Abstract
Anemia is a condition that affects 45 percent of children less than five in low- and middle-income countries (WHO, 2016). In El Salvador approximately one out of every two children 6- to 23-month-old in the poorest municipalities, has some anemia. If untreated, anemia can reduce cognitive capacity, increase the risk of infections, and, in the long term, cause permanent loss of productive capacity (Hass and Brownlie, 2001; Horton and Ross, 2003). According to the WHO, iron deficiency is the most common cause of anemia, and estimates indicate that about half of anemia cases worldwide could be due to this cause (Ezzati et al 2014). Most cases of iron deficiency anemia can be effectively prevented and treated in several ways (De-Regil et al, 2011; WHO, 2016b): increasing the intake of foods with high and easily absorbed iron content (mostly those from animal original such as beef, poultry, fish, among others), or with iron supplementation. Typical forms of supplementation are ferrous sulphate or micronutrient powders, which combine iron with other basic nutrients. In low-income settings, supplementation for prevention and treatment is the most common approach as there might be limited availability of iron-rich foods in households in these settings.
In 2014, El Salvador's government introduced micronutrient supplementation as a preventive treatment for anemia among children 6 to 23 months old. The program involved providing micronutrients free of charge to children aged 6 to 23 months old during child well-visits, developing a social marketing campaign to inform the population of the benefits of micronutrients, educating caregivers on strategies to improve diet and provide supplementation, providing tools to track adherence, and following-up and monitoring adherence through home visits of community health workers (CHW). Although there was a high take-up of micronutrient powders, the program fell short of increasing substantially treatment adherence (Bernal et al., 2020). Treatment adherence can be challenging at scale. In the case of micronutrients, it involves providing them daily for 60 days straight every six months. Other common forms of iron supplementation, such as ferrous sulfate require daily doses non-stop. A correct adherence is crucial for the effectiveness of the program but is challenging from a behavioral perspective. Several biases could prevent caregivers to fully adhere to the treatment (limited attention, mistaken beliefs about anemia or the treatment, among others). A qualitative study by Bernal et al. (2020) showed that in the case of El Salvador, caregivers do not make a correct assessment of the cost-benefit analysis of an adequate adherence to treatment, mostly since anemia symptoms can go easily unnoticed, and benefits of treatment are mostly long-term.
Given the high anemia rate in rural El Salvador, the guidelines for doctors are to prescribe micronutrients to every child between certain ages without testing. Given that there are no relevant side effects of micronutrients even for healthy children and that the probability of having anemia in low-income setting is high, common practice indicates that is that it would not be cost-effective to make anemia screening part of child well visits. As a result, anemia ends up being less salient that other potential diseases and caregivers tend to underscore the risk of their children developing anemia.
This paper studies a relatively low-cost intervention to increase the salience of anemia in order to adjust the caregivers' beliefs related to the probability of their children developing anemia. The intervention involved the introduction of non-invasive anemia screening for children under five years old in primary care units of the Ministry of Health as part of previously established child preventive visits. The main hypothesis behind the intervention is that increasing the saliency of anemia through the non-invasive screening will influence adherence to treatment for this condition. Screening in the treatment group took place during preventive checkups of children at ages 12, 18, 24, 36, 48, and 60 months old. During the screening, health workers explained to caregivers the purpose of the screening and its results using communications materials developed for the intervention. In addition, they provided information and counseling to caregivers regarding the adequate treatment established in clinical guidelines based on the screening result (no anemia, mild, moderate, or severe anemia). In the case of no anemia (even if in the margin), health workers encouraged caregivers to continue with the preventive treatment to keep their children healthy. The intervention was jointly developed with the Ministry of Health with support from technical experts in nutrition. The device used for non-invasive screening will be Massimo’s Rad-67, whose technology has been previously used in clinical settings (Parker et al, 2018) and population-level studies (Shamah Levy et al, 2017). The intervention started in April 2022 and is expected to end in December 2023.