JOURNAL OF SCIENCE, Hue University, N 0 61, 2010 ANEMIA, MEAT CONSUMPTION AND HOOKWORM INFECTION IN WOMEN OF REPRODUCTIVE AGE IN THE NAM DONG MOUNTAINOUS DISTRICT, THUA THIEN HUE PROVIN
Trang 1JOURNAL OF SCIENCE, Hue University, N 0 61, 2010
ANEMIA, MEAT CONSUMPTION AND HOOKWORM INFECTION IN WOMEN OF REPRODUCTIVE AGE IN THE NAM DONG MOUNTAINOUS
DISTRICT, THUA THIEN HUE PROVINCE
Nguyen Van Hoa, Vo Van Thang College of Medicine and Pharmacy, Hue University
Cynthia Ho
VU University Amsterdam
SUMMARY
Anemia is a public health concern in developing countries, especially among vulnerable populations The prevalence of anemia among non-pregnant women of reproductive age in the rural communes of Vietnam is largely unknown This study aimed to determine the prevalence of anemia related to nutrition among women of reproductive aged living in the mountainous communes of the Nam Dong district in Thua Thien Hue province of Vietnam We have assessed the prevalence of anemia, iron deficiency, and the nutritional status of these women in a community based survey A cross-sectional study comprised of an administered questionnaire, laboratory analysis of hemoglobin, and serum ferrittin The Nam Dong district is home to the ethnic majority Kinh and ethnic minority Catu and previous studies in this district have reported great differences in the living conditions between these two ethnicities Of the 425 women, 36.9% were anemic and among the anemic women 40.1% were iron deficient, these women were classified as iron deficient anemia (IDA) Although no significant association was found in the prevalence of anemia between the two ethnic groups, 40.6% of the minority women had moderate anemia and this was 28.0% of the Kinh women Anemia was associated with the meat consumption Efforts to reduce anemia should be targeted at women with low economical and educational level, having the occupation of farmer and belonging to the Catu ethnicity
Key words: anemia, hookworm, reproductive age, women, ethnic, meat consumption,
mountainous
1 Introduction
The prevalence of anemia throughout the world is high, and anemia affects every segment of the population The WHO estimates that mild to moderate cases are associated with reduced physical and mental capacity Severe cases could result in morbidity and mortality in all population groups Consequently, anemia is a public health concern in many countries and leads to significant economic losses Anemia is a
Trang 2physical condition that is defined as having a hemeglobulin (Hb) level below a threshold value, which could be caused by several factors However, nutritional anemia
is the most prevalent and especially iron deficiency could contribute to the onset of anemia Non-nutritional factors, such as infections with malaria and hookworms and genetic disorders play an important role as well Nine out of ten people who suffer from anemia live in developing countries In rural areas the prevalence is often higher as nutritional deficiencies and parasitic infection often prevail within the same individuals
in these areas
Women and children are at greater risk of developing anemia, because these groups are often more vulnerable and have a physical higher need for iron compared to men The consequences for them are more severe, during pregnancy anemia could lead
to a higher risk of both maternal and infant mortality and morbidity Anemia may have adverse effects on young children’s cognitive and motor development which are irreversible
Most governments in both developed and developing countries have iron supplementation programs for pregnant women to reduce maternal anemia Besides this,
in general, women in developing countries have less access to nutritious food, due to their lower socio-economic position Women living in rural areas are often involved in heavy physical work, such as farming, which demands more nutritional intake Hence, non-pregnant women of reproductive age in rural areas might have a higher potential to develop anemia Avoiding the onset of anemia in these women may lower the possibility
of developing maternal anemia during pregnancy Furthermore, anemia can restrict productivity and therefore negatively affect the economy
The situation of anemia among women in rural Vietnam is similar, especially in the less developed areas Surveys conducted in communes reported an average prevalence of anemia between 37 to 50%, among the studied women Even though, many studies have tried to identify the risk factors of anemia, few have focused on the underlying reasons why the study population was exposed to these In addition, the social determinants of health (SDH) which are defined by the WHO as: “the conditions
in which people are born, grow, live, work and age, including the health system”, are factors that are of influence to behavior and perceptions
The objective of the present study is to assess the prevalence of and factors associated with anemia in reproductive aged women of the Nam Dong district of Thua Thien Hue Province in the North Central Coast region of Vietnam
