The girl with Hb 9.4 g/dL and a mother who trusts tonic
A community nutritionist in a peri-urban settlement screens a 14-year-old girl, Rita, during a school health camp. Her height-for-age is normal, BMI-for-age is at the 12th percentile, and haemoglobin is 9.4 g/dL; no other laboratory test is available. Her 24-hour recall shows two cups of strong tea with both main meals, rice and dal twice a day, green leafy vegetables about twice a week, no fruit, and meat once a week; she skips breakfast on school days. The household has irregular daily-wage income, spends roughly 55% of it on food - much of that on packaged snacks the younger children demand - and has four members. Rita has seven-day menstrual periods. The clinic gives free iron–folic acid tablets, but she stopped them after a week because of nausea; her mother prefers a branded tonic that costs about a day's wage. The nutritionist has three follow-up visits, no anaemia re-test until the camp returns in three months, and a small monthly food subsidy from the programme to allocate.
1. Rank the four highest-priority factors driving Rita's anaemia in this setting and justify the order. State what you would deliberately not prioritise yet, and why.
Read the worked answer
Priority order, by leverage rather than by visibility:
- Meal pattern and iron bioavailability. Skipping breakfast and drinking tea with both meals means fewer iron-containing meals and a tannin block on the little iron she does eat. Moving the tea costs nothing and raises absorbed iron more than any single food purchase.
- Menstrual blood loss (seven days). This is the likely reason diet alone will not correct the Hb; it needs clinical referral - dose review and screening for a bleeding disorder. It outranks diet because diet cannot outrun continuing loss.
- Adherence and the tonic. Anaemia will not resolve if the free tablets are abandoned at one week. The nausea is a solvable clinical problem; meanwhile a day's wage goes to an unproven product.
- Household food allocation. 55% of income on food is already high, but part of it goes to packaged snacks, so a small reallocation to eggs, legumes and vitamin-C foods is feasible.
Not prioritised now: weight-gain or BMI counselling (she is not wasted, and it dilutes the message); generic 'eat more fruit and vegetables' advice without costs attached; deworming until the clinic confirms it. A broad education message would miss all three modifiable drivers, and the three-month gap to re-test means the plan has to work without feedback.
2. Design a one-day menu for Rita using familiar local foods that fits the small subsidy and reduces tea interference. Show the meal timing, where the subsidy is spent, and state your cost assumptions.
Read the worked answer
Assumptions: eggs, guava, lemon, groundnuts and green leaves are in the local market; the subsidy roughly covers one egg, one fruit and a weekly pulse top-up per day. The family already owns the staples.
- Before school (07:00): poha or upma with peas and groundnuts, lemon squeezed at the table; no tea.
- Mid-morning (10:30): one guava - the cheapest reliable vitamin C in this market.
- Lunch (13:00): rice, dal, green leafy vegetable cooked in little water, lemon at the table. Tea at about 14:30, a clear hour after the meal.
- After school (17:00): roasted chana, or a boiled egg on days she comes home hungry.
- Dinner (20:00): roti or rice, dal or pea curry, whatever vegetable is cooked; tea again only if she wants it, and again separated from the meal.
Subsidy spending: egg five or six days a week, guava or lemon daily, groundnuts weekly - these are the cheapest enhancers and protein per rupee spent.
Why this shape: nothing is banned, because banning tea usually fails; it is moved. Everything is cooked in the family's existing pots, so the mother can run it without new equipment or refrigeration, and the lemon-at-the-table habit works on any menu. Cast-iron cooking would help further but is not assumed.
3. Rita's mother is sceptical of the tablets and Rita finds them nauseating. Outline how you would use the three visits and what you would ask the clinic to change.
Read the worked answer
Visit 1 - listen before persuading. Ask what the tonic did, what it cost, and what the mother fears about the tablets. Acknowledge that the nausea is real; do not defend a tablet that made her daughter sick. Put the cost in her own terms: one bottle equals one day's wage, which would buy a week of guava and several eggs. Then negotiate a two-week trial: tablet at night after dinner, starting on alternate days, with a small snack. Ask the clinic for a coated preparation or a lower dose with folic acid, and insist on a review of the seven-day bleeding - that is the clinical ask behind the adherence problem. Visit 2 - review, do not lecture. Read Rita's simple symptom note; adjust tablet timing or tea timing; praise whatever worked. Ask the mother what she observed, so she is testing the plan rather than receiving it. Visit 3 - consolidate. Fix the breakfast habit, agree that the subsidy buys eggs and guava, and set the review at the next camp, when the Hb re-test decides.
Reasoning: arguing the mother out of the tonic directly attacks her identity as a provider and usually hardens the position. Making the free tablets and the food visibly cheaper and easier, while letting the Hb result arbitrate, keeps the relationship and the adherence.