CURATIO – Original Article 2

According to this study, n=89 (47.8%) of the population has a poor knowledge while 52.2% (n=94) of the study subjects have good knowledge regarding deficiency anaemia. There is no statistically significant association between level of knowledge and age, ethnicity, marital status, family type, employment status, obstetrics associated factors, source of knowledge, and frequency of attendance to MOH clinic as shown in the table 5. There is a statistically significant association between the level of knowledge and the highest level of education (X2 = 9.376, df= 3, p= 0.025). The participants whose highest level of education falls under the class- certificate/degree/diploma have good knowledge on deficiency anaemia compared to the other highest education level classes. There is a statistically significant association between the level of knowledge and monthly income of the family. (X2 = 6.714, df= 1, p= 0.010). Participants with a monthly income ≥ LKR.75 000 have a better knowledge than participants with a lower monthly family income.

Discussion

Most of the pregnant mothers in this study population had good knowledge towards deficiency anaemia during pregnancy. The preponderance of the study population (90.6%) had heard of the word “deficiency anaemia”. This finding is parallel to a study done among pregnant mothers attending antenatal clinics in Woldia town, North-Eastern Ethiopia, in which more than half, 224 (54.1%), of the respondents had good knowledge about anaemia.

(5) In contrast, a study conducted at Sri Manakula Vinayagar medical college hospital, Puducherry, India revealed that only 39.87% of the participants were aware of and understood the word anaemia.

(6). Although, majority in the current study had a good overall knowledge, knowledge on certain aspects of deficiency anaemia were unsatisfactory.

In this study, 95.1% identified iron deficiency anaemia as a correct type of deficiency. The value was higher than reported in another Sri Lankan study among pregnant mothers in the first trimester. Only 60% of the respondents have heard about iron deficiency anaemia after they got pregnant.(7) Only 38.0% identified folate deficiencyciency anaemia. This value is less than a similar finding presented by a study done in Pumwani maternity hospital, Kenya, in which 73% had heard about folic acid.(8). Only 10.4% (n= 17) identified that vitamin B12 deficiency could lead to deficiency anaemia during pregnancy. Sufficient literature was not found to comment on Knowledge of pregnant mothers towards vitamin B12 deficiency anaemia.

Awareness on iron deficiency anaemia among the study population was satisfactory, while the knowledge regarding folate was relatively poor and knowledge towards vitamin B12 was extremely low. A sizable proportion erroneously identified vitamin C (31.3%) and calcium (27.6%) deficiency as correct types of deficiency anaemias.60.7% identified low Hb level in blood as the correct definition of anaemia. The remaining 19.0% defined anaemia as reduced blood volume. 11.7% chose poor nutrition as the definition for anaemia. 4.9% didn’t know the definition of anaemia. A similar study conducted in Sri Lanka(7) showed that 65 %, 60 %, 80 % and 30 % of the respondents linked iron deficiency anaemia with low Hb level, poor nutrition, reduce volume in the blood, white colour or pale look of the body respectively. 20% didn’t know the meaning of the iron deficiency anaemia in the above study. A study conducted among pregnant mothers in Tabuk region in Egypt found that no one gave the correct answer to the definition of iron deficiency anaemia and 54.3% either didn’t know the answer or gave an incorrect answer.(9). In the present study, only 46.6% identified full blood count was the diagnostic test, while 33.7% identified as a simple blood test. Remaining 19.6% was not aware of the diagnostic test. Another study showed that, 0 respondents had knowledge towards diagnostic tests and 43.0% gave an incomplete answer, while remaining 57.0% didn’t know the answer. (9)

Regarding the correct symptoms and signs of deficiency anaemia, tiredness and dizziness, headache, pale colour of the body, pale colour of the nails and tongue and shortness of breath was identified by 84.7%, 33.7%, 57.1%, 20.9% and 15.3% of the population, respectively. In a similarstudy, (7) 90% of participants found tiredness and headache, 85% found pale colour of the body and 80% found pale colour of the nail, tongue and mucous membrane of mouth as signs and symptoms of iron deficiency anaemia. Another similar study reported that, 9.25% identified tiredness and weakness, 17% and 10.5% identified pallor of face and pallor of nails were symptoms of anaemia, respectively. Palpitation and breathing difficulties were identified by only 8.5%. (10)

This study showed that 57.1% and 84.7% identified inadequate food intake and imbalanced diet could predispose to deficiency anaemia. Only 16.6% knew that worm infection was a causative factor. Heavy blood loss and heredity were recognized by 33.1% and 20.9%, respectively. A close study done in Sri Lanka (7) reported a higher value (90%) for inadequate food intake as the most known causative factor. Only 50% knew heredity was responsible for deficiency anaemia. This is higher than the current study’s finding. In contrast, an Egyptian study described that only 14.7% correctly identified signs and symptoms, while 49.3% gave incorrect answers and the remaining 36.0% didn’t know the answers. (9).