A cross-sectional survey with biological data collection was used to reach this objective Comparisons of the obtained data were made between the two ethnic groups: the Kinh and Catu Ethnicity is a SDH which has been reported by several studies in Vietnam to play an important role in health related issues The results provided by this
Trang 3study could be useful for healthcare providers and decision makers to allocate resources and to plan effective intervention programs It will also provide information for further studies to identify the causal relationships between the risk factors and anemia This survey could serve as a baseline study for such intervention programs
2 Methods
Survey: The survey consisted of a structured questionnaire and was
administered among the total study population In addition, blood- and stool samples were collected and the women’s length and weight were determined to assess the hemoglobin (Hb) level and serum ferritin level, infection with intestinal helminthes and the nutritional status, respectively
Setting: The present study was conducted in the mountainous Nam Dong district,
Thua Thien-Hue province, Vietnam It is relatively poor and contains sizable ethnic minority populations Malaria has been eliminated from this district The district is divided into one town and ten communes; each encompasses three to five villages The communes Hương Hữu and Thương Long were classified as having a very poor economic status, and Khe Tre was classified as having the highest economic status by the local authorities Biological data was collected at commune healthcare centers (CHC) by the healthcare staff, and the interviews were conducted at the participant’s house by local school teachers The collection of data was between July and August
2009, during the dry season
Sampling: Women of reproductive age were defined in this setting as aged
between 15 and 49 years and all were eligible for the participation The sample size was estimated to be 425 women, based on a prevalence of anemia 35% and included a possible 10% lost of data A population record of the commune/town is kept at each CHC and from these records, women between the ages 15-49 years were selected, producing a sampling frame for each place The subjects were chosen by simply random selection from the sampling frames and proportionally to total number of the women from these frames The selected women were informed and approached by the CHC staff to participate in the study
Laboratory methods: Blood and stool samples were collected from each
participant A 5ml sample of venous blood was collected using a closed collection system into tubes containing fast clotting agent The samples were transported on dry ice to Hue College of Medicine and Pharmacy (2 days late) for analysis by Hematology Service The Hb level was measured with the KX-21 machine (Symex, Japan) The World Health Organization (WHO) standards were used to define the anemia status among the women: Normal: Hb levels ≥12.0 (g/dL), mild anemia: Hb levels 10.0-11.9 (g/dL), moderate anemia: Hb levels 7.0-9.9 (g/dL), severe anemia: Hb levels <70 (g/dL) Iron deficiency was defined as a serum ferritin of <15 (ng/ml), according to the WHO
Trang 4recommendations for women of reproductive age Serum ferritin levels were measured among the anemic subpopulation only Due to the high costs of the analysis method it was impractical to test all women Women who were found to be anemic and iron deficient were classified as IDA
Stool samples were collected to screen for hookworm, Ascaris and Trichuris
infection and infection with protozoa was screened as well, using the formalin ether technique The women were provided with plastic bags and a wooden spatula the day before the blood sampling and were ask to return these with their stool sample the next day to the CHC
Body Mass Index (BMI) was used as an indicator for the nutritional status The women’s weight and length were measured at the CHC during their visit for the blood sampling The WHO criteria for nutritional status among Asian adults were: underweight: BMI≤18.5 kg/m2, normal: BMI 18-22.9 kg/m2, overweight: BMI ≥23 kg/m2
Questionnaire: Participating women were asked to complete a questionnaire
after the collection of biological data The questionnaire was administered by local primary or secondary teaching staff, who received special training for this purpose The choice for a face to face interview was because an illiteracy rate of around 30% was expected among the women, based on previous surveys in this area The interviews took place during house visits and after informed consent were obtained Data collected, included potential demographic risk factors for iron deficiency and hookworm infection, dietary meat consumption, ethnic group, education, number of children, domestic sanitary facilities and frequency of wearing shoes
Analysis: EpiData was used to enter data and all respondents were checked for
