Assessment of women’s knowledge and perceptions on anaemia- an intervention with nutrition education

Introduction

Anemia is a serious global public health problem that particularly affects young children and pregnant women. World Health Oraganisation (WHO) estimates that 42% of children less than 5 years of age and 40% of pregnant women worldwide are suffering from anemia. The African and Eastern Mediterranean regions and Southeast Asian countries carry a high burden of anemia among WRA. India is one of the countries with a very high prevalence of anemia in the world.

According to WHO estimates (2021), anemia affects 53% of women of reproductive age (15-49) in India. According to NHFS-5 data (2019-2021), 67.1% of the children (6-59 months), 57.2% of the non-pregnant women (15-49 years), 52.2% of pregnant women (15-49 years), 57.0% of all women (15-49 years), and 59.1% of all women age 15-19 years are suffering from anemia, while in Telangana state, 70% of the children (6-59 months), 57.8% of non-pregnant women (15-49 years), 53.2% of pregnant women (15-49 years), 57.6% of all women (15-49 years), and 64.7% of all women age 15-19 years are suffering from anemia.

Anemia is more common in women of reproductive age (WRA) with low socio-economic status, are underweight, or have recently given birth. Anemia is a condition in which the number of red blood cells or the hemoglobin concentration within them is lower than normal (WHO). This results in symptoms such as fatigue, weakness, dizziness and shortness of breath. The optimal hemoglobin concentration needed to meet physiologic needs varies by age, sex, residence, smoking habits and pregnancy status. The most common causes of anemia include nutritional deficiencies, particularly iron deficiency, folate, vitamins B12 and vitamin A deficiency. Anemia is associated with impaired cognitive and motor development in children, as well as reduced labour capacity in adults, all of which have an impact on a country’s economic development. Anemia during pregnancy and the first two years of children have irreversible effects on infants’ brain growth, which reduces their Intelligence Quotient (IQ) (Rani et al. 2018; Hassan et al. 2005). Anemia in adolescents, reduces concentration, academic performance, productivity, and physical strength, and increases the risk of infection. Anemia among pregnant women can result in poor maternal and fetal outcomes such as abortion, intrauterine growth retardation, post-partum hemorrhage, stillbirths, low-birth-weight, prematurity, and perinatal mortality (Beckert et al. 2019; Tunkyi, 2018; Kavle et al. 2008). Prevalence of iron deficiency anemia is high in low socio-economic groups (Meharun et al. 2016).

            Anemia has become a major challenge in India and has also had an impact on a country’s economic development. Several studies show that nutrition education reduces the prevalence of certain diseases, including anemia, in many countries. Therefore, given the increase in anemia in the country, promoting and educating people about anemia through nutrition education interventions is essential.

            Jalambadani et al. (2015) reported that after a 3-month educational intervention programme, there was an increase in the mean score of knowledge, attitude, perceived behavioural control, and intention and also there was an increase in the iron intake in the experimental group. Zarei et al. (2014) reported that after the educational intervention programme the mean score of enabling factors, predisposing factors decreased and also there was an increase in the iron intake among the participants from 68 to 95% 3 months after the intervention. Sharifirad et al. (2011) reported that after intervention through the PRECEDE educational model, (Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation) there was a significant increase in the mean scores of awareness and attitude levels in the intervention group.

            Given the importance of prevention of iron deficiency anemia, the necessity of nutrition education for women of reproductive age, and the lack of knowledge about anemia among women, the present study aimed to determine the effectiveness of nutrition education on iron deficiency anemia among women of reproductive age.

Methodology:

Research design and sample selection

An experimental (pre-posttest) research design was adopted for the study. The respondents were categorized into experimental groups and control groups. A total of 300 women who are in reproductive age group (15-49) were selected from 5 adopted villages (Gungal, Subhanpur, Amdapur, Edira and Kaslabad) of All India Coordinated Research Project on Women in Agriculture (AICRP-WIA), Rangareddy district. A sample of 250 respondents was classified as the experimental group and 50 respondents as the control group.

