Volume 7, Issue 4, April – 2022 International Journal of Innovative Science and Research Technology

ISSN No:-2456-2165

Knowledge, Attitude and Practice Related to Iron

Deficiency Anemia among Women of Child Bearing
Age, Khartoum, Sudan
Tagreed Ahmed (1st Author with equal contribution)
Jazan University – Faculty of Medicine
Department of Anatomy Jazan, KSA

Osman Abdelrahman, (1st Author with equal contribution)

Roving senior officer, Operations, Health Insurance
The Mediterranean and Gulf Cooperative Insurance and Reinsurance Company. Riyadh, KSA

Abstract: fruits (2.5 point); Grewiatennax (2.5 points); milk (1

Background: This cross-sectional study was conducted point); others (1 point).
at Khartoum locality, Khartoum, Sudan. Ibrahim Malik
teaching hospital was selected to carry out the study on Results:
their antenatal care clinic. The study was conducted in The total number of participants in this study was 119
the period between October to December 2014. women. The mean age of the participants was 27.3 +5
(Mean+SD). The mean level of hemoglobin for the
Purpose: We have accomplished this study due to our participants was 10.4 + 0.12 gram/dl (mean + SD). Levels
beliefs regarding the importance of maternity health and of hemoglobin were also found to decrease with
the key factors affecting it. One of the major and multiparity, and primigravida had higher hemoglobin
underrated factors is the importance of iron. It is levels compared to multiparous women.60.7 % of
necessary to explore the factorsthat lead to the pregnant women were identified as a high-risk group for
development of iron deficiency anemia among pregnant iron deficiency anemia. 47.1 % have agreed on the
Sudanese women in order to design effective importance of meat, and only 20.2 % have agreed on the
interventions that reduce the burden of the problem. importance of legumes for pregnant women. Meanwhile,
72.2 % stressed the importance of fruits during
Methodology: A questionnaire with close-ended pregnancy. Interestingly, (58.0 %) stated that it is
statementswas distributed to pregnant women who necessary to consume milk and dairy products.
attended the antenatalcare clinic at Ibrahim Malik Interestingly, only five women mentioned that the
hospital.The questionnaire consisted of thirty-three pregnant woman should eat what she usually eats, but in
standardized questions divided into four sections: a greater amount.
Section A of the questionnaire covered questions on the
demographics of respondents; Section B contained Regarding their beliefs and attitude about the
questions to evaluate the knowledge of respondents; importance of taking iron tablets, 98.3% have admitted
Section C contained questions to evaluate the attitudes of the beneficial effects of these tablets on the health of both
respondents; Section D contained questions on practices the mother and the fetus.
of the respondents.
All women involved in the study have confirmed the
For the calculation of the total score for risk groups importance of eating iron-rich foods during pregnancy.
of iron deficiency anemia, the weights assigned for 86.6 % of pregnant women in the study managed to
selecting a specific group were as follows: pregnant report the record of their last hemoglobin measurement.
women and children (5 points); pregnant women only 57.1 % of the participants reported that they regularly
(2.5 points); children (2.5 points);nursing mothers (2.5 drink tea after meals. Ninety-five participants (79.8 %)
points); elderly (1 point). The sum of frequencies for reported regular use of iron tablets during pregnancy.
each category was then multiplied by the assigned weight
points. The total sum of points calculated for all Conclusion: Overall, findings indicated that women who
categories was then divided by the expected full total had poor knowledge of iron deficiency anemia, had
sum of the score which is the product of multiplying the unfavorable attitudes and weak practice and those who
sum of frequencies by 5. had good knowledge had appropriate behavior. Levels of
knowledge and attitudes towards the factors
Using different weights for each selected item, the contributing to the development of iron deficiency
same procedure was followed to calculate the total sum anemia during pregnancy were shown to be acceptable.
of scores for the selection of food items. The score
weights assigned for different food items were as follows: Keywords:- Knowledge; Attitude; Practice; Khartoum;
meat (5 points); pourpier (2.5 points); vegetables (2.5 Anemia.
points); pigeon pea (2.5 points); legumes (2.5 points);

