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Risk and Prevalence of Anemia among Women Attending Public and Private Universities a
Marcelo Rodrigues Marques , Lília Maria Monteiro De Oliveira E b
c
Silva , Marcia Luiza Dos Santos Beserra Pessoa , Marcos Antônio Da d
Mota Araújo & Regilda Saraiva Dos Reis Moreira-Araújo a
c
Department of Nutrition, University of São Paulo, São Paulo, Brazil
b
Unified Teaching Center Estácio, Piauí, Brazil
c
Department of Nutrition, Federal University of Piauí, Piauí, Brazil
d
Click for updates
Municipal Health Foundation, Piauí, Brazil Published online: 15 May 2015.
To cite this article: Marcelo Rodrigues Marques, Lília Maria Monteiro De Oliveira E Silva, Marcia Luiza Dos Santos Beserra Pessoa, Marcos Antônio Da Mota Araújo & Regilda Saraiva Dos Reis Moreira-Araújo (2015): Risk and Prevalence of Anemia among Women Attending Public and Private Universities, Ecology of Food and Nutrition, DOI: 10.1080/03670244.2015.1037442 To link to this article: http://dx.doi.org/10.1080/03670244.2015.1037442
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &
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Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Ecology of Food and Nutrition, 00:1–9, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0367-0244 print/1543-5237 online DOI: 10.1080/03670244.2015.1037442
Risk and Prevalence of Anemia among Women Attending Public and Private Universities MARCELO RODRIGUES MARQUES Department of Nutrition, University of São Paulo, São Paulo, Brazil
LÍLIA MARIA MONTEIRO DE OLIVEIRA E SILVA Downloaded by [New York University] at 15:20 08 June 2015
Unified Teaching Center Estácio, Piauí, Brazil
MARCIA LUIZA DOS SANTOS BESERRA PESSOA Department of Nutrition, Federal University of Piauí, Piauí, Brazil
MARCOS ANTÔNIO DA MOTA ARAÚJO Municipal Health Foundation, Piauí, Brazil
REGILDA SARAIVA DOS REIS MOREIRA-ARAÚJO Department of Nutrition, Federal University of Piauí, Piauí, Brazil
Anemia is a global public health problem. Women are known to be more susceptible to anemia; however, no controlled study has yet assessed differences in the prevalence of anemia exclusively among women with higher education. The aim of the study was to establish the prevalence of anemia among women attending universities. The hemoglobin concentration of 140 women aged 18 to 45 years old from a private and a public university was measured. Anthropometric and socioeconomic data were also collected. The risk of developing anemia was almost threefold higher among the students attending the public university (OR: 2.71; p = .0248). The prevalence of anemia was much higher than in the overall female population (79%). The higher education was not a protective factor for anemia in women when analysed separately from the total population of women. KEYWORDS anemia, higher education, public university, women
Address correspondence to Regilda Saraiva dos Reis Moreira-Araújo, Department of Nutrition, Federal University of Piauí, S/N. Bloco 13, CEP 64049-550, Piauí, Brazil. E-mail: [email protected] 1
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Anemia is a generic term used to refer to a condition characterized by low red cell blood count or low blood hemoglobin (Hb) level. From the clinical perspective, anemia is characterized by paleness of the skin and of the mucous membranes. From the hematological perspective, the World Health Organization (WHO) defines anemia as Hb concentration < 13 g/dL (130 g/L) among men and < 12 g/dL (120 g/L) among women. Any decrease in the Hb concentration below the normal range reduces the oxygen-carrying capacity (Reithinger et al. 2013; UNICEF, United Nations University, and WHO 2001). Women are known to be more susceptible to iron deficiency anemia than men worldwide. In Brazil, the estimated prevalence of anemia is 30% among pregnant women and 30% to 42.3% among women of reproductive age. According to WHO estimates, anemia affects more than two billion people worldwide (WHO 2004). The anemia caused by iron deficiency affects people from every social class, it is closely related to poverty, low educational levels and precarious living conditions due the low intake or lack of access to food rich in iron (Ailinger et al. 2009; Ministry of Health 2008; Sato et al. 2010). Several anthropometric, socioeconomic, and biochemical factors are known to be associated with low serum Hb levels. All these also may be determinants to interfere in iron biodisponibility, including gender, educational level, income, age, body mass index (BMI), seasonality, and parasitology (Baart et al. 2011; Skjelbakken, Dahl, and Lu˛chen 2010). Nonetheless, not all anemias are caused by iron deficiency. Some studies have shown that other diets components are also risk factors for anemia when folic acid, vitamins A, B12 and C, and protein intake are inadequate (Jordão, Bernardi, and Barros Filho 2009; Price et al. 2011; Thomson et al. 2011). Furthermore, there are some genetic disorders related to hemoglobin malfunction: structural hemoglobin variants and thalassemias. The structural hemoglobin variants are the result of amino acid substitutions that culminate in physic-chemical changes in stability of the hemoglobin molecule and consequent function alterations. The thalassemias conditions result from a reduced synthesis of the hemoglobin molecule chains (α- and β- chains). These genetic disorders can cause from asymptomatic conditions to severe anemia (Karakochuk et al. 2015). Educational level is among the factors that have been investigated due to its importance on socioeconomic context of anemia prevalence, particularly in underdeveloped countries. The reason is that education is associated with ease of understanding therapeutic regimes and access to information and healthcare services and is thus considered as a protective factor (Gebremedhin and Enquselassie 2011; Thomson et al. 2011). After 90’s, Brazilian higher education system has changed from a public system to a diversified system in which the private sector has been inserted. According to the Brazilian Ministry of Education, in 2010 there were
