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Community-based research essential for delivery of optimal nutrition: Researcher

BY Ruwan Laknath Jayakody

Public health trainees and students must constantly build on, disseminate, and translate the public health knowledge and evidence base into practice, by conducting high-quality research within the setting of various communities and applying and using the results in an expeditious and comprehensive manner, to provide and deliver optimal nutritional care to the public.

This requirement was highlighted by R. Jayatissa, attached to the Health Ministry, in a review on the “Translation of evidence into practice: Public health nutrition research” which was published in the Journal of the College of Community Physicians of Sri Lanka 27 (1) on 9 July 2021.

As studies have noted, there exists a vast gap with regard to the application of the evidence generated through public health research in community settings and thereby the translation of the research into practice.

Jayatissa cited: “Closing the gap between research and practice: An overview of the systematic reviews of interventions to promote the implementation of research findings” by I. Bero, R. Grilli, J. Grimshaw, E. Harvey, A. Oxman, and M. Thomson, “Getting research findings into practice: Implementing research findings in developing countries” by P. Garner, R. Dale, R. Dickson, T. Dans, and R. Salinas, and “Getting evidence into practice: What works in developing countries?” by K. Siddiqi, J. Newell, and M. Robinson, to back up this statement.

K. Siddiqi and M. Robinson observed in “Getting evidence into practice in developing countries” that this gap may be owing to the poor dissemination of the research findings for use in community settings and not convincing the policymakers adequately. Jayatissa explains that while on the one hand, policy makers may be reluctant to take risks in relation to public health measures that would affect large numbers of people, on the other hand, they may also be willing to act more promptly than researchers, the latter being a group that demands high standards of reliability and validity in terms of research results. That said, there are instances where, as noted by G. Walt in “Health policy: An introduction to process and power”, policymakers are not willing to act, even when there is – according to the researchers – clear evidence, and when the risk posed by taking action is less, Jayatissa noted.

The World Health Organisation (WHO) notes that “nutrition research” is conducted to determine the extent, severity, and causes of nutrition-related problems for the purpose of advocacy and planning. This is done in order to test new interventions to control nutritional problems, to monitor nutrition programmes or interventions, so as to increase the coverage and to identify challenges, and to evaluate nutrition programmes or interventions to test their impact. Walt, however, notes that research on interventions in nutrition and food habits is more difficult to undertake, while its effects are more difficult to measure, pointing out also that therefore funds for the same are more difficult to secure.

In Sri Lanka, a case in point concerns the supplementation of iron, with regard to school going adolescents.
R. Mudalige and P. Nestel noted in the “Prevalence of anaemia in Sri Lanka” that the provision of iron supplements to anaemic schoolchildren (it was found by A. Draper in “Child development and iron deficiency: The Oxford brief” that 36% of adolescents in Sri Lanka were anaemic) resulted in the improvement of their school performance, verbal, and other skills. That it is difficult to address anaemia fully by merely providing iron treatment during pregnancy, has also been noted by Jayatissa. Hence, the Health Ministry sought to prioritise adolescents by focusing on the need to provide adolescent girls with small – daily or weekly – doses of iron supplements.

Hence, a series of research studies were conducted to ascertain the feasibility of this strategy.

The first by R. Jayatissa and C.L. Piyasena on “Adolescent schoolgirls: Daily or weekly iron supplementation?” was done to identify a cost-effective preventive programme for the purpose. This study was designed as a double blind, placebo-controlled clinical trial among girls aged 10-17 years. The daily treatment group (243 girls) were given a dose of ferrous sulphate (60 mg of elemental iron) and 250 micrograms of folic acid in a combined tablet (iron/folate) and 100 mg of Vitamin C five days per week, while the weekly treatment group (230 girls) was given the same dose of iron/folate and Vitamin C, but only once a week on Monday, and they were given a placebo replacement for the iron/folate and Vitamin C during the other four days, and the control group (217 girls) was given the placebo replacement for iron/folate and Vitamin C, five days per week. The trial was implemented for six months. This was done to compare the efficacy of weekly and daily iron supplementation towards improving haemoglobin (protein in red blood cells that carries oxygen), and serum ferritin (blood protein that contains iron) concentrations.