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Volume 7, Issue 4, April – 2022 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
I. INTRODUCTION respondents; Section D contained questions on practices of
the respondents.
Anemia is a condition in which the number of red
blood cells (RBCs) and/or the amount of hemoglobin in the Questions of Section B were used to testify to the
blood falls below normal levels [1,2,3]. Anemia, especially knowledge of pregnant women regarding risk groups of
iron-deficiency anemia (IDA) is one of the most widespread IDA, nutrition, types of iron-rich diet, substances interfering
public health problems that affect populations in both with intestinal iron absorption, and the importance of iron
developed and developing countries. According to the tablets. Section C investigated the attitude of pregnant
WHO, anemia affects 1.62 billion people, which women towards the importance of visiting the antenatal care
corresponds to 24.8% of the population. And about 2.2 units, the importance of monitoring the hemoglobin level at
billion people were estimated to be iron deficient[4]. The the inter-pregnancy interval.
highest prevalence of anemia and iron deficiency occurs
among pre-school children (47.4%) and pregnant women The last section included questions to investigate the
(41.8%) [4,5,6]. Although in the developed world it is not actual practices of pregnant women about the issues of the
so widespread as in developing countries, it is still not most important foods, tea consumption, and use of iron
completely solved in the United States, Canada, and tablets, as well as the birth spacing, the number of
European countries. Recent reports showed that from 3.5% pregnancies, and the last record of hemoglobin level.
to 7.4% of pregnant women in the USA had IDA in the first
trimester. In the third trimester, it is even higher: from 15.6 Total scores of participants’ responses were tabulated
to 58% [7]. However, Africa has the highest proportion of in frequency tables. A working scale was specifically
individuals affected accounting for 47.5% of preschool designed to weigh the relative importance of each item
children and 67.9% of pregnant women[6]. selected by the participants. For the calculation of the total
score for risk groups of IDA, the weights assigned for
Anemia can result from a wide variety of isolated or selecting specific group were as follows: pregnant women
coexisted causes including nutritional deficiencies, worms’ and children (5 points); pregnant women only (2.5 points);
infestations, parasitic infections, and hemoglobinopathies, children (2.5 points); nursing mothers (2.5 points); elderly
however, iron deficiency is the most common cause of (1 point). The sum of frequencies for each category was then
anemia worldwide, and it is generally assumed that 50% of multiplied by the assigned weight points. The total sum of
the cases of anemia are due to iron deficiency [4, 6]. points calculated for all categories was then divided by the
Although IDA is usually due to nutritional insufficiency of expected full total sum of the score which is the product of
iron, it may also be caused by an underlying medical multiplying the sum of frequencies by 5.
problem such as gastrointestinal blood loss, malabsorption
syndrome, chronic inflammatory disease, or heavy Using different weights for each selected item, the
menstrual losses. same procedure was followed to calculate the total sum of
scores for the selection of food items. The score weights
II. MATERIAL AND METHODS assigned for different food items were as follows: meat (5
points); pourpier (2.5 points); vegetables (2.5 points);
A. Study design and sample size pigeon pea (2.5 points); legumes (2.5 points); fruits (2.5
This is a descriptive cross-sectional study. Ibrahim Malik point); Grewiatenax (2.5 points); milk (1 point); others (1
Teaching Hospital (IMTH) was selected for the study. A point).
convenient purposive sampling technique was adopted.
B. Data Analysis
The study was conducted in the Khartoum state of The data were analyzed using SPSS software package
Sudan. All pregnant women attending the antenatal clinic in (IBMSPSS version 16.0). Simple frequencies were
Ibrahim Malik Teaching Hospital during the study period calculated for the open and close ended questions. Cross
were asked to participate in the study. Those who met the tabulation and Chi-square (κ2) were used to analyze the data.
criteria of inclusion and consented to participate were Statistical tests were used to analyze the relationship of
selected for participation in the study. knowledge and attitude, knowledge and practice, and
attitude and practices as well as the relationship of each of
Pregnant women who attended the selected maternity
knowledge, attitude and practices with the demographic and
clinics regardless of their gestational age, educational level,
health and demographic data.
or residence area are included. Women who were suffering
from a severe illness unrelated to iron deficiency or those C. Ethical consideration
who are health professionals will be excluded from the Ethical clearance was obtained from the appropriate
study. health authority and institutions involved. Informed consent
was obtained from all participants before enrollment in the
The records of hemoglobin levels were obtained from
study.
the antenatal follow-up records. The questionnaire consisted
of thirty-three standardized questions divided into four
sections: Section A of the questionnaire covered questions
on the demographics of respondents; Section B contained
questions to evaluate the knowledge of respondents; Section
C contained questions to evaluate the attitudes of