missing biological data and incomplete questionnaires The survey data was exported to SPSS v15.0 for further analysis The prevalence of anemia, iron deficiency, IDA and BMI were calculated using the cut-off defined above Hookworm, Ascaris, Tricuris and infection with intestinal protozoa was classified as positive when eggs or cells were found in the stool BMI and hookworm infection were tested for association with anemia and IDA The association between certain SDH and the above mentioned were tested, as well All associations and differences were computed with the Chi-square test
or the Fischer’s exact test
Ethical considerations: Ethical approval was received from the College of
Medicine and Pharmacy of Hue University and the local authority of the Nam Dong district In addition, the project was approved by the consultant of Community Research Excellence of Netherlands-Vietnam project Permission of the village heads was asked
to conduct the research project in their villages and to use local school or other government buildings to accommodate the FGDs Informed consent was obtained
Trang 5before the start of the data collection The subjects received an incentive for their participation in the study They received 30,000 VND for providing blood and stool
3 Results
The demographic and socio-economic data for the 425 women of reproductive age who participated in the study are presented in table 1 56.9% of the total study population belonged to the Kinh ethnicity and 41.4% to the Catu ethnicity Because of the small number of other ethnic minorities, three women were Pako (0.7%) and four belonged to another minority (0.9%), it was decided to combine these and the Catu women into one group: minority (43%), for further analysis
The mean age of the Kinh was 33 years (SD 9.9) and that of the minority was 28 years (SD 8.4) More than three quarter of the women was married and among these the majority had one to three children The educational level of the Kinh women was significantly higher than that of the minority, 24.6% of the minority women had never received education compared to 2.9% of the Kinh women None of the subjects had a college or university education level The majority of the minority women (86.9%) were farmers and 34.7% of the Kinh women had this occupation More than two out of three women classified themselves to have a medium economic level However, about one third of the minority women had a low economic level, while this was significantly lower for the Kinh women (2.8%) The main water source for Kinh women was a well (66.1%) and next water from the tap (22.7%) This was significantly different for the minority women, water from a spring (59.9%) was their main source and well water was used by 27.3% of them Significant differences were also found in the sanitation, 90.2%
of the minority vs 41.7% of the Kinh used a pit as a latrine and 55% of the Kinh had a septic tank, while this was 4.9% for the minority
Table 1 Socio-demographic characteristics of reproductive aged women in Nam Dong district
Variables Category
Total study populatio
n N=425 (%)
Kinh n=242 (%)
Minorit
y n=183 (%)
P * -value (Kinh vs minority)
Age (years)
15-19 20-24 25-29 30-34 35-39 40-44
13.6 13.4 18.6 16.2 13.4 12.2
12.0 9.1 12.8 15.7 16.1 18.2
15.8 19.1 26.2 16.9 9.8 4.4
<0.0001
Trang 645-49 12.5 16.1 7.7
Marital status
Single Married Widowed Divorced
19.6 77.1 2.1 1.2
20.2 74.4 2.9 1.7
18.6 79.8 1.1 0.5
>0.05
Number of
children
No children 1-3 children
≥4 children
22.4 61.9 15.8
22.3 59.5 18.2
22.4 65.0 12.6
>0.05
Education
level
None Primary Secondary High school
12.2 32.0 25.6 30.1
2.9 32.2 28.9 36.0
24.6 31.7 21.3 22.4
<0.0001
Occupation
Farmer Salesperson Government employer Housewife Handicrafts Other
57.2 12.7 12.9 4.2 2.1 10.8
34.7 21.1 19.4 7.0 3.7 14.0
86.9 1.6 4.4 0.5
0 6.6
<0.0001
Economic
level
High Medium Low
13.2 69.9 16.9
17.4 76.9 5.8
7.7 60.7 31.7
<0.0001
Water source
Well Tap Spring Other
49.4 15.1 31.5 4.0
66.1 22.7 10.3 0.8
27.3 4.9 59.6 8.2
<0.0001
Sanitation
None Pit Two-compartment Septic tank
0.9 62.6 2.8 33.4
0 41.7 2.9 55.0
2.2 90.2 2.7 4.9
<0.0001
Trang 7* Chi-square test
Table 2 Biological characteristics of women of reproductive age in Nam Dong
Variables Category
Total study population N=425 (%)
Kinh n=242 (%)
Minority n=183 (%)
P * -value (Kinh vs minority)
Anemic
63.1 36.9
61.6 38.4
65.0 35.0
>0.05
Iron deficient
59.9 40.1
67.7 32.3
48.4 51.6
0.015
Intestinal
parasitic
infection
None Infectionb Hookworm Ascaris Trichurius Other
53.9 46.1 28.2 5.4 15.3 2.8
58.3 41.7 17.4 6.6 20.7 3.3
48.1 51.9 42.6 3.8 8.2 2.2
0.037
<0.0001
>0.05
<0.0001
>0.05
BMI
Underweight Normal Overweight
22.4 62.1 15.5
29.3 55.8 14.9
13.1 70.5 16.4
<0.0001
* = Chi-square test
a = population size n=157 for IDA total, Kinh n=93 and minority n=64
b = infection with hookworm, Ascaris, Trichurius or protozoa
