socio—ecological factors affecting pregnant women’s anemia status in freetown, sierra leone

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Socio—Ecological Factors Affecting PregnantWomen’s Anemia Status In Freetown, Sierra LeoneFredanna M’Cormack a & Judy Drolet ba Department of Health Promotion , Coastal Carolina University , P.O. Box 26195Conway , SC , 29528b Department of Health Education and Recreation , Southern Illinois University ,Carbondale , IL , 62901Published online: 28 Feb 2013.

To cite this article: Fredanna M’Cormack & Judy Drolet (2012) Socio—Ecological Factors Affecting PregnantWomen’s Anemia Status In Freetown, Sierra Leone, American Journal of Health Education, 43:6, 327-340, DOI:10.1080/19325037.2012.10598863

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American Journal of Health Education — November/December 2012, Volume 43, No. 6 327

BACKGROUNDMore than 500,000 pregnant women die

from childbirth complications every year. 1 Cited are several causes of maternal mortality including hemorrhage, sepsis, complications with abortion and anemia. Anemia is listed as direct cause of 4% of maternal deaths and an indirect cause of morbidity and 20-40% of maternal deaths due to exacerbation of conditions in HIV/AIDS and hemorrhagic situations.1 A major contributing factor to anemia is iron deficiency, which contributes to 100,000 maternal deaths.1,2 According to an anemia report, Sierra Leone has anemia

prevalence over 40% (59.7%), which is con-sidered severe, with approximately 160,000 pregnant women having the condition.1,3,4 A previous report by the Helen Keller In-ternational found anemia prevalence to be almost 70%.5

Several social determinants of health have been cited as having an impact on maternal health such as poverty, access to health care, health disparities and societal inequalities, among others.6,7 Social deter-minants of health also may impact anemia status of pregnant women.

Poverty is considered an underlying

factor affecting health access. According to the first Sierra Leone Poverty Reduction Strategy Paper (SL-PRSP), the total poor in Sierra Leone are 70%. In urban Western Area, however, this figure is much lower:

Fredanna M’Cormack is an assistant profes-sor in the Department of Health Promotion at Coastal Carolina University, P.O. Box 26195, Conway, SC 29528; E-Mail: [email protected]. Judy Drolet is professor of Health Educa-tion in the Department of Health Education and Recreation at Southern Illinois University, Carbondale, IL, 62901.

Socio-Ecological Factors Affecting Pregnant Women’s Anemia Status In Freetown, Sierra Leone

Fredanna M’Cormack and Judy Drolet

ABSTRACT

Background: Sierra Leone has high maternal mortality. Socio-ecological factors are considered contributing factors

to this high mortality. Anemia is considered to be a direct cause of 4% of maternal deaths and an indirect cause of

20-40% of maternal deaths. Purpose: The current study explores socio-ecological contributing factors to the anemia

status of 171 pregnant Sierra Leone women. Methods: A structured questionnaire framed around the Modified Eco-

logical Model for Health Behavior and Health Promotion was distributed to women visiting five health care facilities

in Freetown, Sierra Leone. Results: Participants were more likely to have anemia in the second and third trimester

than the first trimester (χ2 =6.12; χ2 =6.33). Participants indicating economic difficulties were likely to have anemia.

Seventy-seven percent of participants had anemia (hemoglobin <11.0g/dL). Discussion: Findings indicate that poverty,

time of intervention, and socio-cultural factors have an impact on anemia. In addition, use of radio communication

is beneficial to deliver health messages to the masses. Translation to Health Education Practice: Developing and

implementing comprehensive programs that consider socio-cultural factors are necessary to raise awareness and ad-

dress misconceptions about anemia causes, prevention, and treatment. These programs must be multi-sectored and

include participants, health care workers, government, non-governmental agencies and community.

M’Cormack F, Drolet J. Socio-ecological factors affecting pregnant women’s anemia status in Freetown, Sierra Leone. Am J Health Educ.

2012;43(6):327-340. Submitted October 11, 2011. Accepted February 29, 2012.

Research Article

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328 American Journal of Health Education — November/December 2012, Volume 43, No. 6


that full poor in urban Western Area made up 17.1% of the population (earn < $2/day; < Le 64,223/month), whereas, the food poor made up 3.2% of the population in that region (earn < $1/day; < Le 31,420/month).8 Poverty affects nutrition status, likely to have food insecurity and access to health services.9-11

To combat high maternal mortality, global efforts are returning to primary health care to “put people at the center of health care,”12(p xii) where essential health care is “made universally accessible to indi-viduals and families in the community by means acceptable to them through their full participation and at a cost that the commu-nity and country can afford,”12(p xii) and the Declaration of Alma-Ata to address health inequalities and pursue “social justice and the right to better health for all, participation and solidarity.”12(p xii)

Global health policies are intended to have government support and are geared to address disparities and make services comprehensive, available and accessible. African countries having successful policies that address maternal mortality include: Ma-lawi, where the nation’s high-level politicians made the commitment to address maternal mortality and child survival in an effort to improve both; Burkina faso, which pro-vided free services to poor pregnant women needing emergency caesarean surgery; and Madagascar that has made improving com-munity-based care and strengthening their human resources capabilities their focus13 Currently in Sierra Leone, the government has taken note and initiated in April 2010, the free health care initiative in the nation. Now in Sierra Leone, free health care is pro-vided to pregnant women, lactating mothers and children under the age of five years.14