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278 public and 2,100 private institutions in Brazil. In this actual scenario, the education is as a public asset, in which the government is the main provider or is a regulatory element. Since the tuition fees were excessive for the majority of the population in private sector, it is common an oversupply of places and people with higher family income in these institutions (INEP 2010; Strauss and Borenstein 2014). No controlled study has yet assessed the prevalence of anemia exclusively among women with higher education. The aim of this study was to investigate the prevalence of anemia among women of reproductive age attending two different institutions of higher education and to analyse possible differences between the groups.
METHODS Data and blood samples were collected at two institutions of higher education, one public and one private, at Teresina, state of Piauí, Brazil, from January to August 2010. The total number of female students in 2009 was provided by each institution. Based on those numbers, the sample calculation was carried out by statcalc pack (epi-info 6.04b software) (Dean et al. 1994) considering the expected frequency of 10%, an alpha error 5% and a 95% confidence level, the minimum sample size was estimated to be 140 participants. The recruitment of women was randomized and the participation was spontaneous. After that, the sample was characterized based on anthropometric and socioeconomic data (age, height, BMI, use of vitamin supplements, practice of physical activity, and family income) collected using a questionnaire applied at the time of collection. The questionnaire was developed based on that used by Marques (2006) for a similar study and was validated. The blood samples were collected by finger puncture from 70 (half the sample size) women aged 18 to 45 years old (reproductive age) from each institution for a total of 140 samples. The Hb level was measured using the cyanomethemoglobin method, (Hailine 1958; WHO 1968) and the absorbance was read using a CELM® spectrophotometer; anemia was defined as Hb concentration < 12 g/dL (UNICEF et al. 2001).
Ethical Issues This study was conducted according to the guidelines of the Declaration of Helsinki, and all the procedures involving human subjects were approved by the research ethics committee of Federal University of Piauí (Universidade Federal do Piauí – UFPI). The participants signed an informed consent form to comply with the guidelines for human research prescribed by Brazilian Health Ministry/National Health Council, MS/CNS resolution no. 196, from October 10, 1996 (Brasil 1996).
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Data Analysis The data resulting from the collections and biochemical testing were subjected to statistical analysis using the SPSS software (SPSS1998). Bartlett’s test was used to assess the population’s homogeneity. Pearson’s Chi-square and Student’s t-test were used to compare means (Ebrahim and Sullivan 1995). The results of logistic regression analysis were expressed as odds ratios (OR). The significance level was set to 5% and the confidence interval to 95% in all the analyses.
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RESULTS Bartlett’s test was used to assess the homogeneity of variance among the participants. The result of the Chi-square test was 3.89, p = .678, indicating that the groups were homogeneous. Table 1 describes the sample characteristics for each institution. The participants’ mean age, body weight, and height did not differ between the two institutions. Approximately 28.6% of the students at the private institution reported being physically active versus 18.6% of those attending the public institution; this difference was not statistically significant. However, it is worth noting that 76.4% of the studied population reported not performing physical activity on a regular basis and that walking (97%) was the predominant form of activity, with a frequency of approximately 4 days/week. The participants’ nutritional status was assessed based on BMI; our findings showed that the vast majority of the participants had normal weight (greater than 75%). Overall, the nutritional status of the participants from the two institutions was similar, as indicated by the lack of a statistically significant difference (p = .128). The participants were asked about the use of vitamin supplements with iron, and most participants reported not using any such supplement. The mean Hb level was approximately 10.8 g/dL for the sample as a whole; TABLE 1 Characterization of the study population at each educational institution (mean ± SD) Characteristics Age (y) Weight (Kg) Height (m) Physically active (n◦ ) Iron supplementation (%) Mean Hb (g/dL)
Public institution (n = 70)
Private institution (n = 70)
Statistics
23.3 ± 7.4 58.8 ± 10.3 1.6 ± 0.1 20 5.7 10.4 ± 1.1
23.4 ± 5.9 58.7 ± 7.6 1.59 ± 0.1 13 11.4 11.3 ± 1.0
t = 0.30, p = .968 t = 0.80, p = .993 t = 0.53, p = .596 χ2 = 1.94, p = .163 t = 6.63, p = .001 t = 6.63, p = .001
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Anemia among Women with Higher Education TABLE 2 Distribution and risk for anemia by institution and income Distribution of anemia in institutions (%) Public Private ≤ 3 (MW∗ ) > 3 (MW)
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∗
78.4 64.4 Anemia according family income (%) 37.8 62.2
Odds ratio
Confidence interval
z
p
2.71
1.13–6.47
2.24
.0248
1.91
0.75–4.86
1.362
.173
MW = minimum wage = R$ 510.00.
