Anemia is defined by the World Health Organization as a reduction in the proportion of red blood cells or decline in the concentration of hemoglobin level or insufficient oxygen caring capacity to fulfill the physiological demand [1].

The most common cause of anemia in the general population is iron deficiency. An estimate by the World Health Organization (WHO) that around to over half a billion women of reproductive women aged 15–49 years were suffering from anemia in 2019 and most of them suffer due to iron deficiency [2].

Anemia is the most prevalent deficiency disease. There are various nutritional and non-nutritional factors associated with anemia, but the most common cause is Iron deficiency. Most vulnerable groups for anemia are children and women of reproductive age. In India, more than half population of pre-school age children and reproductive age women is suffering from anemia. In the last some decades there have been considerable improvements observed in most of the health indicators, including a decline in infant or child and maternal mortality rates and a drop in the fertility rate [3]. In contrast, India remains in a poor situation concerning nutritional status. In the 2021 Global Hunger Index, India scored 27.5 with a rank of 101 (fall from 94 in 2020) out of 116 countries [4].

The overall situation of nutrition status in India is poor, whereas the situation of women’s health conditions was much more adverse because of the existence of gender discrimination from birth and uneven distribution of health services [5].

Nutrition deficiencies such as protein, vitamin C and iron push women towards anemia. Anemia is adversely affecting women of reproductive age and child health which in turn results in increased morbidity and maternal death and also hamper social-economic growth [6]. Indian government had started anemia prophylaxis efforts long time ago and still continuing to bring down its occurrence.

National Family Health Survey is the large-scale survey conducted in India to provide high quality data on health and family welfare and related emerging issues. Studying the time trend for anemia prevalence and other related parameters reported in NFHS surveys helps how well India has performed until now and how far is it from the goal of becoming Anemia free country.

Objective

To assess the trend of anemia prevalence in Himachal Pradesh over last 15 years among various age groups reported in NFHS (3, 4 and 5).

Secondary data from previous 15 years report of NFHS were studied thoroughly and data on prevalence of anemia among age group (6-59 months and 15-49 years’ females) were analyzed. Comparison of prevalence of anemia in India and Himachal Pradesh (H.P). Further districts of HP were compared to check intra-district discrepancies.

Prevalence of anemia in India has increased in all age groups but maximum among children under 5 years in last 5 years. Whereas in Himachal Pradesh the prevalence has overall decreased except in children under 5 years, an increase of 2% (53.7% NFHS-4 to 55.4% NFHS-5) was seen. Among 12 districts best performing districts with decrease of anemia among both under 5 years and women of reproductive age was seen were Solan with decrease of 21.4% (71.8% in NFHS 4 to 50.4% in NFHS 5) in children under 5 years and Kinnaur with decrease of 29.1% (80.8% in NFHS 4 to 51.7% in NFHS 5) in women of reproductive age group.

In India decreasing trend was seen from NFHS 3 (69.4%) to NFHS4 (58.6%) then sudden increase of 9% (58.6% NFHS4 to 67.1% NFHS5) was seen, whereas in Himachal Pradesh increase was seen 53.7% in NFHS4 to 55.4% in NFHS 5 (Figure 1).

Figure 1: Prevalence of Anemia in Children Aged Less than 5 years in India and Himachal Pradesh

Maximum increase of 20.4% was seen in district Kullu whereas maximum decrease of 21.4% was seen in district Solan which can be labelled as best performing district (Figure 2).

Figure 2: Prevalence of Anemia in 12 Districts of Himachal Pradesh NFHS 4 and NFHS 5

Anemia in Children

Iron deficiency particularly affects preschool-age children (0-5 years) because of the disequilibrium at this age between rapid growth and insufficient iron intakes. 

In children, anemia is found to be interlinked with the malnutrition and breastfeeding. While situation of under-nutrition had slightly improved for preschool children by showing a decrease in prevalence of underweight (35.8 to 32.1%), stunted (38.4 to 35.5%) and wasted (21.0 to 19.3%) children from NFHS-4 to NFHS-5, prevalence of severe wasting has increased (7.5% in NFHS4 to 7.7% in NFHS5) such increase was not reported in previous family health surveys.