Table 2 presents the biological characteristics of the women The prevalence of anemia among the women is 36.9% and is defined by a cut-off value of the hemoglobin (Hb) level of Hb <12g/dL No significant differences between the prevalence of anemia among the Kinh and minority women were found Though, when only the anemic women were selected and categorized into mild (10 ≤ Hb <12 g/dL), moderate (7 ≤ Hb<10 g/dL) and severe (Hb<7 g/dL) anemia, a difference in the distribution of the anemic condition between the ethnicities could be detected (table 3) The majority of the anemic women had mild anemia, followed by moderate anemia and severe anemia was rare However, 40.6% of the anemic minority women had a moderate anemic condition
vs 28.0% of the anemic Kinh women The serum ferritin level was measured among the women who were tested as being anemic (n=157) The prevalence of iron deficiency
Trang 8anemia (IDA) among this sub population was 40.1% and significantly more minority women had IDA (51.6%) than Kinh women (32.3%) The Body Mass Index (BMI) served as an indicator for possible malnutrition and the women were divided into one of the three categories: underweight, normal or overweight More than one out of the seven women was overweighed (15.5%) and more than one out of the five women was underweighted (22.4%) The majority of the women had a normal BMI (62.1%) Interestingly, the minority women had a significant higher BMI value
Table3 The percentage distribution of the anemic condition
Anemic condition Total anemic
n=157 (%)
Kinh n=93 (%)
Minority n=64 (%)
Table 4 The percentage distribution of the anemic conditions and the SDH
SDH
Percentage distribution of Anemia (%)
N=425
P * -value
normal mild moderate severe
Economy
High
Average
Low
16.6 61.6 15.3
6.3 78.1 15.6
11.5 63.5 25.0
0 66.7 33.3
0.051
Occupation
Salesperson
Government employer
Housewife
Farmer
Handicrafts
Other
13.1 13.1 3.4 57.5 1.9 11.2
14.6 13.5 7.3 49.0 4.2 11.5
7.7 11.5 3.8 69.2
0 7.7
11.1 11.1
0 66.7
0 11.1
>0.05
Educational level
>0.05
Trang 9Primary
Secondary
High school
29.9 27.2 29.1
36.5 24.0 33.3
30.8 21.2 30.8
55.6 22.2 22.2
*=Fischer’s exact test
The percentage distribution of the different anemic conditions among the women
in relation with some of the SDH is presented in table 4 A weak association was found between the anemia and economic level Overall, the majority of all the anemic conditions had an average economic level However, 15.3% of the normal women had a low economic level, for the mild 15.6%, moderate 25.0% and severe 33% None of the severe cases had a high economic level and the highest percentage of women with a high economic level could be found among the normal women The association between occupation and anemia was not significant, but slightly more moderate and severe anemic women were farmers No association between anemia and educational level was found in this study, although to some extent more anemic women had a primary education when compared with normal women
Table 5 The percentage distribution of and the SDH meat intake in servings/week
SDH Meat intake in servings/week (%)
* -value
<1 1-2 3-4 5-7
Economy
High
Average
Low
5.4 10.8 40.3
33.9 45.8 54.2
42.9 37.0 5.6
17.9 6.4
0
<0.0001
Occupation
Salesperson
Government employer
Housewife
Farmer
Handicrafts
Other
7.4 1.8
0 23.0 11.1 4.3
35.2 21.8 50.0 52.3 44.4 50.0
48.1 60.0 44.4 20.6 44.4 37.0
9.3 16.4 5.6 4.1
0 8.7
<0.0001
Educational level
Trang 10Primary
Secondary
High school
13.2 9.2 10.9
50.7 48.6 38.3
30.1 37.6 39.1
5.9 4.6 11.7 Ethnicity
Kinh
Minority
2.5 31.7
40.9 51.9
48.8 10.9
7.9 5.5
<0.0001
*Fischer’s exact test
Meat consumption was found to be significantly associated with anemia status (P-value <0.05, Fischer’s exact test), higher meat intake resulted into less severe anemia However, no significant association with anemia among the total study population and IDA was found The relationship between meat intake and some of the SDH was assessed and presented in table 5, to consider the influence of the SDH on the nutritional practices The economic level of the women was found to be significantly positive associated with the meat intake in servings per week Of the category five to seven servings/weak, 17.9% had high economical level, 6.4% had average economical level and none of these women had low economical level For the women that served less than once a week meat this was 5.4%, 10.8% and 40.3% respectively Meat intake was also associated with occupation: government employees and salespersons that, in general, have more income had more servings of meat/week when compared to farmers Educational level and ethnicity were both associated with meat intake Women with higher education had more servings of meat when compared to women with a lower education Kinh women had more meat servings than women from ethnic minorities
Table 6 Survey data of the mean food consumption per week
Food item (Servings/week)
Total Mean ± SD N=425
Kinh Mean ± SD n=242
Minority Mean ± SD n=183
Soya bean products 1.73 ± 0.76 2.09 ± 0.74 1.25 ± 0.47 Table 6 presents the survey data of the mean nutritional intake of the women per