however, a statistically significant difference was found upon separate analysis per institution. The family income was over the equivalent of three times the value of the minimum wage in 65% of the study population; most of that proportion corresponded to the students attending the private institution (90%), and the difference between institutions was statistically significant (χ2 = 38.4, p = .001). The prevalence of anemia in the overall sample was 79.2% (n = 111). According to the prediction model used, attending the public institution was associated with an almost threefold higher risk for susceptibility to anemia. Approximately 62.2% of the women who reported a family income higher than the equivalent of three times the value of the minimum wage exhibited anemia; thus, the risk of anemia was not inversely correlated with family income (table 2).
DISCUSSION The anthropometric and socioeconomic data were similar in the students from both institutions and did not exhibit any statistically significant difference, except with regard to the income profile, use of iron supplements, and prevalence of anemia. Although most of the study population was sedentary, they exhibited normal weight based on BMI. The differences in the mean Hb concentration and in the prevalence of anemia between the students from the two institutions might be related to the use of iron supplements. However, despite the use of supplements, the prevalence of anemia observed was high relative to the Brazilian female population (Batista Filho, Souza, and Bressani 2008; Sato et al. 2010). One further relevant finding was that in the particular population assessed, characterised by a high educational level, the family income did not behave as a significant factor with regard to anemia. The prediction models of risk for anemia in women used in previous studies suggest that even an educational level as low as having attended
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elementary school promotes reduction of the risk for anemia, especially among poor females. Similarly, although a high educational level does not reduce the prevalence of anemia among wealthy people, it behaves as a protective factor. The reason is that women who attend formal education in turn influence a broad range of intermediate determinants such as dietary behavior, sanitary practices and access to health services and health information, among others (Gebremedhin and Enquselassie 2011; Nguyen et al. 2015; Thomson et al. 2011; Wilunda, Massawe, and Jackson 2013). This also accords with Nguyen and others that found that low education was significantly associated with an increased risk for anemia in Vietnam women. Those findings were associated with better nutritional conditions (Nguyen et al. 2015). As an innovative contribution, this study assessed the prevalence of anemia among women attending higher education separately, i.e., independently from the overall female population, in which education is a protective factor, according to previous studies (Ahmed and Al-Sumaie 2011; Gebremedhin and Enquselassie 2011; Wilunda, Massawe, and Jackson 2013). Surprisingly, the results of this study indicate that higher education was not protective against anemia. Although preliminary, this finding suggests that the risk factors described in previous studies most likely diluted the real risk to which this specific population (women with higher education) is exposed. This hypothesis might account for the high prevalence of anemia observed. In addition, cultural factors might have influenced the results. In Brazil, women with high educational levels do not usually seek care at public services, where prevention traditionally plays a central role. Because they have an income higher than the average of users of the public Unified Health System (Sistema Único de Saúde - SUS), members of this group tend to seek care at private facilities, which focus on the health–disease relationship only and are only seen when clinical symptoms of illness manifest. As anemia is mostly a subclinical condition, the results of this study might be related to the participants’ preferences regarding healthcare facilities (Maia Costa Cabral et al. 2012; Pires et al. 2013; Ribeiro et al. 2006). The public or private character of the educational institutions was related to the risk of anemia. The lack of influence of income notwithstanding, the prevalence of anemia was higher among the students attending the public institution, to wit, the ones with lower family income, for whom the susceptibility risk was almost threefold higher compared to that of the students attending the private institution. These findings are consistent with those of Long and colleagues, who found a indication that women who earned money during six months were more likely to report being able to travel alone to seek health care in West Bengal. In this context the access to health care facilities may be determinant for anemia differences (Long et al. 2013).