Biological and environmental issues also have been found to have an impact on anemia status and maternal and child health. Genetic conditions such as sickle cell anemia have a negative impact on anemia status. The prevalence of sickle cell anemia and trait (carrier) is between 10–30%. Helminthes infection is endemic in Sierra Leone and contributes to anemia.15

In addition, family planning and repro-ductive behavioral factors also are contrib-uting factors. Practices to save newborns include promotion of the delay of preg-nancy until after 18 years and recommend birth spacing of at least 24 months apart.13 According to the 2002 Population Report, “children born three years or more after a previous birth are healthier… and more likely to survive at all stages of infancy and childhood.”16 Increased birth spacing might occur if women’s status is improved by “rais-ing age at marriage, increasing education, and expanding employment opportunities.” According to the 2002 Population Report, “if parents can feel that their well-being is as secure with female children as with male children, they may want to wait longer be-fore having another child.”16

Intervals of at least two years have shown beneficial results. In the last five years, how-ever, studies have shown that birth spacing between three and five years has additional benefits to both child and maternal surviv-al.16 According to the same report, women who give birth at 27- to 32-month intervals are “1.3 times more likely to avoid anemia; 1.7 times more likely to avoid third-trimester bleeding; and 2.5 times more likely to survive childbirth” than women who gave birth at 9- to 14-month intervals (p. 2).16 Conversely, findings from the Latin American Center for Perinatology found no change in risk of third-trimester bleeding and anemia, for maternal survival.16 In terms of maternal death, an improvement occurred between 9-14 months and birth spacing more that 33 months. from 1986 - 2001, the percent of women having birth spacing less than three years dropped in Africa. Although data for Sierra Leone were not found, this drop was evidenced in other West African countries such as Ghana (11%), Cote d’Ivoire (8%), Senegal (7%), Togo (6%), and Nigeria (4%) between the first survey period (1986-1989) and the last survey period of the report (1998-2001).16

PURPOSEThis study assessed the role specific

socio-ecological factors play on the anemia

status of pregnant women living in urban Sierra Leone. To provide a framework to identify and assess maternal anemia status, the Modified Ecological Model for Health Behavior and Health Promotion (MEM-HBHP) was developed (figure 1).17 – 21

METHOD

Ethical considerationsThe Office of Research Development and

Administration at Southern Illinois Univer-sity Carbondale and the Research and Ethics Committee of the Ministry of Health and Sanitation in Sierra Leone granted human subjects approval. Consent was obtained from top administrators of the five health facilities participating in the study. In ad-dition, participants provided consent by marking the consent form with a signature or thumbprint.

Facility selection Samples of convenience were selected

from five health facilities based on services provided to pregnant women as well as their proximity to an urban area, freetown. The health facilities included two government-run hospital (GH and MCH), a private Christian hospital (private east), a private reproductive health clinic (private west), and a private obstetric and gynecological clinic (private OBGyN).

Participant selectionParticipants were recruited over a pe-

riod of four months, to participate in an unmatched case-controlled study based on convenient purposeful sampling. Health workers and nurses working at the reception area at each health facility identified every pregnant woman visiting the health facilities. When it was determined that it was their first visit to the clinic, they were directed to the researcher or trained research assistants. Eligibility was established by asking par-ticipants the following question “is this your first time visiting a health professional (doc-tor, nurse, maternal and child health aide) for the current pregnancy?” Participants were considered eligible if they responded, “yes” to the question, which determined that it was the first prenatal visit for the

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current pregnancy of the pregnant woman. Participants were explained the research by the researcher or research assistants in the local language (Krio) and asked if they would be interested in participating as they waited to be seen for prenatal services. Par-ticipants indicated their consent by signature or thumbprint.

The researcher and research assistants trained to collect data obtained biographical information and clinical data. To determine cases (having anemia) and controls (not having anemia), participants underwent fin-ger-sticks in order to collect blood samples to assess hemoglobin (Hgb) levels. Mobile battery operated hemoglobin-testing kits (StatM Hemoglobin Meter) and controls from Clinical Laboratory Improvement Amendments (CLIA) waived were used to collect the blood samples. Hemoglobin levels less than 11g/dL was indicative of anemia according to WHO standards.

Instrument The questionnaire distributed was

derived from sections of the validated De-mographic and Health Survey (DHS),22 Key Indicators Survey (KIS)23 and World Health Survey.24 In addition to the fixed alternative (closed) items, open-ended items were in-cluded for elaboration purposes.

The questionnaire that existed in Eng-lish were translated into Krio and checked independently for resolution of differences. The questionnaire was then back translated into English. The original English survey and the back-translated survey were further checked for resolution of differences and adjusted as necessary.

The researchers read the contents of the questionnaire to the participants, as the region where they lived was considered to have low literacy. The questionnaire was read in the local language (Krio).

Data analysesParticipants responded to a structured

questionnaire regarding their anemia knowledge, attitudes and behaviors. quan-titative data collected were analyzed using SPSS version 10 and Excel 1997 for Win-dows. Descriptive statistics were computed

with relevant data reported and differences between cases and controls were calculated using chi-square and t-tests. Chi-square was appropriate to use for attitude items that had two forced choices: accept or reject. Statisti-cal significance was reported if P-value was less than 0.05.