In the present study, low birth weight, premature delivery postpartum anaemia, abortions and maternal death were identified by 76.7%, 50.9%, 30.1%, 40.5% and 28.2% as complications. A parallel study reported the following results. (7) A lesser percentage (32%) was aware of low birth weight as a complication. A lesser percentage (30%) identified premature delivery. Nearly half of the respondents mentioned intrauterine death and abortion as complications. Conversely, another study showed that only 2.0% had awareness on complications 52.3% had no knowledge. (9) 44.8% identified age of the mother higher than 35 years as a potential risk factor. Increased parity, poor birth spacing, and Goitre were identified as correct risk factors by 46.6%, 24.5%, and 4.9%, respectively. The risk of maternal death during labour and foetal growth retardation were reported as consequences of anaemia during pregnancy in a study done among pregnant women in Eritrean refugee camps, northern Ethiopia. (11)

Having a balanced diet was identified as a preventive practice by 95.7% of the present study population. A similar study revealed that 90% participants knew getting a well-balanced diet was a correct preventive method. (7) In a contrast, a study in Karnataka indicated that 57% knew well balanced diet could prevent anaemia during pregnancy. (10) Use of prophylaxis prescribed by the physician was chosen by 73.6% in this study. According to another Sri Lankan study, 96% identified use of iron supplements was a correct preventive method. (7) Another study conducted in Karnataka proclaimed that 68.5% respondents recognized daily intake of iron and folic acid tablet is necessary preventive practice, which is a slightly lesser value. (10) In the present study, treating worm infections and keeping more than 2 years of birth space between consecutive pregnancies were chosen by 20.2%, and 29.4%, respectively as effective ways of preventing deficiency anaemia during pregnancy. A comparable study displayed that 31% participants recognized treating worm infection was a correct method to prevent iron deficiency anaemia. Contrarily, 5% identified keeping more than 2 years of birth space was an accurate method of prevention (7) Another study indicated that only 7% had given accurate responses to ways of prevention while 59.0% had given incomplete answer. The remaining 34.0% had either given incorrect answers or had nil knowledge. (9) Another study indicated that 64.5% correctly identified treating hook worm infestation as a preventive method. (10)

For the food items that are rich in iron, dark green leafy vegetables, white meat, dried fruits, cereals, sea food, poultry, and red meat were identified by 88.3%, 27.0%, 3.7%, 30.7%, 41.7%, 26.4%, and 52.8% respectively. An equivalent study indicated that more than half of the respondents identified eggs (92%), chicken liver (75%), red meat (72%), green vegetables (68%), grains (61%), fruits (60%), fish (60%) and chicken (54%) as iron rich- food sources. The least known iron-rich food source was enriched cereals. (7) Another comparable study obtained green leafy vegetables and sprouted grains 54.3%, meat 49.0% and liver 48.5% were recognized, respectively as iron rich food items. (10). Only 35.0% of the study subjects identified beef, liver, and chicken as good sources of vitamin B12. Only 24.5% identified milk, yogurt, and dairy products as vitamins B12 enriched food items. Eggs as a food item rich in Vitamin B12 was recognized by 36.8%. Leafy green vegetable, citrus fruits, beans, peas and nuts, whole grains, and liver were identified by 29.4%, 22.1%, and 38.4% as being rich in folate, respectively. Results show that knowledge on food items rich in iron is relatively satisfactory when compared to knowledge on foods rich in vitamin B12 and folate.

Majority knew coffee (83.4%) and tea (71.8%) should be avoided after consuming an iron containing meal. But only 23.9% knew that chocolate should also be avoided after an iron rich meal. As reported by (7) knowledge regarding the effect of coffee (88%) and tea (92%) in the absorption of iron was at a significantly higher level similar to this study findings. Conversely, 44.7% identified tea and coffee had to be avoided after meals to prevent anaemia in a study conducted in Tabuk Region. Foods containing tannin (14.1%) and foods containing phytates (13.5%) were inhibitors of iron absorption from the gut were known by a little population. Similarly, (6) indicated that cereals containing inhibitors for iron absorption was faultily considered as a good source by 18.35% of respondents.

Adding extra lime to gotukola sambal to enhance iron absorption was recognized by 69.3%, while only 50.3% knew that refraining from coffee or tea after a main meal was a good food practice. Having more citrus fruits and green vegetables were recognized by 42.9% and 44.2%, respectively. Lesser percentage of 30.3% knew of citrus fruits in another study. (9) In another study, 48.0% identified that citrus fruits were promoters of iron absorption. (10). 72.4% identified iron sulphate as a prophylaxis while only 56.4% knew folic acid was also a preventive treatment. A foreign study revealed that 68.5% respondents recognized daily intake of iron and folic acid tablet was a necessity to prevent anaemia. (10) Only 19.0% identified continuation of iron supplements for 6 months after delivery as a correct preventive treatment. In the present study, only 25.2% had learned that B12 supplements was also a prophylactic treatment. The knowledge on vitamin B12 and deficiency anaemia caused by it was unsatisfactory in the present study population, according to the results.

The most popular source of knowledge in this study was nurse/midwife. (n=55, 33.7%) According to a study conducted in Saudi Arabia, 29% had chosen relatives as their source of knowledge.