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As this work was a descriptive study, some limitations are deserving of discussion. The collected dataset did not allow for analysis of the effect of common causes of anemia (iron deficiency, parasitic infections, hemoglobinopathies). In addition, the very small number of institutions assessed underscores the need for further studies. The latest census of higher education in Brazil analyzed the top ten largest undergraduation courses in relation to amount of enrollment showed us that it is encouraging to assess in future studies the magnitude of these results due 55.5% of all enrolled students and 59.5% of graduates were women (INEP 2013). Therefore, the fact that the population segment targeted in this study is usually neglected in prevalence and prevention studies attaches extreme importance to its findings.
CONCLUSION This study is the first to report that higher education is not a protective factor for anemia in women when analysed separately from the total population of women. Moreover, the risk and prevalence of anemia in female students of reproductive age is higher in a Brazilian public university than in a private university. The findings of this study suggest that this population should be assessed separately, and epidemiological studies are required for confirmation.
ACKNOWLEDGMENTS Marcelo Marques thanks the Brazilian Research Foundation (CNPq) for its scholarship.
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Brasil, C. N. S. 1996. National Health Council Resolution 196/96 – Guidelines and norms regulating research with human beings. [In Portuguese.] http:// www.bioetica.ufrgs.br/res19696.htm. Dean, A. G., J. A. Dean, D. Coulombier, K. A. Brendel, D. C. Smith, A. H. Burton, R. C. Dicker, et al. 1994. Epi Info, Version 6: A word processing, database, and statistics program for epidemiology on microcomputers. Atlanta, GA: Centers for Disease Control and Prevention. Ebrahim, G. J., and K. R. Sullivan. 1995. Mother and child health research methods. London: Book-Aid. Gebremedhin, S., and F. Enquselassie. 2011. Correlates of anemia among women of reproductive age in Ethiopia: Evidence from Ethiopian DHS 2005. Ethiopian Journal of Health Development 25 (1): 22–30. Hailine, A. 1958. Standard methods of clinical chemistry. New York: Academic Press. INEP - National Institute of Educational Research. 2010. Census of higher education 2010 technical summary. http://download.inep.gov.br/informacoes_estatisticas/ 2010/sinopses_estatisticas_ed_superior/sinopse_educacao_superior_2010_2.zip (accessed January 19, 2015). INEP - National Institute of Educational Research. 2013. Census of higher education 2013 technical summary. http://download.inep.gov.br/informacoes_estatisticas/ sinopses_estatisticas/sinopses_educacao_superior/sinopse_educacao_superior_ 2013.zip (accessed February 19, 2015). Jordão, R. E., J. L. D. Bernardi, and A. de Azevedo Barros Filho. 2009. Iron deficiency anemia prevalence in Brazil: A systematic review. [In Portuguese.] Revista Paulista de Pediatria 27 (1): 90–98. doi.org/10.1590/S0103-05822009000100014. Karakochuk, C. D., K. C. Whitfield, S. I. Barr, Y. Lamers, A. M. Devlin, S. M. Vercauteren, H. Kroeun, et al. 2015. Genetic hemoglobin disorders rather than iron deficiency are a major predictor of hemoglobin concentration in women of reproductive age in rural Prey Veng, Cambodia. The Journal of Nutrition 145 (1): 134–142. doi:10.3945/jn.114.198945. Long, K., L. Gren, C. Rees, J. West, P. Cougar Hall, B. Gray, and B. Crookston. 2013. Determinants of better health: A cross-sectional assessment of positive deviants among women in West Bengal. BMC Public Health 13 (1): 372. Maia Costa Cabral, D., H. A. Martins, B. E. Sawaya Botelho, and B. J. R. de Mello. 2012. A study of patient partnership at a primary health care unit in São Paulo city. [In Portuguese.] Revista de APS 15 (3): 238–244. Marques, E. A. 2006. Iron deficiency anemia and its relation to food intake, parasitosis and anthropometry in preschool de Caxias. Master in Health Sciences thesis, Universidade Federal do Piauí. Ministry of Health. 2008. National demographic and health survey of children and women: End report. São Paulo: Government of Brazil, Ministry of Health. Nguyen, P. H., I. Gonzalez-Casanova, H. Nguyen, H. Pham, T. V. Truong, S. Nguyen, R. Martorell, et al. 2015. Multicausal etiology of anemia among women of reproductive age in Vietnam. European Journal of Clinical Nutrition 69 (1): 107–113. doi:10.1038/ejcn.2014.181. Pires, M., R. Gomes Maia, L. Bernarda Donato Göttems, T. Vilela Cupertino, L. Simões Leite, L. Ribeiro do Vale, M. Augusto de Castro, et al. 2013. The use of primary
