Báo cáo nghiên cứu khoa học: "Thiếu máu, nhiễm trùng giun móc ở phụ nữ trong độ tuổi sinh sản ở các huyện miền núi Nam Đông, tỉnh Thừa Thiên Huế" pps

185 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 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 186 physical 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 187 study 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 188 recommendations 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/m 2 , normal: BMI 18-22.9 kg/m 2 , overweight: BMI ≥23 kg/m 2 . 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 189 before 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 190 45-49 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 191 * 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) Anemia Normal Anemic 63.1 36.9 61.6 38.4 65.0 35.0 >0.05 IDA a Normal Iron deficient 59.9 40.1 67.7 32.3 48.4 51.6 0.015 Intestinal parasitic infection None Infection b 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 192 anemia (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 (%) Mild 61.1 66.7 53.1 Moderate 33.1 28.0 40.6 Severe 5.7 5.4 6.3 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 None 13.8 6.3 17.3 0 >0.05 193 Primary 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 (%) N=425 P * -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 None 42.3 44.2 11.5 1.9 <0.0001 194 Primary 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 Meat 2.31 ± 0.81 2.62 ± 0.67 1.90 ± 0.80 Fish 2.97 ± 0.90 3.21 ± 0.79 2.64 ± 0.93 Vegetables 3.68 ± 0.69 3.65 ± 0.69 3.72 ± 0.70 Eggs 1.65 ± 0.68 1.85 ± 0.67 1.38 ± 0.59 Fruit 2.19 ± 0.89 2.44 ± 0.79 1.86 ± 0.83 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 [...]... by meat 2.31 (SD 0.81), fruit, soya bean products and eggs 4 Discussion We found that the prevalence of anemia among the women is 36.9% The prevalence in Nam Dong district is comparable to that of a survey in the Yen Bai province, northwest of Vietnam, where 37.5% of the non-pregnant women were found to be anemic However, the prevalence of anemia differs between the communes ranging from 27.3% to 48.1%... 2001 The prevalence of hookworm, Ascaris and Trichurius infection among the reproductive aged women in the Nam Dong district were 28.2%, 5.4% and 15.3%, respectively These are significantly lower compared to a survey among reproductive aged women in the Central North Coast region (1995), which Nam Dong district is a part of This survey reported a prevalence of 67.5% for hookworm, 80.8% for Ascaris and... and B.M Popkin, In an era of economic growth, is inequity holding back reductions in child malnutrition in Vietnam? Asia Pac J Clin Nutr, 2003; 12(4): 405-10 9 Pasricha, S.R., et al., Anemia, iron deficiency, meat consumption, and hookworm infection in women of reproductive age in northwest Vietnam Am J Trop Med Hyg 2008; 78(3): 375-81 198 10 Gilgen, D and C.G Mascie-Taylor, The effect of weekly iron... in farming and hand washing might be impractical, since their hands get dirty all the time during work 5 Conclusion Anemia was a moderate public health problem among the reproductive aged women in the Nam Dong district and more than 40% was attributed to iron deficiency The majority of anemic cases were mild among all women, but the ethnic minority had a higher prevalence of moderate anemia The anemia... sections about nutrition and IHI A weak association was found between economical level and anemia and no association with occupation and educational level have been found However, these three SDHs are strongly linked together, as people from families with a higher income often have better educational chances and education improve living and working conditions BMI is often used as an indicator for the... iron supplementation on anaemia and on iron deficiency among female tea pluckers in Bangladesh J Hum Nutr Diet 2001; 14(3): 185-90 11 Le Hung, Q., et al., Anemia, malaria and hookworm infections in a Vietnamese ethnic minority Southeast Asian J Trop Med Public Health 2005; 36(4): 816-21 199 . 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. 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. 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.