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Volume 7, Issue 4, April – 2022 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165

Food item Frequency* % Score+

Fruits 86 72.2 215
Milk 69 58.0 69
Vegetables 57 47.9 142.5
Meat 56 47.1 280
Legumes 24 20.2 60
Pigeon pea 12 10.1 30
Total 304 796.5 (52.4 %)
Table 1: Knowledge on types of food needed during
pregnancy

+Scores were calculated using a scale of relative

weights for different items as described in material and
methods

*The number of participants who identified a particular

Fig. 1: The levels of hemoglobin decreases with number
type of food needed during pregnancy.
multiparity
III. RESULTS

The total number of participants in this study was 119 Regarding the knowledge on sources of rich-iron
women. The mean age of the participants was 27.3 +5 foods, thirty-eight women (31.9%) identified meat as the
(Mean=SD). most important source of iron. Forty-three (36.1 %)
mentioned green leafy vegetables as an important source of
The mean level of hemoglobin for the participants was iron. Large proportion (42.0 %) of women have specifically
10.4 + 0.12 gram/dl (mean + SD). According to the CDC mentioned the green leafy vegetable pourpier (purslane),
definition of anemia during pregnancy fifty women (42.0 %) while (22.8 %) have indicated the legume, pigeon pea as
of the group investigated in this study had hemoglobin important sources of iron. However, few women mentioned
levels below the cut-off point of anemia. Sixteen women the wild fruit Grewiatennax, bread,lemon, fishes and eggs as
representing 13.4% of the participants didn’t report their iron-rich sources. Twenty-four (20.2 %) women have
hemoglobin level. While the rest of women (44.5%) were incorrectly mentioned milk as an important source of iron.
categorized as not anemic. Table 2

However, in this study, although not significantly Meanwhile twenty-six women (21.8%) failed to
different, the levels of hemoglobin were found to decrease identify at least one iron-rich food. Overall, a totalof ninety-
with the gestational age. three women (78.2%) have correctly mentioned at least one
of the iron-rich foods.
Levels of hemoglobin were also found to decrease
with multiparity, and primigravida had higher hemoglobin Eighty-six women (72.3 %) have correctly identified
levels compared to multiparous women.Figure (1) the effect of tea drinking on the intestinal absorption of iron,
Although the differences were not statistically and ninety-one have correctly identified the effect of
significant, participants who had bleeding or abortion events vitamin c (ascorbic acid) on the iron absorption. However,
showed slightly lower levels of hemoglobin compared to very small number of the participants admitted that they do
those who didn’t experienced such conditions. not know the effect of either tea or vitamin C as shown in
Figure 2 below.
Fifty-six women (47.1 %) have indicated the
importance of meat, and only twenty-four (20.2 %) have Food item Frequency* % Score+
identified the importance of legumes for pregnant women.
Pourpier 50 42.0 125
Meanwhile eight six women (72.2 %) stressed the
(purslane)
importance of the fruits during pregnancy. Interestingly,
Fruits 53 44.5 106
sixty-nine women (58.0 %) stated that it is necessary to
Vegetables 43 36.1 107.7
consume milk and dairy products. Interestingly, five women
Meat 38 31.9 190
mentioned that the pregnant woman should eat what she
Milk 24 20.2 24
usually eats, but in greater amount, the results are shown in
Pigeon pea 27 22.8 67.5
Table 1 below.
Grewiatennax 05 4.2 12.5
Others# 11 9.2 11
Total 251 643.5 (51.3 %)
Table 2: Knowledge on iron-rich foods