Open-ended questions elicited brief re-sponses. qualitative responses were coded, themes developed, themes interpreted, and finally interpreted themes were summarized using quantifiable measures (frequencies).

RESULTSTwo hundred and sixty-seven (N = 267)

eligible pregnant women from five facilities were selected for the study. Of those eligible, 68 did not complete the survey for reasons such as time conflict, facility hours of op-eration conflict, or did not consent. One

hundred and ninety-seven interviews were conducted but 26 were discarded due to lack of hemoglobin results and/or improper recording of data. Therefore, data were col-lected from 64% (N = 171) of those eligible that were used for analyses.

The current study found that 77% of par-ticipants (N = 131) did not meet the WHO hemoglobin standards (Hgb > 11g/dL) and were classified as having iron deficiency ane-mia. All facilities except for the private OB/GyN had more participants with anemia. Anemia prevalence by facility is presented in figure 2. Results of the socio-ecological factors affecting anemia status are presented under each construct of the MEM-HBHP.

Intrapersonal FactorsParticipants in this study reflected the

range of ethnic groups present in Sierra Leone. Participants were approximately 25

Figure 1. Modified Ecological Model for Health Behavior and Health Promotion

Developed by author, based on ideas from Hochbaum GM, 1958;17, 18 McLeroy et al, 1988;19 Moos R, 1980;20 and Bandura, 1977.21

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years of age at the time of the study (M = 23.85 years; Mode = 20 years), most had delivered at least one child (Para = 0.96) and were over 19 years at the time of their first pregnancy (M = 19.68 years) (Table 1). Most participants had an education be-yond elementary school (49% had attended secondary school, while 10% had some college/university). Twenty-six percent of participants received no formal education or attended a trade school. fourteen percent attended some school at the elementary level (figure 3).

More than half the women interviewed were married (56%) or engaged (20%) and 23.5% indicated they were single (Table 2). Three-quarters of women were employed outside of the home (73%) yet most (62%; N = 106) were poor or food poor (making two dollars or less per day) (figure 4; figure 5; Table 2). The majority of women inter-viewed (80.5%) depended on their husbands or partners to cover their health needs dur-ing the pregnancy (figure 4).

Participant knowledge about anemia causes was poor. The average score for the 10 dichotomous items was 6.42 out of 10. Participants made some good responses to the open-ended questions, including cor-rectly identifying poor dietary intake, poor protein intake and malaria, as causes for anemia. Several inaccurate responses were

offered: participants incorrectly responded that being worried, having anemia and having high blood pressure, among others, caused anemia.

Social and Cultural EnvironmentParticipants ate foods that those in their

social network (mothers, grandmothers, mother-in-law, and so on) or health care professionals recommended. Similarly, participants refrained from eating foods dissuaded by their social network. Most participants indicated that they were told to eat sweet potato leaves as this food was considered a good choice during pregnancy. Participants also were told to eat pumehun (a dish that contains potato leaves, fermented sesame seed, okra, pepper, salt, bullion cubes, jakato (Solanum macrocarpon Linn. – type of eggplant), and dried fish, steamed with white/“country” rice) and other types of green leafy vegetables, such as cassava leaves, borlogee, krein krein, patmengee, salad (let-tuce), and Salone greens (similar to turnip/collard). Recommendations to eat fruits such as bananas, mango, pineapple, lime, orange, and plantain were provided. Other recom-mended foods included protein rich foods such as black-eyed beans, groundnuts (pea-nuts), fish, beef and chicken. Recommended foods were native to the region available in freetown and Western Area.

foods that participants were told to avoid

due to health implications included foofoo, gari, sugar or rice. These foods were believed to affect fetal growth such as the fetus would “grow too big” (reference to gestational diabetes). Participants also were told not to drink soft drinks, chew kola nuts, or take non-prescribed/street/ “country” medica-tions (traditional herbs). Some recom-mendations were based on cultural beliefs. for example, participants were told not to eat eggs, suck on lime, or eat foofoo, as these foods were believed to cause spontaneous abortions (“steal” the baby).

Social peers and health professionals sometimes provided erroneous recom-mendations to participants. for example, participants often were told to eat foods with a lot of palm oil, or drink purple col-ored soft drinks (such as Vimto) because the red coloring was believed to improve blood (anemia) status though this color-ing is artificial and non-nutritive. Some participants were told to eat foofoo (cooked fermented cassava/yucca) or gari (dried and processed cassava/yucca) although cassava actually interferes with iron absorption. In addition, participants said that they were told to take “blood medicine,” which was generally a multivitamin concoction, with some alcohol content.

Participants in the study were more likely to see a health care worker in the second

Figure 2. Anemia Prevalence by Health Facility

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Table 1. T-test Comparisons of Demographic Affecting Anemia Status

Clinical Items Anemia Status N (%) Mean (SD)P-value

(2-tailed)

Gravidae (average pregnancies) Have Anemia 131 (76.6) 1.98 (1.30)

Do not have anemia 40 (23.4) 2.20 (1.18) .333

Total 171 (100) 2.03

Parity (average births) Have Anemia 131 (76.6) 0.95 (1.25)


Total 171 (100) 0.96

Current Age

Have Anemia 130 (76.5) 23.53 (5.57)


Total 170 (100) 23.85

Age at 1st pregnancy

Have Anemia 117 (77.5) 19.76 (4.13)


Total 151 (100) 19.68

BMI

Have Anemia 118 (76.1) 25.64 (4.76)


Total 155 (100) 25.97

Note: Hgb = hemoglobin χ2: *P < 0.05; **P < 0.01

Figure 3. Last Grade Level Reached by Participants

trimester of their pregnancy or after 12 weeks gestation (Table 2). During health visits, the attending nurse indicated that she would stress the importance of visiting the facility. In addition, the nurse would stress the importance of the participant having at least six prenatal visits, filling their prescrip-tions, taking prescriptions and acting on the advice provided.