(9) Nevertheless, in the present study, only 1.8% selected family members as their source of knowledge. There was a significantly satisfactory level of attendance to the MOH clinic among the study subjects, as 158 (87.8%) had more than 76% attendance. According to the same study 53.3% participants had shown regular antenatal visit. (9) On the contrary, a cross sectional, descriptive institution- based study conducted in India revealed that the most popular source of knowledge towards iron deficiency anaemia was doctors. (6) In the current study, there was no statistically significant association between the level of knowledge and age, ethnicity, marital status and family type.

There was a statistically significant association between the level of knowledge and the highest level of education (p= 0.025). The participants whose highest level of education fell under the class- certificate/degree/diploma had good knowledge compared to the other classes. This finding is compatible with a cross-sectional study carried out in Karnataka (10). This study found that there was significant association between cause of anaemia and women’s education (p<0.001) and there was significant association between sign and symptoms of anaemia and women’s education (p<0.001). The study found that there was a significant association between prevention and treatment of anaemia and women’s education (p<0.001).(10) Further, a facility-based cross- sectional study, depicted that mothers who had completed secondary education and above were two times more likely knowledgeable about anaemia than mothers who attended non-formal education (AOR = 2.19, 95% CI 1.32- 3.64)(5) Additionally, a multicentre cross-sectional study revealed that the likelihood of knowledge was 2.5 (adjusted odds ratio (AOR) = 2.5, 95% CI: 1.22, 7.75) times greater among secondary school participants than non- school attendees.(12)

There was no statistically significant association between the level of knowledge and employment status in the present study (p=0.692). However, a multicentre cross-sectional study revealed that merchant women were seven (AOR = 7.02; 95% CI: 2.88, 17.09) times more likely to be knowledgeable than housewives. (12)

There was a statistically significant association between the level of knowledge and monthly income of the family. (p= 0.010). Participants with a monthly income ≥ LKR.75 000 had a better knowledge than participants with a lower monthly family income. A study conducted in Southern Ethiopia reported that mothers earning 5000 Ethiopian Birr per month are 55% more likely to have a favourable attitude towards preventive nutritional practices than mothers earning less than 1000 birr per month. (AOR = 0.45; 95% CI: 0.10, 1.66) (12)

There was no statistically significant association between level of knowledge and factors associated with pregnancy (p>0.05). Conversely, a multicentre cross-sectional study observed that compared to primigravida women, multiparous women were 4.8 (AOR = 4.77; 95% CI: 1.15–8.66) times more likely to be knowledgeable. (12)

There was no statistically significant association between the level of knowledge and the source of knowledge, frequency of attendance to MOH clinic. However, a facility-based cross- sectional study conducted in Northern Ethiopia observed that mothers who had four or more antenatal clinic visit were three times (AOR = 3.12, 95% CI 1.38–7.07) more likely knowledgeable on the benefits of iron folic acid supplementation than mothers who had less than four times ANC visit.(5)

External Validity: The study was conducted among pregnant mothers attending selected MOH areas in Colombo district. The selected district being an urbanized area would have a negative effect on generalizability to the Sri Lankan population. Underrepresentation of ethnicities other than Sinhala also might have caused a negative impact on external validity.

Internal Validity: Anonymity of the participants was reassured to reduce the occurrence of social desirability bias. An interviewer administered questionnaire may have caused an interviewer bias. Using a questionnaire validated by a group of experts, pretesting and training of data collectors also might have enhanced the quality of the study.

Limitations: The sample was gathered from two selected MOH areas in Colombo district which is an urbanized area. Furthermore, non-inclusion of mothers receiving antenatal care from private sector and under representation of other ethnicities makes our study population not exactly representing the antenatal clinic attendees of the whole country. Although the questionnaire had a broad context with multiple stems to cover knowledge on anaemia the determination of the exact knowledge was affected by multiple choice options which might have influenced the answering by guessing and random selection.

Conclusions

Majority of this study population (52.2%) had good knowledge despite the mean score (38.9) of the population was low. 90.6% had heard of the word deficiency anaemia and 95.1% out of them identified iron deficiency anaemia as a correct type of deficiency anaemia. Only 38.0% and 10.4% identified folate deficiency and vitamin B12 deficiency anaemias as correct types of deficiency anaemia, respectively. A sizable proportion erroneously identified vitamin C and calcium deficiency as correct types of deficiency anaemias. The most popular source of knowledge on deficiency anaemia was nurse/midwife. (33.7%) There were statistically significant associations between good knowledge towards deficiency anaemia and higher level of education and high monthly family income. There were no statistically significant associations between the level of knowledge and age, ethnicity, marital status, family type, employment status, obstetrics related factors, source of knowledge, and frequency of attendance to MOH clinic.

Acknowledgement

University of Sri Jayewardenepura for funding the research. A special thank goes to all the Medical Officers of Health (MOHs) for allowing us to conduct the study at their workstations and to all the participants, who willingly engaged in our research to provide data.

Conflict of Interest

Authors declare that there is no conflict of interest.

The abstract of the study has been submitted to the IRCHS 2023.

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