Instruments

A structured questionnaire was used for the study. It included profile characteristics, and anemia knowledge and perception.

Data collection

            In the first discussion, the aim and procedures of the study were explained to the respondents of the selected villages, and the respondents were assured of voluntary participation, confidentiality of all provided data, and the right to withdraw at any moment. The respondents’ haemoglobin levels (Hb) were tested with the help of a healthcare professional. The pretest questionnaire was administered and explained to all the respondents, and blood samples were collected from both groups. Anthropometric measurements of height, weight, and mid-upper arm circumference of all the respondents were taken to assess their Body Mass Index (BMI).

The nutrition education programme was conducted with only the experimental group over a period of 45 days. The intervention group and the control group, were provided with the posttest questionnaires to assess the impact of the nutrition education programme on knowledge, perception levels, but the control group did not undergo the educational program. The duration of this intervention was chosen based on previous research, which showed that intervention durations ranged from one week to three months. (Chaluvaraj, 2018 and Gopal, 2017).

Nutrition education program

The nutrition education programme materials (videos) were developed based on the knowledge and perception gaps and needs that were identified from the pre-test. The videos were screened as a nutrition education programme over 45 days, and each session lasted for approximately 20 min. The content of the nutrition programme material was appropriate, updated and simple information about anemia, symptoms, food sources, balanced diet, and nutrition values of food items that are related to anemia. The intervention was instructed in the local language (Telugu) and checked by the experts for content validity.

Data analysis

Data analysis was performed using IBM SPSS Statistics for Windows, Version 16.0. 

Results

            Table 1 presents the general profile of the respondents. Out of the total population, 61.00% of the respondents were within the age group of 15-26 years, 28.67% of the respondents had high school education, 62.67% were married, and 32.00% of them were housewives.

Findings related to BMI levels indicated that according to the ICMR guidelines, the majority (63.00%) of the population had normal BMI levels, while 26.00% of the respondents were suffering from underweight, 7.76% were overweight and 3.33% were obese. Jamnok et al. (2020) found in their study that 70% were normal, 21.1% were underweight, 7.6% were overweight and 1.4% were obese. According to the National Health Family Survey (NHFS)-5 report (2019-2021) in India, 21.2% of the women were underweight and 19.7% obese in rural areas, while in Telangana, 21.6% of the women were underweight and 23.8% of the women were obese. Mulianingsih et al. (2022) reported that 87.3% of adolescents had normal BMI levels. Underweight can result in health issues like anemia, malnutrition and osteoporosis, while being overweight or obese leads to chronic diseases such as type 2 diabetes, high blood pressure, heart or blood vessel problems, cardiovascular disease, musculoskeletal problems. Pallavi et al. (2012) reported that pre-diabetic and diabetic participants had higher BMI.

Findings related to the prevalence of anemia indicated that, according to the WHO guidelines, out of the total population, 87.33% of the respondents were suffering from anemia. Based upon the severity of anemia, 44.00% had mild anemia, 41.00% had moderate anemia and 2.33% had severe anemia. Meanwhile, 12.67% of the respondents were non-anemic. The possible reasons for these differences might be their consideration of different age groups, eating habits, and varied socio-economic status. Iron is an essential element for blood production. About 70% of the body’s iron is found in the red blood cells of the blood called hemoglobin. Hemoglobin is essential for transferring oxygen in your blood from the lungs to the tissues. Insufficient levels of Hb in the blood result in anemia. Moyna et al. (2022) reported that reported nutritional anemia and low BMI lead to serious health issues among women of the reproductive age group. They also found that 58% of the respondents were anemic in their study.

Knowledge of the respondents on anemia before and after intervention

Table 4 presents the knowledge of respondents with regard to anemia before and after intervention. The results demonstrated that before intervention in the experimental group, about 51.60% had heard about iron deficiency anemia, 44.80% of the respondents could recognize symptoms/signs of anemia, 31.20% knew health risks to children, 32.80% knew health risks to adolescents, 36.40% knew health risks to pregnant women, 26.40% could recognize causes of anemia, 29.60% knew anemia prevention methods, 39.20% could identify or knew sources of iron-rich foods, 14.40% were familiar with the foods that help the body absorb and use iron. Only 6% of the respondents knew the daily requirements of iron as a nutrient.