Although the majority of participants worked outside the home, they often did not cover health care costs. There was a heavy reliance on husbands/significant others to cover costs for the prenatal care visit (>80%).

Religion also played a role in the lives of the participants. Prayer was a method often used to ward off any negative occurrences.

Of those who indicated they did something to their water before drinking it (N = 62), 15% (N = 10) mentioned that they prayed over the water before drinking to deter or reduce risk of infections.

Religious activities took place at the health facilities. Christian religious ser-vices or prayer services were held prior to commencing the day’s activities in each of

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Figure 4. Occupation of Participants

Figure 5. Economic Status

the health facilities, except for the private practice. Christian songs would be sung or a pastor would read from a Bible. Clients would participate by singing along and clapping their hands. The pastor would bless the facilities and the work being done in the facilities. Religious activities observed at the facilities were based on Christian faith even though the majority of the participants were Muslim (61%) (Table 2).

Cues to ActionThe main cues to action were in the form

of reminders from the healthcare provider

at the health facility (N = 32, 18.7%) or a family member (N = 37, 21.6%) (Table 3). During this period, helpful information was disseminated, misconceptions were addressed and information was shared with participants to incorporate in their lifestyle when they returned home, or until the next visit. The majority of information shared by health care providers dealt with medica-tion, vitamins, and nutrition. Most of what was shared was oral as almost half of these participants were not literate.

Participants often listened to the radio

(N = 135, 79.0%). Some had access to tele-vision sets (N = 69, 40.6%). forty percent (N = 69) of radio listeners indicated that they had heard about anemia prevention and treatment on the radio. The majority of participants (N = 82, >75%) who watched television did so sporadically and would be for the purpose of watching movies. Sixteen percent (N = 28) of participants mentioned that they had heard anemia messages on television. Only 33% (N = 57) of partici-pants read newsprint. Eleven (6.5%) of those who read newsprint read about anemia. No

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Tabl

e 2.

Ch

i-squ

are

Com

pari

son

s of

An

emia

Mes

sage

s Po

ten

tial

ly A

ffec

tin

g A

nem

ia S

tatu

s

WH

O S

tand

ards

Not

Ane

mic

(>11

.0g/

dL)

Hav

e An

emia

Don

’t H

ave

Anem

iaTo

tal

P-va

lue

95%

CI

Beha

vior

Item

sRe

spon

seN

(%)

N (%

)N

(%)

χ2(2

-taile

d)O

RLo

-Hi

Who

in s

ocia

l ci

rcle

spo

ke

abou

t ane

mia

Fam

ily M

embe

r 14

(60.

9%)

9 (3

9.1%

)23

(100

%)

Teac

her

3 (1

00%

)0

(0.0

%)

3 (1

00%

)

Frie

nd/N

eigh

bor

8 (8

8.9%

)1

(11.

0%)

9 (1

00%

)

Oth

er0

(0.0

%)

1 (1

00%

)1

(100

%)

NA

106

(78.

5%)

29 (2

1.5%

)13

5 (1

00%

)

Tota

l13

1 (7

6.6%

)40

(23.

4%)

171

(100

%)

8.40

.078

NA

NA

Was

told

to e

at/

dr

ink

spec

ific

ite

ms

whe

n pg

No

86 (7

8.2%

)24

(21.

8%)

110

(100

%)

Yes

45 (7

3.8%

)16

(26.

2%)

61 (1

00%

)

Tota

l13

1 (7

6.6%

)40

(23.

4%)

171

(100

%)

0.43

.514

1.27

4.6

15 –

2.6

39

Who

sai

d to

ta

ke ir

on

supp

lem

ent

Hea

lth w

orke

r26

(78.

8%)

7 (2

1.2%

)33

(100

%)

Fam

ily/F

riend

11

(91.

7%)

1 (8

.3%

)12

(100

%)

Self

4 (8

0.0%

)1

(20.

0%)

5 (1

00%

)

TBA

1 (1

00%

)0

(0.0

%)

1 (1

00%

)

Oth

er P

erso

n2

(100

%)

0 (0

.0%

)2

(100

%)

No

one

84 (7

3.0%

)31

(27.

0%)

115

(100

%)

Tota

l12

8 (7

6.2%

)40

(23.

8%)

168

(100

%)

3.31

.652

NA

NA

Spok

en to

hea

lth

care

wor

ker

abou

t ane

mia

No

(81.

3%)

103

(74.

1%)

36 (2

5.9%

)13

9 (1

00%

)

Yes

(18.

7%)

28 (8

7.5%

)4

(12.

5%)

32 (1

00%

)

Tota

l (20

0%)

131

(76.

6%)

40 (2

3.4%

)17

1 (1

00%

)2.

