas compliance to IFA among adolescent girls is extremely poor. Some of the dietary practices followed in this region could impair the iron absorption level and treatment effect. Hence, all pregnant women and adolescent girls should be advised to take Vitamin C rich foods, wheat-based items. Pregnant women from last trimester of gestation, young adolescent girls, and school drop-out girls need special consideration under the program implementation. Pregnant women from high socioeconomic status need to be sensitized for better compliance.


Authors gratefully acknowledge the cooperation rendered by the laboratory technician and village health nurses helped in hemoglobin estimation and mobilization of study participants respectively.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1]

  [Table 1], [Table 2], [Table 3]

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