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care and emergency services in sus Belo Horizonte: Health problem, procedures and choice of services. [In Portuguese.] Saúde e Sociedade 22:211–222. Price, E. A., R. Mehra, T. H. Holmes, and S. L. Schrier. 2011. Anemia in older persons: Etiology and evaluation. Blood Cells, Molecules, and Diseases 46:159–165. Reithinger, R., J. M. Ngondi, P. M. Graves, J. Hwang, A. Getachew, D. Jima, and Group Ethiopia Malaria Indicator Survey Working. 2013. Risk factors for anemia in children under 6 years of age in Ethiopia: Analysis of the data from the cross-sectional Malaria Indicator Survey, 2007. Transactions of the Royal Society of Tropical Medicine and Hygiene 107 (12): 769–776. doi:10.1093/trstmh/trt096. Ribeiro, M., C. Sampaio de Almeida, R. Barradas Barata, M. Furquim de Almeida, and Z. Pereira da Silva. 2006. Sociodemographic characteristics and pattern of use of health services for users and non-users of SUS - 2003 PNAD. [In Portuguese.] Ciência & Saúde Coletiva 11:1011–1022. Sato, A., P. Sayuri, E. Fujimori, S. Cornbluth Szarfarc, A. L. Vilela Borges, and M. A. Tsunechiro. 2010. Food consumption and iron intake of pregnant women and women of reproductive age. [In Portuguese.] Revista Latino-Americana de Enfermagem 18: 247–254. doi.org/10.1590/S0104-11692010000200016. Skjelbakken, T., I. M. S. Dahl, and M. L. Lu˛chen. 2010. Changes in body mass index and smoking habits have a different impact on hemoglobin concentration in men and women: A longitudinal follow-up of the Tromsu˛ study, 1994–2002. Gender Medicine 7 (3): 230–239. SPSS. 1998. SPSS for Windows professional and advanced statistics, release 8.0. Chicago: SPSS Inc. Strauss, L. M., and D. Borenstein. 2014. A system dynamics model for longterm planning of the undergraduate education in Brazil. Higher Education 69:375–397. Thomson, C. A., J. D. Stanaway, M. L. Neuhouser, L. G. Snetselaar, M. L. Stefanick, L. Arendell, and Z. Chen. 2011. Nutrient intake and anemia risk in the Women’s Health Initiative Observational Study. Journal of the American Dietetic Association 111 (4): 532–541. doi:10.1016/j.jada.2011.01.017. UNICEF, United Nations University, and WHO. 2001. Iron deficiency anemia: Assessment, prevention, and control: A guide for program managers. Geneva: World Health Organization. WHO. 1968. Nutritional anemias. Technical Report Series No 405. Geneva: World Health Organization. WHO. 2001. United Nations University/UNICEF. Iron deficiency anaemia, assessment, prevention and control: A guide for programme managers. Geneva: World Health Organization. WHO. 2004. Focusing on anemia: Towards an integrated approach for effective anemia control. Geneva: World Health Organization. Wilunda, C., S. Massawe, and C. Jackson. 2013. Determinants of moderate-tosevere anemia among women of reproductive age in Tanzania: Analysis of data from the 2010 Tanzania Demographic and Health Survey. Tropical Medicine & International Health 18 (12): 1488–1497.
Ecology of Food and Nutrition Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/gefn20
Risk and Prevalence of Anemia among Women Attending Public and Private Universities a
Marcelo Rodrigues Marques , Lília Maria Monteiro De Oliveira E b
c
Silva , Marcia Luiza Dos Santos Beserra Pessoa , Marcos Antônio Da d
Mota Araújo & Regilda Saraiva Dos Reis Moreira-Araújo a
c
Department of Nutrition, University of São Paulo, São Paulo, Brazil
b
Unified Teaching Center Estácio, Piauí, Brazil
c
Department of Nutrition, Federal University of Piauí, Piauí, Brazil
d
Click for updates
Municipal Health Foundation, Piauí, Brazil Published online: 15 May 2015.