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ISSN No:-2456-2165
+
Scores were calculated using a scale of relative results show a positive attitude with regard to the mothers’
weights for different items as described in material and need to replenish their iron store postpartum.
methods
All the women in the study stressed the importance of
* The number of participants who identified a birth spacing for the health and wellbeing of the mother.
particular type of food as good source of iron This result indicated the awareness and wide acceptance of
family planning programs among the study population.
# other types of foods include bread, raisin, carrot,
okra, watercress and lemon Sixty-eight women (57.1 %) reported that they
regularly drink tea after meals.

Tea Vitamin C Ninety-five women (79.8 %) reported a regular use

91
86 of iron tablets during pregnancy, and another twenty
women (16.8 %) reported that they use iron pills
occasionally. Only four women admitted that they do not
use iron pills at all. Figure (3)

100 95

80
26 29

Number
60

4 40
2
20
20
Do not know Decrease Increase 4
0
Fig. 2: The distribution of participants by their knowledge Don’t Use Ocassionally Regularly
on the effect of tea and vitamin C on iron absorption in the Fig. 3: Usage of iron supplement pills by participants
gut
The average birth spacing interval for the multiparous
Regarding believes and attitude about the importance women in the study group was 14 months. Out of the
of taking iron tablets, one hundred and seventeen women ninety-one multiparous women in the study, twenty-three
(98.3%) have admitted the beneficiary effects of these (25.3 %) have reported a birth spacing interval of 12 month
tablets on the health of both the mother and the fetus. or less, thirty women (32.9 %) have reported a birth interval
Out of the 119 participants involved in this study 118 between 12 to 24 month, and thirty-eight women (41.8 %)
women (99.2 %) agreed on the importance of attending the have had a birth interval of more than 24 month. Figure (4)
maternity clinic during pregnancy. Only one woman (.8%)
failed to report her believe about this issue. 45 41.8%
All of the participants involved in the study exhibited 40
positive attitude regarding the importance of monitoring 32.9%
the hemoglobin levels during pregnancy.One hundred and 35
three women (86.6 %) managed to report their record of 30
her last hemoglobin measurement. 25.3%
25
Meanwhile, the reports about the actual practice have
shown that sixteen participants (13.4 %) failed to report 20
their hemoglobin level indicating unfavorable practice with
15
regard to this issue.
10
All women involved in the study have confirmed the
importance of eating iron-rich foods during pregnancy. This 5
indicate a wide spread of the awareness of the importance of
iron for the health of fetus and pregnant mothers. 0
less than 12 12 -24 month more than24
Most of the women (89.9 %) have indicated the month month
importance of continuing iron supplementation during
Fig. 4: The distribution of participants by the length of birth
nursing. Only twelve women (10.1 %) reported that it is not
interval
necessary to continue iron intake after delivery. These