61.1

060.

409

.134

– 1

.246

Cont

inue

s on

the

next

pag

e

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W

HO

Sta

ndar

ds N

ot A

nem

ic (>

11.0

g/dL

)

Hav

e An

emia

Don

’t H

ave

Anem

iaTo

tal

P-va

lue

95%

CI

Whi

ch h

ealth

ca

re w

orke

r sp

oke

abou

t an

emia

Nur

se (

9.9%

)16

(94.

1%)

1 (5

.9%

)17

(100

%)

Mid

wife

(1.8

%)

2 (6

6.7%

)1

(33.

3%)

3 (1

00%

)

Doc

tor (

4.7%

)6

(75.

0%)

2 (2

5.0%

)8

(100

%)

TBA

(1.2

%)

2 (1

00%

)0

(0.0

%)

2 (1

00%

)

Oth

er (0

.6%

)1

(100

%)

0 (0

.0%

)1

(100

%)

Don

’t Kn

ow1

(100

%)

0 (0

.0%

)1

(100

%)

NA

(81.

3%)

103

(74.

1%)

36 (2

5.9%

)13

9 (1

00%

)

Tota

l (10

0%)

131

(76.

6%)

40 (2

3.4%

)17

1 (1

00%

)4.

79.5

70N

AN

A

Spok

e to

som

e-on

e in

soc

ial

circ

le

No

(77.

8%)

194

(78.

2%)

29 (2

1.8%

)13

3 (1

00%

)

Yes

(21.

6%)

27 (7

3.0%

)10

(27.

0%)

37 (1

00%

)

NA

(0.6

%)

0 (0

.0%

)1

(100

%)

1 (1

00%

)

Tota

l (10

0%)

131

(76.

6%)

40 (2

3.4%

)17

1 (1

00%

)3.

73.1

55N

AN

A

Anyt

hing

don

e

to w

ater

bef

ore

dr

inki

ng

No

86 (8

1.9%

) 19

(18.

1%)

105

(100

%)

Yes

45 (7

2.6%

)17

(27.

4%)

62 (1

00%

)

Tota

l 13

1 (7

8.4%

)36

(21.

6%)

167

(100

%)

2.00

.157

1.71

.810

– 3

.610

Wha

t is

done

to

wat

er b

efor

e

drin

king

Not

hing

84

(80.

0%)

21 (2

0%)

105

(100

%)

Bottl

ed

7 (6

3.6%

)4

(36.

4%)

11 (1

00%

)

Boil

11 (6

4.7%

)6

35.3

%)

17 (1

00%

)

Chlo

rinat

e 3

(75%

.0%

)1

(25.

0%)

4 (1

00%

)

Stra

in-c

loth

7

(87.

5%)

1 (1

2.5%

)8

(100

%)

Filte

r 3

(100

%)

0 (0

.0%

)3

(100

%)

Pray

ove

r8

(80.

0%)

2 (2

0%)

10 (1

00%

)

Oth

er

8 (6

6.7%

)4

(33.

3%)

12 (1

00%

)

Tota

l 13

1 (7

7.1%

)39

(22.

9%)

170

(100

%)

5.28

10.2

45N

AN

A

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W

HO

Sta

ndar

ds N

ot A

nem

ic (>

11.0

g/dL

)

Hav

e An

emia

Don

’t H

ave

Anem

iaTo

tal

P-va

lue

95%

CI

Hea

lth c

over

age

Hus

band

(80.

5%)

105

(77.

2%)

31 (2

2.8%

)13

6 (1

00%

)

Fam

ily &

in-la

ws

(7.1

%)

9 (7

5.0%

)3

(25.

0%)

12 (1

00%

)

Self

(6.5

%)

8 (7

2.7%

)3

(27.

3%)

11 (1

00%

)

Wor

k (2

.4%

)3

(75.

0%)

1 (2

5.0%

)4

(100

%)

Sibl

ings

(1.8

%)

3 (1

00.0

%)

0 (0

.0%

)3

(100

%)

Aunt

/Unc

le (1

.2%

)2

(100

.0%

)0

(0.0

%)

2 (1

00%

)

Oth

er (.

6%)

1 (1

00.0

%)

0 (0

.0%

)1

(100

%)

Tota

l13

1 (7

7.5%

)38

(22.

5%)

169

(100

%)

1.95

.924

NA

NA

Mar

ital s

tatu

sSi

ngle

(23.

5%)

33 (8

2.5%

)7

(17.

5%)

40 (1

00%

)

Enga

ged

(20.

0%)

23 (6

7.6%

)11

(32.

4%)

34 (1

00%

)

Mar

ried

(56.

5%)

75 (7

8.1%

)21

(21.

9%)

96 (1

00%

)

Tota

l13

1 (7

7.1%

)39

(22.

9%)

170

(100

%)

2.43

.296

NA

NA

Rel

igio

nM

uslim

(61.

2%)

85 (8

1.7%

)19

(18.

3%)

104

(100

%)

Chris

tian

(38.

8%)

46 (6

9.7%

)20

(30.

3%)

66 (1

00%

)

Tota

l13

1 (7

7.1%

)39

(22.

9%)

170

(100

%)

3.31

.069

1.94

5.9

44 –

4.0

09

Trim

este

r of 1

st

heal

th c

are

visit

< 12

wee

ks (<

1st)

35 (6

4.8%

)19

(35.