To cite this article: Marcelo Rodrigues Marques, Lília Maria Monteiro De Oliveira E Silva, Marcia Luiza Dos Santos Beserra Pessoa, Marcos Antônio Da Mota Araújo & Regilda Saraiva Dos Reis Moreira-Araújo (2015): Risk and Prevalence of Anemia among Women Attending Public and Private Universities, Ecology of Food and Nutrition, DOI: 10.1080/03670244.2015.1037442 To link to this article: http://dx.doi.org/10.1080/03670244.2015.1037442
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &
Downloaded by [New York University] at 15:20 08 June 2015
Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Ecology of Food and Nutrition, 00:1–9, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0367-0244 print/1543-5237 online DOI: 10.1080/03670244.2015.1037442
Risk and Prevalence of Anemia among Women Attending Public and Private Universities MARCELO RODRIGUES MARQUES Department of Nutrition, University of São Paulo, São Paulo, Brazil
LÍLIA MARIA MONTEIRO DE OLIVEIRA E SILVA Downloaded by [New York University] at 15:20 08 June 2015
Unified Teaching Center Estácio, Piauí, Brazil
MARCIA LUIZA DOS SANTOS BESERRA PESSOA Department of Nutrition, Federal University of Piauí, Piauí, Brazil
MARCOS ANTÔNIO DA MOTA ARAÚJO Municipal Health Foundation, Piauí, Brazil
REGILDA SARAIVA DOS REIS MOREIRA-ARAÚJO Department of Nutrition, Federal University of Piauí, Piauí, Brazil
Anemia is a global public health problem. Women are known to be more susceptible to anemia; however, no controlled study has yet assessed differences in the prevalence of anemia exclusively among women with higher education. The aim of the study was to establish the prevalence of anemia among women attending universities. The hemoglobin concentration of 140 women aged 18 to 45 years old from a private and a public university was measured. Anthropometric and socioeconomic data were also collected. The risk of developing anemia was almost threefold higher among the students attending the public university (OR: 2.71; p = .0248). The prevalence of anemia was much higher than in the overall female population (79%). The higher education was not a protective factor for anemia in women when analysed separately from the total population of women. KEYWORDS anemia, higher education, public university, women
Address correspondence to Regilda Saraiva dos Reis Moreira-Araújo, Department of Nutrition, Federal University of Piauí, S/N. Bloco 13, CEP 64049-550, Piauí, Brazil. E-mail: [email protected] 1
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Anemia is a generic term used to refer to a condition characterized by low red cell blood count or low blood hemoglobin (Hb) level. From the clinical perspective, anemia is characterized by paleness of the skin and of the mucous membranes. From the hematological perspective, the World Health Organization (WHO) defines anemia as Hb concentration < 13 g/dL (130 g/L) among men and < 12 g/dL (120 g/L) among women. Any decrease in the Hb concentration below the normal range reduces the oxygen-carrying capacity (Reithinger et al. 2013; UNICEF, United Nations University, and WHO 2001). Women are known to be more susceptible to iron deficiency anemia than men worldwide. In Brazil, the estimated prevalence of anemia is 30% among pregnant women and 30% to 42.3% among women of reproductive age. According to WHO estimates, anemia affects more than two billion people worldwide (WHO 2004). The anemia caused by iron deficiency affects people from every social class, it is closely related to poverty, low educational levels and precarious living conditions due the low intake or lack of access to food rich in iron (Ailinger et al. 2009; Ministry of Health 2008; Sato et al. 2010). Several anthropometric, socioeconomic, and biochemical factors are known to be associated with low serum Hb levels. All these also may be determinants to interfere in iron biodisponibility, including gender, educational level, income, age, body mass index (BMI), seasonality, and parasitology (Baart et al. 2011; Skjelbakken, Dahl, and Lu˛chen 2010). Nonetheless, not all anemias are caused by iron deficiency. Some studies have shown that other diets components are also risk factors for anemia when folic acid, vitamins A, B12 and C, and protein intake are inadequate (Jordão, Bernardi, and Barros Filho 2009; Price et al. 2011; Thomson et al. 2011). Furthermore, there are some genetic disorders related to hemoglobin malfunction: structural hemoglobin variants and thalassemias. The structural hemoglobin variants are the result of amino acid substitutions that culminate in physic-chemical changes in stability of the hemoglobin molecule and consequent function alterations. The thalassemias conditions result from a reduced synthesis of the hemoglobin molecule chains (α- and β- chains). These genetic disorders can cause from asymptomatic conditions to severe anemia (Karakochuk et al. 2015). Educational level is among the factors that have been investigated due to its importance on socioeconomic context of anemia prevalence, particularly in underdeveloped countries. The reason is that education is associated with ease of understanding therapeutic regimes and access to information and healthcare services and is thus considered as a protective factor (Gebremedhin and Enquselassie 2011; Thomson et al. 2011). After 90’s, Brazilian higher education system has changed from a public system to a diversified system in which the private sector has been inserted. According to the Brazilian Ministry of Education, in 2010 there were
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278 public and 2,100 private institutions in Brazil. In this actual scenario, the education is as a public asset, in which the government is the main provider or is a regulatory element. Since the tuition fees were excessive for the majority of the population in private sector, it is common an oversupply of places and people with higher family income in these institutions (INEP 2010; Strauss and Borenstein 2014). No controlled study has yet assessed the prevalence of anemia exclusively among women with higher education. The aim of this study was to investigate the prevalence of anemia among women of reproductive age attending two different institutions of higher education and to analyse possible differences between the groups.