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ISSN No:-2456-2165
Regarding food consumption during pregnancy, practice showed that sixteen participants (13.4 %) failed to
Table (3) below, shows the results of the iron-rich foods report their hemoglobin level.
consumed by the women during the last two days. A total
of eighty-one women (68.1 %) indicated that they The majority of women investigated had satisfactory
consumed no legumes in their meals during last two days. knowledge on the risk factors of IDA. The overall score of
These results are revealing a wide gap between the the respondents on the knowledge of risk groups of IDA was
women’s knowledge and their actual practice with regard 53.2 %. However, this reveals that 46.8 % of women need
to the importance of eating legumes during pregnancy. further health education on the risk factors of IDA, and
health education programs in the antenatal care clinics could
Fifty-nine women (49.6 %) indicated that they have have positive impact.
consumed some type of fruits during the last two days.
These results reflect a considerable concordance between The overall score of the women investigated was 52.4
the beliefs and practices with regard to the importance of % on the scale of nutritional requirements during pregnancy.
fruits during pregnancy. They also scored 51.3 % on answering the questions about
iron-rich sources of food, and their score on the actual
Food item Frequency* % e nutritional practices during pregnancy was 53.6 %.These
results reveal a high degree of consistency between the
Meat 59 49.6 295 women’s knowledge, attitudes and practices with regard to
Milk 47 39.5 47 the nutritional aspects. However, results indicated that
Vegetables 62 52.1 155 around 47.6% of the women need further counseling in
Legumes 38 31.9 95 order to change their attitudes and practices with regard to
Pigeon pea 07 05.9 17.5 nutritional aspects. Interestingly, more than two thirds of the
Others 23 19.3 23 women (72.2 %) stressed the importance of the fruits intake
236 632.5 (53.6 %) during pregnancy, and 53 participants (44.5%) indicated
Table 3: Food consumption during the last two days fruits as good source of iron. Although, fruits in general are
known as good sources of minerals, ascorbate and citrate
* The number of participants who indicated intake of a which may increase iron uptake in the duodenum[12],
particular type of food during pregnancy however, fruits do not necessarily provide significant
IV. DISCUSSION amount of bio available iron due to the presence of phytates,
phosphates, oxalates and phenolic derivatives such as
Lack of knowledge, unfavorable attitudes and tannins which impede iron absorption in the gut[13] . Thus,
malpractices are substantially contributing to the widespread women should be aware of the types of fruits they consume
of IDA among women of childbearing age in most of during pregnancy. Moreover, forty-three (36.1%)
developing countries[8]. According to the American center participants have mentioned vegetables as good source of
of Disease control (CDC) definition of anemia during iron. Although, particular types of green leafy vegetables
pregnancy, fifty women (42.0 %) of the group investigated and legumes are known iron-rich sources. Again, care
in this study had hemoglobin levels below the cut-off point, should be taken, because most green vegetables are also rich
with a mean level of hemoglobin of 10.4 + 0.12 gram/dl. phytic acid which interferes with iron absorption in the gut.
The prevalence of anemia in this study is similar to that
reported in previous studies from different parts of Sudan Fifty-nine (49.6 %) of the women have reported
[9,10,11]. Moreover, in this study, although not significantly consumption of meat during the last two days. Although
different, the levels of hemoglobin were found to decrease meat is an excellent nutritional source for iron, high quality
with the gestational age, and were also found to decrease proteins and vitamins, this practice of having meat as a
with multiparity. This is not surprising, because fall in regular component of meals could actually be reflecting a
hemoglobin levels in late pregnancy reflects normal common attitude among Sudanese households rather than
physiological changes including expansion of plasma awareness about the importance of meat for pregnant
volume, and is not necessarily a sign of poor maternal women.
nutrition. However, the decreased hemoglobin in An interesting point was that, twenty-four respondents
multiparous women could be a consequence of depleted iron (20.2%) have incorrectly mentioned milk as a good source
store, as multiparous women tend to have greater menstrual of iron, and forty-seven women (39.5 %) have reported
losses that increase with parity. Additionally, although the regular drinking of milk. This reflect a widely spread
differences are not statistically significant, participants who believe about the importance of milk as a good nutritional
had bleeding or miscarriage events have also shown slightly source for pregnant women. It is important to note that, milk
lower levels of hemoglobin compared to those who did not could have adverse effects, because, although milk is an
experienced such conditions. These findings are of interest excellent source of most essential nutrients and minerals for
because iron deficiency is a recognized cause of miscarriage human, it is exceptionally poor in iron, and may result in
which in turn leads to depleted iron stores in the body and decreased serum ferritin levels [14,15,16].
increased risk of multiple miscarriages. However, although,
all of the participants involved in the study exhibited a
positive attitude regarding the importance of monitoring the
hemoglobin levels during pregnancy, the results of actual

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Volume 7, Issue 4, April – 2022 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
Legumes are a rich source of food proteins. Amongst month. These findings indicated the awareness and wide
various legumes, pigeon pea (Cajanuscajan) occupies an acceptance of family planning programs among the study
important place as an excellent source of proteins, population.
carbohydrates and fats and is significantly rich in trace
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ISSN No:-2456-2165
[16.] Jonathon L. Maguire, G.L., Sharmilaa Kandasamy,
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