2%)

54 (1

00%

)

>12

wee

ks (>

2nd)

96 (8

2.1%

)21

(17.

9%)

117

(100

%)

Tota

l13

1 (7

6.6%

)40

(23.

4%)

171

(100

%)

6.12

*.0

13.4

03.1

94 –

.837

< 12

wee

ks (<

1st)

35 (6

4.8%

)19

(35.

2%)

54 (1

00%

)

> 24

wee

ks(>

3rd)

27 (9

0.0%

)3

(10.

0%)

30 (1

00%

)

Tota

l62

(73.

8)22

(26.

2%)

84 (1

00%

)6.

33*

.012

.205

.055

– .7

64

Not

e: H

gb =

hem

oglo

bin;

χ2:

*P

< 0

.05;

**P

< 0

.01

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one indicated reading anemia messages on billboards or posters (Table 3).

Environment

Environmental Impact on Participant Behavior

Sixty-two participants (37%) either drank bottled water or did something to their water prior to drinking. Of those, only a quarter (N = 43) indicated water treatment methods recommended by the Centers for Disease Control and Preven-tion: drink bottled water, boil water, chemi-cally disinfect water, or portable water filter (Table 2).

Women used outdoor cooking hearths to prepare meals daily. Sometimes this form of cooking was used as many as three times a day because refrigeration was not possible. Unrefrigerated food would spoil in the warm climate, causing microorganisms (bacteria and parasites) to proliferate enteritis, which may contribute to anemia. Participants, in general, consumed rice and potato leaves or cassava leaves with some fish about once or twice a day, everyday. Most meals were eaten with a palm oil base. for breakfast, most participants would drink either tea or coffee with milk and sugar. Although their dietary intake was substantial, it was very heavy on rice and had very little variety.

Biological Environment Impact on Anemia Status

Participants mean age was 23.8 years. On average, participants were 19.7 years at the time of their first pregnancy. Partici-pants were pregnant three times or less (av-erage number of pregnancies = 2.0) before the age of 24. Sixty percent of participants who were on their second pregnancy, however, had less than 36 months spacing between children.

In regard to other conditions, 78% of study participants had malaria, while 66% reported having had helminthes infections in the past. Participants who were currently receiving treatment for infections or malaria were indicated. It was unclear if all other par-ticipants had any illness during the study, as they were not tested. The majority of partici-pants were not taking preventive measures to combat worms, malaria, or anemia.

Policies Addressing Maternal Health Sierra Leone’s National Operational Hand-

book for Primary Health Care outlines health goals and objectives for the nation. Maternal/child and reproductive health services are one of ten foci for the nation’s health. This handbook, however, did not provide objec-tives to develop and implement prevention initiatives.25 The Sierra Leone PRSP-II26 and Sierra Leone’s National Health Sector Strate-gic Plan27 outline the nation’s policy on health matters. Although policy focus on maternal health and nutrition include the “provision and distribution of micronutrients to… pregnant women,”26 it fails to, address iron supplementation to combat anemia.8, 26, 27 Current policies to address interventions specific to anemia are inadequate.28

Cost/Benefit AnalysisThe cost benefit analysis appears to be

based primarily on financial viability. Several times the issue of money to pay for services, to eat the proper foods, to find transporta-tion fares to visit a health facility, to purchase the necessary treatments, prophylaxis, or an-tenatal vitamins were expressed as concerns of participants.

DISCUSSIONA current focus on addressing maternal

mortality and anemia is occurring glob-ally. Within recent months, two separate international reports assessing the state of global anemia and maternal mortality have been published.3,12 Although these reports are valuable, they are missing key data on Sierra Leone, a nation with one of the worst records of maternal mortality and child survival in the world.

This study provided a baseline of anemia prevalence of pregnant women living in urban Western Area, Sierra Leone and iden-tified potential socio-ecological factors that might have influenced maternal anemia. This study also introduces the Modified Ecologi-cal Model for Health Behavior and Health Promotion (MEM-HBHP) as a framework to study socio-ecological factors.

The MEM-HBHP was beneficial in or-ganizing the study and could be used as a framework to assess socio-economic factors

that contribute to anemia status in preg-nancy. The model in its entirety was not ap-propriate for the study. Intrapersonal factors (knowledge and attitudes), biological factors (reproductive and prior exposure to infec-tions), and cues to action (exposure to media messages), did not yield any statistically sig-nificant differences. According to the study, therefore, the aforementioned factors were not contributing factors to anemia status. Barriers to receiving health care (access to services due to poverty), social and cultural environment (income, family input, martial status), physical environment (source of drinking water), however, did yield statisti-cally significant results. The MEM-HBHP as an instrument was beneficial in uncovering important socio-ecological findings.

Anemia prevalence of 76.6% is higher than any other reports.3,5 The high propor-tion of poverty in the women in the study (62%) was four times higher than the re-gional prevalence of 17%. These findings could be a true reflection of the status of the pregnant women, or it could be that individ-uals self-identified as poor to gain sympathy from investigators. If it is the former, the high level of poverty may be normal as there is more poverty found with women than regional and national averages. High poverty levels among women have been linked to the feminization of poverty as women globally, including Sierra Leone, are more susceptible to be negatively impacted by poverty than men.9 Women often expressed that they did not have the money to see a health care pro-fessional but that their significant other did. In most cases, income that a woman earned did not go towards prenatal care but instead to food, coal and wood for cooking and other household maintenance activities.

