|Year : 2014 | Volume
| Issue : 2 | Page : 120-124
Prevalence of anemia among tribal women of reproductive age-group in Wayanad district of Kerala
BM Shrinivasa1, Rekha Rachel Philip2, Vijaya Kumar Krishnapali3, Asha Suraj3, PR Sreelakshmi3
1 Department of Community Medicine, Jagadguru Sri Shivarathreeswara Medical College, Mysore, Karnataka, India
2 Department of Community Medicine,Amrita Institute of Medical Sciences, Kochi, Kerala, India
3 Department of Community Medicine, Government Medical College, Trivandrum, Kerala, India
|Date of Web Publication||19-May-2014|
B M Shrinivasa
Department of Community Medicine, Jagadguru Sri Shivarathreeswara Medical College, Mysore 580 004, Karnataka
Source of Support: None, Conflict of Interest: None
Context: Nutritional anemia is a major public health problem of women in India. Kerala has good health indicators in comparison to other states of India. However, the health of tribals, one of the marginalized communities, of the state is poor. Aims: Primary objective of the study was to estimate the prevalence of anemia among tribal women of 15-45 years of age of Wayanad District. Settings and Design: A cross-sectional survey in 10 clusters of Wayanad district of Kerala. Subjects and Methods: A cross-sectional survey was done among a sample of 347 tribal nonpregnant, non-lactating women aged between 15-45 years in 10 clusters of Wayanad on the basis of probability proportional to size in 2010. Anemia was diagnosed by estimating the hemoglobin concentration in the blood with the use of direct cyanmethemoglobin method. Results: The mean hemoglobin of the study group was 9.04 gm% (Standard deviation (SD) 1.64) and coefficient of variance is 18.14%. Prevalence of anemia was found to be 96.5% (n = 335) (Standard error = 0.986 and 95% confidence interval, CI, 94.53, 98.47). Mild anemia (Hemoglobin = 10-11.9 gm%) was found to be 30.5%. About (55.9%) had moderate degree anemia (Hb 7-9.9 gm%). Prevalence of severe anemia (<7 gm%) was found to be 10.1%. Conclusions: Prevalence of anemia was substantially high among women of reproductive age group of Wayanad.
Keywords: Anemia, hemoglobin, tribal women
|How to cite this article:|
Shrinivasa B M, Philip RR, Krishnapali VK, Suraj A, Sreelakshmi P R. Prevalence of anemia among tribal women of reproductive age-group in Wayanad district of Kerala. Int J Health Allied Sci 2014;3:120-4
|How to cite this URL:|
Shrinivasa B M, Philip RR, Krishnapali VK, Suraj A, Sreelakshmi P R. Prevalence of anemia among tribal women of reproductive age-group in Wayanad district of Kerala. Int J Health Allied Sci [serial online] 2014 [cited 2020 Mar 29];3:120-4. Available from: http://www.ijhas.in/text.asp?2014/3/2/120/132699
| Introduction|| |
Anemia is a major public health problem among women in India especially in the rural and tribal belt.  Studies have shown that the tribal women, due to certain adverse realities like insufficient food intake, frequent infections, lack of access to health services, illiteracy, unhygienic personal habits, and adverse cultural practices, have varying degrees of nutrition and health status. ,,,
Diets of South Indian tribes, in general, and Kerala, in particular, are deficient in calories and total protein. They depend on their agricultural produce because of which they often face uncertainty of food supply and thus tend to suffer from undernutrition. In addition, lack of proper health and educational facilities, and prevalence of certain belief systems, in respect of health and nutrition aggravate the situation. Anemia is a major cause of high incidence of premature births, low birth weight, perinatal mortality, and maternal mortality. Though Kerala is often modeled for its good health indicators with the lowest maternal mortality ratio of the nation, there exists hidden morbidities among its marginalized community, which needs to be brought to light for planning appropriate nutritional interventions. The recent infant deaths in the tribal belt of Attappadi region in Kerala highlight the need for effective public health interventions. Hence, the primary aim of this study was to estimate the prevalence of anemia among tribal women of 15-45 years of age of Wayanad district and the secondary aim was to study the determinants of anemia among tribal women aged between 15 and 45 years.