Meanwhile, in the control group, 42% had heard about iron deficiency anemia, 36% of the respondents could recognize symptoms/signs of anemia, 22% knew health risks to children, 28% knew health risks to adolescents, 38% knew health risks to pregnant women, 40% could recognize causes of anemia, 32% knew anemia prevention methods, 46% could identify or knew sources of iron-rich foods, and 18% were familiar with the foods that help the body absorb and use iron. Only 6% of the respondents knew the daily requirements for iron nutrients.

            After the nutritional education intervention on anemia there was an increase in knowledge levels in the experimental group, there was no significant change in the control group. The results demonstrated that after intervention in the experimental group, all the respondents (100%) had heard about iron deficiency anemia, 93.60% of the respondents could recognize symptoms/signs of anemia, 92.40% knew health risks to children, 82.40% knew health risks to adolescents, 83.20% knew health risks to pregnant women, 90.40% could recognize causes of anemia, 79.60% knew anemia prevention methods, 82.40% could identify or knew sources of iron-rich foods, 67.2% of the respondents knew the daily requirements of iron nutrient and 89.20% were familiar with the foods that help the body absorb and use iron.

Meanwhile, in the control group, 64% had heard about iron deficiency anemia, 36% of the respondents could recognize symptoms/signs of anemia, 22% knew health risks to children, 28% knew health risks to adolescents, 38% knew health risks to pregnant women, 40% could recognize causes of anemia, 32% knew anemia prevention methods, 46% could identify or knew sources of iron-rich foods, and 18% were familiar with the foods that help the body absorb and use iron. Only 6% of the respondents knew the daily requirements for iron nutrients.

Perceptions of the respondents on anemia before and after intervention

Table 5 presents the perceptions of the respondents with regard to anemia before and after intervention. The results demonstrated that before intervention in the experimental group, 22% considered anemia as a serious health problem, 20.4% prepared iron-rich foods, 28% confident in preparing iron-rich foods, 39.6% liked the taste of iron-rich foods, 35.6% sought medical attention, 10.4% checked Hb levels regularly, 34.4% willing to take iron supplements, 46% washing hands with soap before consuming food, 54.8% used soap for hand washing after defecation and 68.4% trims their nails regularly.

With regard to the control group, 14% considered anemia as a serious health problem, 22% prepared iron-rich foods, 32% confident in preparing iron-rich foods, 54% liked the taste of iron-rich foods, 50% sought medical attention, 8% checked hb levels regularly, 40% willing to take iron supplements, 58% washing hands with soap before consuming food, and 50% used soap for hand washing after defecation and 64% trims their nails regularly.

After the nutritional education intervention on anemia there was an increase in perception levels in the experimental group, however there was no significant change in the control group. The results demonstrated that after intervention in the experimental group, 64.8% considered anemia as a serious health problem, 87.6% prepared iron-rich foods, 59.2% confident in preparing iron-rich foods, 50.8% liked the taste of iron-rich foods, 89.2% sought medical attention, 11.2% checked hb levels regularly, 74.8% willing to take iron supplements, 79.2% washing hands with soap before consuming food, 92.8% used soap for hand washing after defecation and 80.88% trims their nails regularly.

With regard to the control group, 14% considered anemia as a serious health problem, 226% prepared iron-rich foods, 32% confident in preparing iron-rich foods, 54% liked the taste of iron-rich foods, 50% sought medical attention, 8% checked Hb levels regularly, 40% willing to take iron supplements, 60% washing hands with soap before consuming food, 50% used soap for hand washing after defecation and 64% trims their nails regularly.