The level of poverty was particularly dis-turbing especially when compared to level of education. Almost 60% of participants attended secondary school or higher. The level of education of this group may be a result of two factors. It may be a reflection of the population who were attending a health facility as more educated individuals are likely to visit health facilities. It must be noted that recorded in Sierra Leone,

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Tabl

e 3.

Ch

i-squ

are

Com

pari

son

s of

An

emia

Mes

sage

s Po

ten

tial

ly A

ffec

tin

g A

nem

ia S

tatu

s

WH

O S

tand

ards

Not

Ane

mic

(>11

.0g/

dL)

Hav

e An

emia

Don

’t H

ave

Anem

iaTo

tal

P-va

lue

95%

CI

Beha

vior

Item

sRe

spon

se (%

Tot

al)

N (%

)N

(%)

N (%

)χ2

(2-ta

iled)

OR

Lo-H

i

B13

List

en to

radi

oN

o (2

1.0%

)29

(80.

6%)

7 (1

9.4%

)36

(100

%)

Yes

(79.

0%)

102

(75.

6%)

33 (2

4.4%

)13

5 (1

00%

)

Tota

l (10

0%)

131

(76.

6%)

40 (2

3.4%

)17

1 (1

00%

)0.

40.5

291.

34.5

37 –

3.3

43

B14

Hea

rd a

bout

an

emia

on

radi

oN

o (3

9.4)

51 (7

6.1%

)16

(23.

9%)

67 (1

00%

)

Yes

(40.

6)51

(73.

9%)

18 (2

6.1%

)69

(100

%)

NA

(20.

0%)

28 (8

2.4%

)6

(17.

6%)

34 (1

00%

)

Tota

l (10

0%)

130

(76.

5%)

40 (2

3.5%

)17

0 (1

00%

)0.

91.6

35N

AN

A

B15

Wat

ch T

VN

o (3

5.1

%)

46 (7

6.7%

0)14

(23.

3%)

60 (1

00%

)

Yes

(63.

7%)

83 (7

6.1%

)26

(23.

9%)

109

(100

%)

NA

(1.2

%)

2 (1

00%

)0

(0.0

%)

2 (1

00%

)

Tota

l (10

0%)

131

(76.

6%)

40 (2

3.4%

)17

1 (1

00%

)0.

62.7

321.

03N

A

B16

Hea

rd a

bout

an

emia

on

TVN

o (4

7.9%

)62

(75.

6%)

20 (2

4.4%

)82

(100

%)

Yes

(16.

4%)

23 (8

2.1%

)5

(17.

9%)

28 (1

00%

)

NA

(35.

7%)

46 (7

5.4%

)15

(24.

6%)

61 (1

00%

)

Tota

l (10

0%)

131

(76.

6%)

40 (2

3.4%

)17

1 (1

00%

)0.

57.7

51N

AN

A

B17

Read

new

spap

ers

No

(66.

1%)

89 (7

8.8%

)24

(21.

2%)

113

(100

%)

Yes

(33.

3%)

41 (7

1.9%

)16

(28.

1%)

57 (1

00%

)

NA

(0.6

%)

1 (1

00%

)0

(0.0

%)

1 (1

00%

)

Tota

l (10

0%)

131

(76.

6%)

40 (2

3.4%

)17

1 (1

00%

)1.

29.5

241.

45N

A

B18

Read

abo

ut

anem

ia in

ne

wsp

aper

No

(29.

8%)

40 (7

8.4%

)11

(21.

6%)

51 (1

00%

)

Yes

(6.5

%)

8 (7

2.7%

)3

(27.

3%)

11 (1

00%

)

NA

(63.

7%)

83 (7

6.1%

)26

(23.

9%)

109

(100

%)

Tota

l (10

0%)

131

(76.

6%)

40 (2

3.4%

)17

1 (1

00%

)0.

20.9

05N

AN

A

Not

e: H

gb =

hem

oglo

bin

χ2: *

P <

0.0

5; *

*P <

0.0

1

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68% of women are seen at least once for prenatal care. Of those, 42% saw a midwife, physician, or auxiliary midwife and the remaining 26% probably saw a pharmacist, traditional birth attendant, herbalist, or someone who was not a health profes-sional.8 Although more than two-thirds of participants see a health care provider at least once in their pregnancy, they usually wait until the second and third trimester. Also, the WHO recommends at least four prenatal visits throughout the pregnancy, which was not the case in Sierra Leone.

Although 68% of participants were seen at one prenatal care visit, only 3% of deliver-ies were actually attended by a physician in Sierra Leone. As this study was set in a health care setting, all participants did see a health care provider, albeit later in the pregnancy. A reason why participants might choose not to see a health care professional or see them late may have been due to lack of finances. The study found that 30% of women cited having money to seek prenatal services as a “big problem”.

One’s social and cultural environment played a role in the messages participants heard. qualitative results showed that soci-ety and culture were factors in participants’ decision-making for seeking care and engag-ing in preventive and treatment options. friends and family often recommended par-ticipants eat certain foods while pregnant. Dietary recommendations to limit certain foods were appropriate. for example, soft drinks contain empty calories, kola nut is has stimulant effects on the body and herbal (traditional country) medicines or street medicines could have contraindications for pregnancy. The blood tonics that were en-couraged during pregnancy often contained alcohol. Currently, it is recommended that pregnant women not consume alcohol early in the pregnancy, as no safe level exists.