| Subjects and Methods|| |
A cross-sectional survey was conducted in Wayanad district, which has the largest tribal population in Kerala. One-third of the state's tribal population resides here. Tribal women between 15-45 years of age were the study subjects. We excluded women with chronic debilitating disease, pregnant women, and those diagnosed with sickle cell anemia (complete enumeration and identification of such cases have been done by Indian Council of Medical Research, ICMR, project). The native adivasis mainly consist of various sects like Paniyas, Kurumas, Adiyars, Kurichyas, Ooralis, Kattunaikkans, etc.
The sample size was estimated to be 162 for 80% power and 5% significance level, assuming the prevalence of anemia to be 38%.  Assuming an intracluster correlation coefficient (ICC) of 0.02 (Epi Info version. 6 tables for community survey) and cluster size (m) of 50, design effect was found to be 1.98; hence, final sample size was 321. Assuming a nonresponse rate of 10%, the final sample size was 353. Ten clusters were selected (randomly) from total of 26 by probability proportionate to size technique. The smallest administrative unit, panchayat/municipality was chosen as the cluster. Wayanad district has 25 panchayats and one municipality. All tribal women in the age group of 15-45 years who were nonpregnant and non-lactating were included in the study.
Approval of the chairperson of tribal community development society of each of the 10 panchayats and written informed consent from each of the study participant was obtained. The study was approved by the Ethics Committee of Government Medical College Thiruvananthapuram.
Data on sociocultural practices, obstetric history, utilization of Angan Wadi Centre, and special services for tribes, food frequency of different food groups was collected from the women by structured pretested questionnaire which was administered in local language (Malayalam) in August 2010. Height was measured to the nearest 0.1 cm using a standardized anthropometric rod. Weight was measured to the nearest 0.1kg using OMRON digital weighing scale which was standardized and calibrated before data collection. The methods used were according to the National Health and Nutrition Examination Survey, 2009 revised guidelines of Centers for Disease Control (CDC), Atlanta. The women were explained about the procedure before each measurement. Hemoglobin was measured using Drabkin's cyanmethemoglobin method by a single trained laboratory technician.
Primary outcome variables in the analysis were created from hemoglobin measurements. We classified women as mildly, moderately, or severely anemic based upon their hemoglobin status and World Health Organization (WHO) classification. A hemoglobin concentration of less than 7 g/l was used to define severe anemia, 7-9.9 g/l for moderate anemia and 10-12 g/l for mild anemia. Linear regression was used for building prediction model for hemoglobin. Food habits were recorded based on 1-week food frequency table. The information was subclassified into three groups as: Never used in a week, at least once a week, and daily. The data were analyzed using Statistical Package for the Social Sciences (SPSS) version 16 software.
| Results|| |
The mean age of women in this study was 26.32 years (SD 5.77). Majority of the women had only primary-level education. Daily wagers constituted 42.9% of the study group. Habit of pan chewing was present in 66.9% (n = 232) of women. Out of them, 59.5% (n = 138) chew pan at least once a day. About 52.6% of women were having this habit for more than 5 years. Mean age of menarche was 12 years (SD 4.85) [Table 1].
Rice was evidently the staple food (99%) and consumed it daily. About 311 (89.6%) women consumed fruits at least once a week or daily. Fish was the preferred animal food among majority of the tribal women 88.2% (306). About 85.9% of women had consumed iron and folic acid which was provided for them. Only 10.4% of them were taking the supplementary nutrition [Table 2]. No association could be made out between nutrition and anemia.