Anemia in Women

Prevalence of anemia among women in India has increased 53% in NFHS-4 to 57% in NFHS-5 (increase of 4%), whereas in Himachal Pradesh decrease of 5% was seen from NFHS4-NFHS5 (53.5% in NFHS4, 53.0% in NFHS5) (Figure 3).

Figure 3: Prevalence of Anemia in Women of Age Group 15-49 Years

Kinnaur was best performing district with decrease of 29.1%, whereas Bilaspur and Una can be labelled as worst performing state in terms of anemia control with the increase of 13.9% (Figure 4).

The control of anemia in women of childbearing age is essential to prevent low birth weight, perinatal and maternal mortality, as well as the prevalence of disease later in life.

Figure 4: District Wise Prevalence of Anemia among Women of Reproductive Age Group Aged 15-49 Years

Ever since the inception of anemia monitoring in NFHS, a declining trend was observed for all groups in the successive surveys up to NFHS 4, but a rise was observed in NFHS-5 for all but most prominent in under 5 children. 

India is lagging behind in terms of achieving its national targets of Anemia Mukt Bharat Abhiyan under Poshan Abhiyan [8].

Despite the fact that India has seen a decline in anemia prevalence in successive NFHS survey and had also performed better in other key indicators related to anemia, after NFHS-4 anemia prevalence jumped up in NFHS-5 for all groups

This is evident from the above discussion that the problem of iron deficiency anemia remains a major problem in India.

Since the initiation of Nutritional Anaemia Prophylaxis Programme (NAPP) in 1970 by national government to prevent anemia in the country we have seen various revisions in the policy and renaming of the programme as National Nutritional Anemia Control Programme (NNACP) in 1991, National Iron Plus Initiative (NIPI) programme in 2013 and now reached to Anemia Mukt Bharat under POSHAN Abhiyan (the government’s national nutrition mission) launched in 2018. Government continued its efforts to address nutritional as well as the non-nutritional causes of anemia through prophylactic Iron and Folic Acid (IFA) supplementation providing IFA fortified foods in public health programs, deworming and behaviour change communication. 

We need to ascertain that how many targeted beneficiaries are being benefitted through these provisions actually and to what extent based on in-field conditions rather than on-records data. Therefore, more efforts and dedicated work need to be done to improve the status of anemia.

National family health survey record reveal that all the efforts made in direction to reduce the anemia prevalence in country are promising but still not able to bring the prevalence below 50% in children and women therefore efforts need to be improved and continued further.

Way Forward

Study points to the need for the importance of multistake holder, multidisciplinary strategy to improve the status of anemia in children and women.

1. World Health Organization. Global Anemia Estimates 2021 Edition. Geneva, Switzerland, 2020. https://www.who.int/data/gho/data/themes/topics/anaemia_in_women_and_children#:~:text=Summary%20findings&text=In%202019%2C%20global%20anaemia%20prevalence,women%20aged%2015%2D49%20years.

2. McLean, E. et al. “Worldwide prevalence of anaemia, WHO vitamin and mineral nutrition information system, 1993–2005.” Public Health Nutrition, April 2009, vol. 12, no. 4, pp. 444–454.

3. Yadav, S. and P. Arokiasamy. “Understanding epidemiological transition in India.” Global Health Action, December 2014, vol. 7, no. 1, pp. 23248.

4. Index, G.H. 2021 Global Hunger Index: Hunger and Food System in Conflict Settings. Bonn/Dublin, 2021.

5. Mehrotra, S. “Child malnutrition and gender discrimination in south Asia.” Economic and Political Weekly, March 2006, pp. 912–918.

6. Bentley, M.E. and P.L. Griffiths. “The burden of anemia among women in India.” European Journal of Clinical Nutrition, January 2003, vol. 57, no. 1, pp. 52–60.

7. International Institute for Population Sciences. National Family Health Survey-5, 2019–21. Mumbai: IIPS, 2021. http://rchiips.org/nfhs/factsheet_NFHS-5.shtml.

8. Belwal, E. et al. “Anemia prevalence in India over two decades: Evidence from national family health survey (NFHS).” International Journal of Science & Healthcare Research, 2021, vol. 6, no. 4, pp. 335–340.