The results of Sierra Leone’s 2013 national micronutrient survey were not at all what officials were expecting.

Nutrition experts had long suspected that anemia was having an outsized impact on the country’s morbidity and mortality. The condition, in which a person lacks enough healthy red blood cells, causes fatigue and weakness and can be particularly dangerous for pregnant women and young children.

In addition to revealing the scale of the country’s anemia problem, officials assumed the micronutrient survey would confirm it was being driven by widespread iron deficiency. Global health agencies link anemia primarily to iron deficiency, and most anemia responses center around delivering iron supplements.

As expected, the survey revealed that anemia rates in Sierra Leone were off the charts. More than three-quarters of children between 6 and 59 months old were anemic. It was the cause that was unexpected: Only about 4 percent of children were anemic as a result of iron deficiency.

“We were surprised when the results came out,” said Dr. Mary Hodges, who served as the country director in Sierra Leone for Helen Keller International for 10 years. The global nonprofit helped lead the process of drafting a national strategy following the survey. “Why is so little progress being made [against anemia]? The answer is, We’re barking up the wrong tree.”

The results forced Sierra Leone to reconsider how it responds to the condition. The country’s new anemia control and prevention strategy now focuses on inflammation and infection, which actually appear to be driving the high rates, while integrating a variety of other interventions that are tailored to the needs of particular communities.

And Sierra Leone’s experience might hold lessons for other countries. With global efforts to address anemia stagnating, experts say there is a need to re-evaluate the causes of anemia and craft distinct responses.

In 2012, the World Health Assembly (WHA) set six nutrition targets to be reached by 2025. The second called for a 50 percent reduction in anemia among women of reproductive age – an ambitious goal, but one that reflected how widespread a problem anemia had become. In 2011, 496 million non-pregnant women and 32.4 million pregnant women between the ages of 15 and 49 were anemic, according to the World Health Organization (WHO).

No country is on track to meet the WHA target, according to last year’s Global Nutrition Report. Not only that, but the number of women with anemia has actually increased since 2012.

There is no individual reason why this has happened, but experts worry that part of the problem might be a lack of understanding of what is driving the spread of the condition in specific locations. Iron deficiency remains the leading cause, according to available data, but there are a host of other possible explanations, including deficiencies in vitamins A and B12, parasitic infections and chronic inflammation caused by persistent illnesses.

To effectively combat anemia, experts say, officials need to put in place programs that can effectively target a specific problem where it exists.

“The technical areas of anemia are well mapped out, and there’s a lot of evidence around different interventions for anemia, which are managed by different sectors of government, but what we are trying to understand is how these interventions all work together to create a complete picture,” Dr. Denish Moorthy, the anemia team lead for the SPRING project, told News Deeply. The USAID-funded, seven-year initiative works to strengthen global efforts to identify and improve effective nutrition practices and policies.

“You have to know the depth of the problem of anemia, what causes it, what the interventions for it are, and how you apply the right intervention at the right time to the right group of people.” That may mean going beyond the standard intervention of widespread iron supplementation.

In a list of six steps for reducing anemia that SPRING released late last year, they encouraged countries to first generate evidence and act on it. That process centers on a landscape analysis that both establishes anemia prevalence and its causes.

From there, all of the relevant experts can map out ­– and ultimately implement – targeted strategies that go beyond iron supplementation at community, regional and national levels.

“One of the unique things we found through this approach is broadening the anemia community,” Carolyn Hart, SPRING’s director, told News Deeply. “Getting people to understand that anemia may be their problem, and they may not be a health worker. The people who are now beginning to focus on anemia are different than before.”

Following Sierra Leone’s survey, officials cast a wide net in their search for experts, reflecting the different factors causing anemia. Ultimately, they assembled a network of 220 people to contribute to the anemia reduction strategy. That included experts from the water and sanitation sector who could offer guidance on reducing waterborne infections, but also education officials who could focus on keeping girls in school, where they would have the opportunity to learn more about anemia and how to combat it.

Hodges said the participants “all came away understanding anemia much better as a symptom of underdevelopment.” They also emerged with a seven-year, multifaceted strategy for reducing the country’s anemia rates.

Now the goal for SPRING and other organizations is to get more countries to commit to the process Sierra Leone has just gone through, while convincing governments to sustain any response.

“It needs more help, and I don’t think it’s just international agencies coming in and helping,” Moorthy said. “All we do is a drop in the ocean, compared to the level of investments made by governments.”