The findings revealed that the prevalence of anaemia was reduced from 25% to 9.5% by the way of weekly supplementation, and from 18.5% to 8.6% by daily supplementation, and in the placebo group, the prevalence decreased from 19.8% to 13.4%. Therefore, it was concluded that both weekly and daily iron supplementation is efficacious as long as compliance is good with the weekly supplementation being considered economically beneficial. As Jayatissa notes, this finding not only created a new opportunity for programme delivery, but its data was as per G.H. Beaton and G.P. McCabe’s “Efficacy of intermittent iron supplementation in the control of iron deficiency anaemia in developing countries”, used to provide global recommendations on an iron supplementation regime for adolescents.

The second research by R. Jayatissa was on “The challenging nutritional problems in schoolchildren” which was a national study conducted among adolescent schoolchildren aged 10-15 years to assess the extent of anaemia as a public health problem. A three-stage cluster sampling method was used where 1,521 students from 144 public schools were randomly selected and studied. Through this, it was found that the overall prevalence of anaemia was 11.1%, while the highest prevalence of 37.7% was seen in 14-year-old girls. As a result, the Health Ministry took a policy decision to address anaemia in school adolescents aged 10-15 years by giving them high priority through schools with support extended by the Education Ministry for its delivery, whereby policy discussions took place on linking the weekly iron supplementation programme with the existing school health programme.

The third study on “Correction of anaemia in adolescence through schools by weekly iron supplementation: Experience in 5 Districts” by R. Jayatissa and N. Rajaratna assessed the feasibility and impact of anaemia in schoolchildren with weekly iron supplementation. A multi-stage stratified sampling technique was used to randomly select 600 Grade Seven and 10 students from 30 schools in five districts. Afterwards, a weekly iron supplementation programme was initiated by the Medical Officers of Health (MOHs) of the areas together with the Family Health Bureau’s (FHB) School Health Unit. These children were given the supplementation regime (iron folic acid combined tablet containing 60 mg of elemental iron and 250 micrograms of folic acid and 100 mg of Vitamin C, only once a week on every seventh day on Monday, while on the first day, 500 mg of mebendazole [medicine to treat worms] and a Vitamin A megadose were given) for six months. It was revealed that when the supplementation coverage was over 30%, the reduction of anaemia was 50%. Hence, the weekly iron supplementation which was initiated in all islandwide schools for six months, targeting adolescents between the ages of 11-15 years since 2004, was expanded to all schoolchildren between the ages of five-18 years based on the guidelines issued by the WHO, the FHB, and the Health Ministry.

The fourth study was R. Jayatissa and S.M.M. Hossaine’s “National Nutrition and Food Survey” which sought to assess the impact of the iron supplementation programme after five years of implementation. A household survey was carried out in nine districts selected randomly from each province. A multi-stage cluster sampling method was used to identify 30 clusters per district and a systematic random sampling technique to identify 21 households within each cluster. It was found that there was a prevalence of anaemia among women (non pregnant) aged 15-20 years. It was noted that as a strategy to control anaemia in pre-pregnant women, iron supplementation during the early adolescent period was not sufficient to maintain the iron levels for lengthy periods of time and that therefore, it was recommended to initiate a sustainable, cost-effective solution to control anaemia in adolescents and pre-pregnant women.

The final research in this series was by R. Jayatissa, A. Perera, N. De Alwis, H. Fernando, and D.N. Fernando in the “National Nutrition and Micronutrient Survey in Adolescents in Sri Lanka – 2017”, which also looked into the prevalence of anaemia and the coverage of iron supplementation among school going adolescents between the ages of 10-18 years. A cross-sectional study was carried out among 2,700 children, with 300 children from 135 secondary schools, randomly selected from each province. The prevalence of anaemia, iron deficiency, and iron deficiency anaemia were found to be 8.8%, 22.1%, and 3.8%, respectively, while a higher prevalence was seen among older children, and a marked geographical variation noticed in the percentage of children who always consumed the iron folate received from school (48.8 – 94.8%).

In conclusion, Jayatissa noted that the latter exemplified the nexus between research and policy.

“Iron supplementation is a ‘magic bullet’ approach to iron deficiency as supplementation programmes don’t tackle the root causes of deficiencies.”

Therefore, Jayatissa recommended that more sustainable action focus on dietary modification, eating habits, and food-related customs.