Table 6 presents the percentage difference in anemia knowledge and perception variables in pre and post situations. The results revealed that, an overall difference of 54.8% was found in knowledge after the nutrition education intervention, while in perception, there was 33.08% of overall difference was found. This could be concluded as nutrition education video intervention contributed to increase the scores of difference in knowledge and perceptual levels in the posttest. The findings clearly reveal that the nutrition education intervention had a positive impact on respondents’ knowledge and practice levels. Elsharkawy et al. (2022) indicated that after intervention there was a significant improvement in the mean scores of knowledge, food selection ability, compliance rate, and haemoglobin level for the intervention group than for the control group. Nutrition education initiatives have a good impact on improving nutritional health (María et al. 2011).

Discussion

The current study examined the impact of anemia nutrition education on women’s knowledge and perceptions. To assess the women’s knowledge and perceptions regarding anemia, respondents were interviewed on anemia signs & symptoms, causes, prevention, treatment, complications, dietary behavior, hygiene and additional information about anemia. The study found that most of the respondents belonged to a young age group, had normal BMI levels, and had mild anemia. Most of the respondents had never heard of anemia, while some of the respondents identified it as a shortage of blood levels. Before the nutrition education intervention, they could not identify the signs, symptoms, and causes of anemia. Further, they were not aware of the signs, symptoms, causes and consequences caused by anemia. Deep discussions with respondents revealed that, some of the respondents described weakness and paleness as being caused by anaemia. The most common symptoms of anemia are several micronutrient deficiencies, blood loss, and hookworms (Chaparro & Suchdev, 2019).

Further, the respondents were not aware of the iron-rich foods, which some of the respondents identified as jaggery, sesame seeds, meat, and some green leafy vegetables. These foods were consumed fortnightly. The study also identified that they did not know foods that absorb iron and daily requirements of iron. Pretest study results indicated that there was a substantial lack of knowledge about anemia among the women in the reproductive age group. Ryoo (2011) reported that a lack of knowledge can be a risk factor for undernutrition. The study results were similar to previous studies in which the respondents had low knowledge levels about anemia before the nutrition education interventions.

Based on the pre-test results, the intervention programme was planned and executed for the experimental group. A nutrition education programme is the type of intervention that aims to bring about change in the behaviour of individuals. It is essential to create awareness and to disseminate knowledge related to lifestyle diseases. After the intervention, the results revealed that there was a significant improvement in the mean score of knowledge and perceptions regarding anemia in the experimental group, while there was no improvement in the control group. It is important to note that nutrition education has improved not only the knowledge levels of the respondents but also their dietary and hygiene practices. The findings explain that nutrition education intervention programmes are effective at improving the behaviour of individuals. Shariff et al. (2008) indicated that achieving the desired changes in behaviour in health and nutrition depends on gaining sufficient knowledge, attitudes, good practice, and self-efficacy. Jalambo et al. (2017) reported that health education has demonstrated to be very effective and has resulted in a considerable improvement in haemoglobin levels and nutrition knowledge. Furthermore, Roszanadia and Norazmir (2011) concluded that nutrition knowledge is essential for individuals to acquire a lifestyle that is healthy and free from disease. Hence, there is a need for health care providers and other concerned departments to provide not only iron-folic acid supplements but also nutrition education and counselling to women in the reproductive age group.

Conclusion

            Nutritional education interventions have been widely used for reinforcing knowledge about food habits or healthy lifestyles and are considered a useful strategy for preventing non-transmissible chronic diseases at early ages. In the present study, the nutrition education intervention programme encouraged participants to consume more green leafy vegetables, millets, fruits and other sources of iron and vitamin C. The study shows that nutrition education intervention had a significant increase in the knowledge and perception levels of women about iron deficiency anemia in the intervention group. The study also suggests that a combination of strategies such as nutrition education and supplementation would be effective, to increase nutrient intake and Hb levels in the participants. Hence, the results of the study suggest that, to improve health status, particularly in the prevention of iron deficiency anemia, nutrition educational intervention programmes should be implemented using appropriate models of health education along with the active participation of girls and mothers in the education process in schools.

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