Comprehensive framework for integrated action on the prevention, diagnosis, and management of anemia: An introduction

The World Health Organization (WHO) announced in 2021 a commitment to develop a comprehensive framework for integrated action on the prevention, diagnosis, and management of anemia and to establish an Anaemia Action Alliance to support the implementation of the framework. WHO commissioned four background papers to provide reflections about the most pressing issues to be addressed for accelerating reductions in the prevalence of anemia. Here, we provide a complete vision of the framework.

It further consolidates information on the barriers and opportunities to reduce the burden of anemia and make progress toward national and global targets.
Background papers were developed on four priority topics to help inform the framework: causes and risk factors of anemia; diagnosis of anemia and its underlying causes; preventive and therapeutic interventions; and the integrated management of anemia. The four papers are published in a special virtual issue of Annals of the New York Academy of Sciences. 1,[5][6][7][8] Each paper summarizes the existing literature on the topic and contains perspectives that will be essential for driving country impact and activities that are actionable for reducing anemia within a multisectoral approach. The perspectives consider the most affected population groups (women, children, and adolescents), the various causes and risk factors of anemia, and issues as they relate to multiple disciplines (e.g., nutrition, malaria, neglected tropical diseases, education, finance), human rights, living conditions, and the impact of climate, as relevant. Each paper includes three sections: an introduction that provides a framing of the topic; major gaps or challenges in generating effective action and impact; and ways forward, with a focus on innovation. Together, the papers consolidate information on the barriers and opportunities to reduce the burden of anemia and urge stakeholders to examine the prerequisites for achieving the global targets for anemia reduction.
Anemia remains a major public health concern and is tightly linked to socioeconomic status, education, and gender inequality. The effects of anemia can range from mild to severe and include fatigue and decreased productivity, poor cognitive and motor development in children, poor birth outcomes, and increased morbidity and mortality in women and children with severe anemia. [9][10][11][12][13][14][15] Globally, it is estimated that 40% (269 million) of children 6-59 months of age, 37% (32 million) of pregnant women, and 30% (571 million) of women 15-49 years of age are affected by anemia, with the WHO regions of Africa and South-East Asia being most affected. 3 For all population groups combined, the Global Burden of Disease Study 2019 estimated that approximately 23% of the world's population suffered from any form of anemia, affecting 1.8 billion people. 16 The first paper of the special issue 5 reviews the main determinants of anemia. Anemia has complex etiology and is the consequence of a wide range of causes and biological, socioeconomic, and ecological risk factors. The primary causes of anemia include micronutrient deficiencies, infection and inflammation, gynecological and obstetric conditions, inherited red blood cell disorders, and chronic diseases.
While iron deficiency is the most common cause of nutritional anemia, iron deficiency anemia contributes to less than half of the global burden of anemia, highlighting the need for a comprehensive multisectoral approach. 15 Some of the most affected population groups in lowand middle-income countries are often at the greatest risk of suffering from several causes simultaneously, while also being exposed to a number of risk factors associated with anemia. Low socioeconomic status is linked with an increased risk of anemia through multiple pathways, such as poor living conditions, including poor water, sanitation, and hygiene, air pollution, smoking, food insecurity, and poor dietary quality (e.g., low dietary diversity due to predominantly relying on grain-based diets). 14,17 Low attainment of formal education is another risk factor for anemia, as fewer years of formal education may affect a woman's ability to access and understand the information provided on health, nutrition, and family planning and/or to earn a higher income, hence potentially affecting her access to health and nutrition services. 18 In addition to socioeconomic barriers, context-specific gender and social norms within households may affect women's and adolescent girls' ability to seek health services and consume sufficient, safe, and nutritious food to meet their dietary needs.
The second paper 6  Clinicians must understand the causes of absolute and functional anemia to diagnose and effectively treat anemia in individuals. Actions toward anemia diagnosis and control at public health levels will require global, regional, and country actions that should cover general and context-specific characteristics. Research into the biology, epidemiology, diagnosis, and treatment of anemia is still crucial for advancing the field, and innovation is needed, particularly for tools to diagnose anemia and its determinant in a single, more affordable, field-friendly, and less time-consuming test.
The third paper 7 examines the preventive and therapeutic interventions for impact. As the causes and risk factors for anemia are complex and diverse, interventions to address anemia will need to be equally diverse and based on the specific underlying disease and its pathophysiology at individual and population levels. 5,7 A range of interventions have been shown to be effective for improving hemoglobin and reducing anemia by addressing determinants related to nutrition, infection, and reproductive health (Table 1). 14,20 Dietary micronutrient intakes can be improved through dietary diversification, food fortification (mass or targeted), and supplementation of the most affected population groups. In areas with active malaria transmission, TA B L E 1 Current interventions to prevent, diagnose, and manage anemia (adapted from Ref. 14).

• Education about causes and consequences of anemia • Food-based strategies and micronutrient interventions (iron, vitamin A, folate, vitamin B12)
○ Dietary diversification and enhancing the bioavailability of micronutrients ○ Micronutrient supplementation ○ Food fortification (mass, targeted, point-of-use, and biofortification) ○ Complementary feeding ○ Social and behavior change communication strategies Although the 2019 Global Burden of Disease data indicate that the greatest portion of anemia cases are due to dietary iron deficiency, the importance of considering more than just iron-related interventions has been highlighted during recent years and more countries have been incorporating interventions aimed at reducing anemia into larger national nutrition plans or have been developing multisectoral national anemia policies and strategies. 16,22 To facilitate this, tools and guidelines have been developed to support national and district-level landscape analyses. For example, USAID's Strengthening Partnerships, Results, and Innovations for Nutrition Globally (SPRING) Project has developed an Anemia Landscape Analysis tool to help guide countries in designing their anemia programs. 23 Additionally, the WHO has developed a set of questions, set out in the form of a decision tree, to aid users in identifying not only the contributors of anemia in their context, but also the priorities based on current policies and strategies, leadership and coordination, resources available, and the monitoring and evaluation of the program. 15 This stepwise approach can be useful to stakeholders when designing their context-specific and multisectoral response to anemia reduction.
Although these tools are available and some countries have had success in their utilization, limitations have been reported, particularly on: • Socioeconomic and cultural norms that limit access to healthy diets and quality health care.
• Insufficient or outdated data on the primary causes and risk factors of anemia to inform national priorities.
• In the absence of adequate data, priority has typically been given to the implementation of interventions providing iron; however, coverage and quality of these interventions has typically been poor due to weak delivery systems.
• Insufficient communication, leadership, and innovation on anemia.