METHODS Data and blood samples were collected at two institutions of higher education, one public and one private, at Teresina, state of Piauí, Brazil, from January to August 2010. The total number of female students in 2009 was provided by each institution. Based on those numbers, the sample calculation was carried out by statcalc pack (epi-info 6.04b software) (Dean et al. 1994) considering the expected frequency of 10%, an alpha error 5% and a 95% confidence level, the minimum sample size was estimated to be 140 participants. The recruitment of women was randomized and the participation was spontaneous. After that, the sample was characterized based on anthropometric and socioeconomic data (age, height, BMI, use of vitamin supplements, practice of physical activity, and family income) collected using a questionnaire applied at the time of collection. The questionnaire was developed based on that used by Marques (2006) for a similar study and was validated. The blood samples were collected by finger puncture from 70 (half the sample size) women aged 18 to 45 years old (reproductive age) from each institution for a total of 140 samples. The Hb level was measured using the cyanomethemoglobin method, (Hailine 1958; WHO 1968) and the absorbance was read using a CELM® spectrophotometer; anemia was defined as Hb concentration < 12 g/dL (UNICEF et al. 2001).
Ethical Issues This study was conducted according to the guidelines of the Declaration of Helsinki, and all the procedures involving human subjects were approved by the research ethics committee of Federal University of Piauí (Universidade Federal do Piauí – UFPI). The participants signed an informed consent form to comply with the guidelines for human research prescribed by Brazilian Health Ministry/National Health Council, MS/CNS resolution no. 196, from October 10, 1996 (Brasil 1996).
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Data Analysis The data resulting from the collections and biochemical testing were subjected to statistical analysis using the SPSS software (SPSS1998). Bartlett’s test was used to assess the population’s homogeneity. Pearson’s Chi-square and Student’s t-test were used to compare means (Ebrahim and Sullivan 1995). The results of logistic regression analysis were expressed as odds ratios (OR). The significance level was set to 5% and the confidence interval to 95% in all the analyses.
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RESULTS Bartlett’s test was used to assess the homogeneity of variance among the participants. The result of the Chi-square test was 3.89, p = .678, indicating that the groups were homogeneous. Table 1 describes the sample characteristics for each institution. The participants’ mean age, body weight, and height did not differ between the two institutions. Approximately 28.6% of the students at the private institution reported being physically active versus 18.6% of those attending the public institution; this difference was not statistically significant. However, it is worth noting that 76.4% of the studied population reported not performing physical activity on a regular basis and that walking (97%) was the predominant form of activity, with a frequency of approximately 4 days/week. The participants’ nutritional status was assessed based on BMI; our findings showed that the vast majority of the participants had normal weight (greater than 75%). Overall, the nutritional status of the participants from the two institutions was similar, as indicated by the lack of a statistically significant difference (p = .128). The participants were asked about the use of vitamin supplements with iron, and most participants reported not using any such supplement. The mean Hb level was approximately 10.8 g/dL for the sample as a whole; TABLE 1 Characterization of the study population at each educational institution (mean ± SD) Characteristics Age (y) Weight (Kg) Height (m) Physically active (n◦ ) Iron supplementation (%) Mean Hb (g/dL)
Public institution (n = 70)
Private institution (n = 70)
Statistics
23.3 ± 7.4 58.8 ± 10.3 1.6 ± 0.1 20 5.7 10.4 ± 1.1
23.4 ± 5.9 58.7 ± 7.6 1.59 ± 0.1 13 11.4 11.3 ± 1.0
t = 0.30, p = .968 t = 0.80, p = .993 t = 0.53, p = .596 χ2 = 1.94, p = .163 t = 6.63, p = .001 t = 6.63, p = .001
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Anemia among Women with Higher Education TABLE 2 Distribution and risk for anemia by institution and income Distribution of anemia in institutions (%) Public Private ≤ 3 (MW∗ ) > 3 (MW)
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∗
78.4 64.4 Anemia according family income (%) 37.8 62.2
Odds ratio
Confidence interval
z
p
2.71
1.13–6.47
2.24
.0248
1.91
0.75–4.86
1.362
.173
MW = minimum wage = R$ 510.00.
however, a statistically significant difference was found upon separate analysis per institution. The family income was over the equivalent of three times the value of the minimum wage in 65% of the study population; most of that proportion corresponded to the students attending the private institution (90%), and the difference between institutions was statistically significant (χ2 = 38.4, p = .001). The prevalence of anemia in the overall sample was 79.2% (n = 111). According to the prediction model used, attending the public institution was associated with an almost threefold higher risk for susceptibility to anemia. Approximately 62.2% of the women who reported a family income higher than the equivalent of three times the value of the minimum wage exhibited anemia; thus, the risk of anemia was not inversely correlated with family income (table 2).