Other dietary recommendations that were dissuaded, as they were considered to cause spontaneous abortions, were eggs that are a good and inexpensive source of protein (needed during fetal growth) and lime that is excellent to combat nausea. Although foofoo (fermented yucca/cassava) if consumed in

large amounts may decrease dietary variety and balance and may inhibit iron absorp-tion, yucca has not been found to be a direct cause of spontaneous abortions.

Physical and biological elements such as helminthic infections and anemia may affect pregnant women’s health status. In light of this, health care providers automatically prescribe anti-helminthes and iron-folate supplements during their prenatal visits. It is debatable, however, whether prophylaxis are actually taken as prescribed.

Water contamination also might be a problem for pregnant women. Seventy-five percent of Sierra Leoneans in urban regions have access to improved water sources.29 Travel reports still recommend “hygienic precaution [be taken] with all food, drink and drinking-water consumed,” while in Sierra Leone.4 Use of the “coal pot” (outdoor cooking hearths), might have negative effects on pregnant women as continual exposure to bio-fuel smoke during cooking is a con-tributing factor of anemia. 30

The most likely source for health infor-mation was the radio as most participants listened to the radio. Television often is not watched mainly due to the lack of electricity to power them. Health messages on bill-boards often were missed or went unnoticed, as it is possible that posters were wordy.

The cost benefit analysis appears to be based primarily on financial viability. Several times the issue of money to pay for services, to eat the proper foods, to find transporta-tion fares to visit a health facility, to purchase the necessary treatments, prophylaxis, or an-tenatal vitamins were expressed as a concern of participants. With the new free health care initiative currently in place, financial constraints should no longer be a barrier to health care access.

Elements of the model (Social and Cultural Environment, Physical Environ-ment, Perceived Barriers and Policy factors) were better indicators of anemia status. These elements should be used to address anemia concerns and develop health pro-motion strategies for pregnant women in freetown and potentially other regions of Sierra Leone.

This study provided a baseline of anemia prevalence of pregnant women living in urban Western Area and identified potential socio-ecological factors that might have in-fluenced maternal anemia. More needs to be done to address the inflated maternal mortal-ity and anemia prevalence in the region.

TRANSLATION TO HEALTH EDUCATION PRACTICE

Social, cultural and economic determi-nants of health were found to affect the anemia status of pregnant women living in urban Western Area, Sierra Leone. These effects have implications for community based training, public policy, professional preparation, health promotion, and health education practice and research. Health education and health promotion profes-sionals must take into consideration culture and religion in their program planning. In addition, health professionals must consider limited education and poverty of the overall population. With 24-26% of the population having some form of formal education, this leaves a majority of the population without basic skills to enable health literacy and understanding of basic health information to promote healthy food consumption and dietary supplements to improve iron status. In addition, health providers who are at the frontlines of primary contact for pregnant women may not have the most updated in-formation to provide current information to their patients. National policies that include free distribution iron supplementation, while good falls short when encouraging pregnant women to consume iron rich foods often found in expensive animal product or not having safe drinking water.

It is necessary to develop and implement comprehensive programs to raise aware-ness and address misconceptions about anemia causes, prevention and treatment. These programs include family planning, sanitation education, and health education training for nurses and physicians, and also in the training of health educators to prepare them to provide prevention services and education within health facilities.

It is important to support current efforts

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to distribute iron supplements. In addition it is necessary to continue advocating for safe drinking water sources, subsequently work-ing the government and non-governmental organizations to build wells, educate about water sanitation practices such as boiling, disinfecting (sodium hypochlorite used within three weeks, ozone, UV, and solar disinfectant), distilling, the use of proper water storage vessels (narrow-mouthed, high density polyethelene (HDPE), 20 liters or 4 gallons that can be easily carried), and the inclusion of social marketing to promote safe water practices.31 Sanitation practices are not limited to water but include safe cooking and storing practices of foods to reduce bacterial contamination.

family planning should be encouraged to decrease fertility rates to five children or less, increase the number of birth spacing to 24 months and increase the age of child bearing between 19 and 35 years.32 family planning initiatives should also include the promotion of access to affordable contracep-tive methods and the development of social marketing campaigns to improve social ac-ceptability of contraceptives.33

Education training for nurses and physi-cians about learning theories are necessary to provide effective health education as these health workers are often the first health pro-fessionals encountered by pregnant women. Health workers also need to maintain access to current information through continuing education to be aptly equipped to provide necessary interventions. Continuing educa-tion should also include understanding of local food combinations that incorporate dark green leafy vegetables, dried beans, fish, shellfish, organ meats and pumpkin seeds.

This study underscored the respect that pregnant women give health care providers and female relatives during this time. To uti-lize this resource, community based health workers, who are known and respected in the community maybe appropriately trained by trained health care providers through tried models such as “train the trainer” to provide basic anemia prevention messages within communities that have limited access.34 Health education campaigns that use radio

vehicles to deliver health communication messages would be most appropriate in Sierra Leone. These messages should focus on debunking dietary myths, while provid-ing salient health messages related to anemia and general maternal health.

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