Screening, Monitoring and Evaluating

Screening for Anemia


All women should receive routine doses of IFA, IPTp, and deworming during pregnancy, and this should not be dependent on screening Ideally, women and children should receive a test for anemia and, if they are anemic, they should be given treatment doses of IFA and tested for malaria and helminths. If the test is positive for these infections, they should be treated for malaria and heliminths. Although screening for anemia is the protocol for most Ministries of Health, screening is often not done because the supplies for screening are not available. Where screening is not consistently available, clinical screening by checking for pallor of the palms or conjunctiva for women and palms for young children is fairly sensitive in identifying severe anemia (Dusch et al, 1999Stoltzfus et al, 1999). Individuals with pallor should be treated for iron deficiency anemia and malaria (if endemic) and possibly dewormed, if worm loads are known to be high. If pallor is not corrected, women or children should be referred to a health center or hospital where accurate tests for anemia are available. New testing devices are under development that would not require that blood is taken. Click here to learn more about these non-invasive anemia tests.


Monitoring and evaluation activities should be designed and incorporated into anemia control programs from the beginning. 


Monitoring collects information about programs on a continual basis. Process indicators provide insight as to how the program is working and allow for mid-course changes and adjustments. Components of a process evaluation can assess if the program is working as originally planned, and allows programmers to learn about which components are /are not working and make necessary corrections. Outcomes that can be measured by process evaluation are listed below (taken from: Stotlzfus et al, 2001).


Self-monitoring can be effective. A woman who receives a reminder card, like the one above from India and another one from Indonesia listed in the resources below, can record when she takes her IFA and then share it with her health care provider when she returns for a resupply. This could be the basis for compliance monitoring by health workers. This contact also can be used to discuss compliance with the mother and reinforce the importance of taking IFA every day.


Measurable Outcomes in Process Evaluation

  • A budget dedicated and spent
  • Supplements and other supplies procured
  • Quality of supplements and commodities
  • Provision of adequate storage
  • Distribution system in place
  • Availability of supplements and commodities at distribution points
  • Training activities planned and conducted for health care workers and others as needed
  • Knowledge, attitudes, and practices of health care workers and other agents
  • Community education programs in place
  • Knowledge, attitudes, and practices of community leaders, family decision makers, and mothers
  • Number of supplements and commodities distributed to women/infants
  • Number of supplements and commodities reported received by mothers/mothers of infants
  • Number of supplements and commodities appropriately used by mothers/infants
  • Program coverage (percentage of intended recipients who actually received supplements/commodities)
  • Number of supplements/commodities consumed by women/infants
Measuring changes in iron deficiency anemia in target groups can be ascertained through impact evaluations. Nationally-representative surveys are one method of providing information on coverage and compliance of iron supplementation and other anemia control commodities. Using sentinel sites, where anemia testing is conducted with a selected population in a geographic area, is another method of monitoring impact over time. Nationally-representative surveys should take place every 3-5 years, such as through Demographic Health Surveys.


Anemia prevalence should be disaggregated by severe, moderate, mild, and all anemia prevalence. As countries make progress in reducing moderate and severe anemia, mild anemia prevalence may increase and overall anemia prevalence may stay the same. This decrease in the proportion suffering from moderate and severe anemia and increase suffering from mild anemia should be interpreted as a success story.


The Demographic and Health Surveys (DHS) have collected information on use of IFA supplements (primarily in pregnant women, although some surveys have asked if children receive iron) before 2000 and anemia prevalence since the early 2000s. DHS also collects information on iron-rich foods consumed by children. However, the collection of these indicators is not consistent across countries. It should be noted that DHS mother’s questionnaire asks questions of women with a child younger than five. The question for IFA supplementation asks women 15-49 months with a child born in the past five years how many days they received or took iron or iron syrup in their last pregnancy, but does not ask  how many IFA supplements women who are currently pregnant have consumed. Asking pregnant women what they have taken would not be representative of the potential number of IFA supplements they could take throughout the course of pregnancy, since they have not finished their pregnancy.


In some surveys, this question is reported as the IFA supplements women received or taken. If presented as the number of IFA supplements women took, this is often misinterpreted as a measure of compliance. Since supplies are a limiting factor for IFA supplementation programs, coverage rates are dependent on supplies. To get more information about compliance with IFA supplementation, one would need to ask women how many IFA supplements they received in their last pregnancy (either given at the clinic or purchased) and, of those IFA supplements, how many supplements women took.


For anemia testing, women 15-49 years of age are tested. DHS also disaggregates anemia prevalence by maternity status (pregnant, breastfeeding, and neither pregnant or breastfeeding).