DISCUSSION The anthropometric and socioeconomic data were similar in the students from both institutions and did not exhibit any statistically significant difference, except with regard to the income profile, use of iron supplements, and prevalence of anemia. Although most of the study population was sedentary, they exhibited normal weight based on BMI. The differences in the mean Hb concentration and in the prevalence of anemia between the students from the two institutions might be related to the use of iron supplements. However, despite the use of supplements, the prevalence of anemia observed was high relative to the Brazilian female population (Batista Filho, Souza, and Bressani 2008; Sato et al. 2010). One further relevant finding was that in the particular population assessed, characterised by a high educational level, the family income did not behave as a significant factor with regard to anemia. The prediction models of risk for anemia in women used in previous studies suggest that even an educational level as low as having attended
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elementary school promotes reduction of the risk for anemia, especially among poor females. Similarly, although a high educational level does not reduce the prevalence of anemia among wealthy people, it behaves as a protective factor. The reason is that women who attend formal education in turn influence a broad range of intermediate determinants such as dietary behavior, sanitary practices and access to health services and health information, among others (Gebremedhin and Enquselassie 2011; Nguyen et al. 2015; Thomson et al. 2011; Wilunda, Massawe, and Jackson 2013). This also accords with Nguyen and others that found that low education was significantly associated with an increased risk for anemia in Vietnam women. Those findings were associated with better nutritional conditions (Nguyen et al. 2015). As an innovative contribution, this study assessed the prevalence of anemia among women attending higher education separately, i.e., independently from the overall female population, in which education is a protective factor, according to previous studies (Ahmed and Al-Sumaie 2011; Gebremedhin and Enquselassie 2011; Wilunda, Massawe, and Jackson 2013). Surprisingly, the results of this study indicate that higher education was not protective against anemia. Although preliminary, this finding suggests that the risk factors described in previous studies most likely diluted the real risk to which this specific population (women with higher education) is exposed. This hypothesis might account for the high prevalence of anemia observed. In addition, cultural factors might have influenced the results. In Brazil, women with high educational levels do not usually seek care at public services, where prevention traditionally plays a central role. Because they have an income higher than the average of users of the public Unified Health System (Sistema Único de Saúde - SUS), members of this group tend to seek care at private facilities, which focus on the health–disease relationship only and are only seen when clinical symptoms of illness manifest. As anemia is mostly a subclinical condition, the results of this study might be related to the participants’ preferences regarding healthcare facilities (Maia Costa Cabral et al. 2012; Pires et al. 2013; Ribeiro et al. 2006). The public or private character of the educational institutions was related to the risk of anemia. The lack of influence of income notwithstanding, the prevalence of anemia was higher among the students attending the public institution, to wit, the ones with lower family income, for whom the susceptibility risk was almost threefold higher compared to that of the students attending the private institution. These findings are consistent with those of Long and colleagues, who found a indication that women who earned money during six months were more likely to report being able to travel alone to seek health care in West Bengal. In this context the access to health care facilities may be determinant for anemia differences (Long et al. 2013).
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As this work was a descriptive study, some limitations are deserving of discussion. The collected dataset did not allow for analysis of the effect of common causes of anemia (iron deficiency, parasitic infections, hemoglobinopathies). In addition, the very small number of institutions assessed underscores the need for further studies. The latest census of higher education in Brazil analyzed the top ten largest undergraduation courses in relation to amount of enrollment showed us that it is encouraging to assess in future studies the magnitude of these results due 55.5% of all enrolled students and 59.5% of graduates were women (INEP 2013). Therefore, the fact that the population segment targeted in this study is usually neglected in prevalence and prevention studies attaches extreme importance to its findings.
CONCLUSION This study is the first to report that higher education is not a protective factor for anemia in women when analysed separately from the total population of women. Moreover, the risk and prevalence of anemia in female students of reproductive age is higher in a Brazilian public university than in a private university. The findings of this study suggest that this population should be assessed separately, and epidemiological studies are required for confirmation.
ACKNOWLEDGMENTS Marcelo Marques thanks the Brazilian Research Foundation (CNPq) for its scholarship.
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