The mean height of study subjects were 150.7 cm (SD 5.16). The mean weight of study subjects was 42.1 kg (SD 6.7). In the present study, 53.6% of the tribal women were found to be underweight. The mean Hb% of the study group was 9.04 gm% (SD 1.6) [Table 3]. Prevalence of anemia was found to be 96.5% (95% CI 94.5, 98.5). More than half of the study participants (55.9%) were found to be moderately anemic [Table 4]. Half of anemic were in age-group 15-25 Years. Sixty-nine percent of the women who were anemic had their pregnancy when they were less than 20 years old [Table 1] and [Table 5]. One-fourth of the tribal women who had their first pregnancy below 18 years of age were currently anemic. The prevalence of anemia was 43.3% among those who had their first pregnancy at 18-20 years of age. Taking hemoglobin as dependent variable, all other variables in study group was put into linear regression model. After taking out nonsignificant variables from the model sequentially, five variables remained significant (P < 0.05) and those are education status of women, habit of pan chewing, age at menarche, number of living children, and body mass index [Table 6].
| Discussion|| |
Estimation of hemoglobin of a sample of 347 tribal women suggests a very high prevalence of anemia in the tribal women when compared to women general population of Kerala (32.7%) and the tribal women of Kerala (51.9%).  The reason for this high prevalence could be varied. In nonpregnant women, WHO suggests 12 gm% of hemoglobin to be taken as cut off for diagnosing anemia. The mean Hb of this study sample was 9.6 gm%. Whether the WHO cut off can be applied to this ethnic group needs to be studied. However, the prevalence of anemia alone can give only a very rough estimate of the likely prevalence of iron deficiency anemia.  Nutritional iron deficiency anemia is a mild anemia because iron loss is reduced to some extent in iron deficiency. While the prevalence of mild anemia was lesser in our study compared to tribals in Kerala, more than half of our study participants had moderate degree anemia, which was higher than tribals as reported in NFHS 3. However, the most striking revelation of our study was the high prevalence of severe anemia among tribal women compared to 0.4% among other women of the state.
We estimated hemoglobin level using direct cyanmethemoglobin method, considered as the gold standard unlike NFHS 3, which used improved HemoCue Hb 201+ analyzer. Higher estimates of hemoglobin concentration is given by HemoCue method and thus tends to underestimate the prevalence of anemia. ,
Since the prevalence of anemia is very high (96.5%) in our study, variability of anemia cannot be explained statistically. So, linear regression taking hemoglobin as outcome variable was used to explain the variability. Prevalence of anemia seemed to be highest among tribal women aged between 15-25 years. However, among general population of Kerala, it was found in 20-29 years age-group. The higher prevalence of anemia among lower age-group in the present study could be due to several reasons. There is a possibility of pregnancy at earlier ages than other women of state. The high prevalence of severe anemia could be due to uncorrected anemia in successive pregnancies. Studies indicate that two-thirds of the maternal deaths occur among women in the age-group 20-30 years and anemia contributes to 19% of maternal deaths in India.  Studies have indicated that in combination with obstetric hemorrhage, anemia is estimated to be responsible for 17-46% of cases of maternal deaths. ,, The present study showed 10% difference in prevalence of anemia with respect to primary and secondary education status of women. This was supported by linear regression model for hemoglobin level which suggested that increase in education status increases hemoglobin level (P = 0.02).
The low socioeconomic status (SES) of tribal women force them to work in low-income jobs, resulting in poor purchasing power, hence low quality diet, undernutrition, and anemia. The present study revealed that 49.9% of anemic tribal women have no economic activity. Almost half (44.2%) of the women engaged in unskilled work are anemic. Previous studies say that only 9% of women employed in high-income jobs are anemic. 
In our study, tribal women showed increase in prevalence of anemia with increase in the number of pregnancies. Furthermore, 46% of severe anemia was seen among women who had three or more children. Murty et al. has reported high fertility as a common factor for anemia among tribal population of India.  Repeated pregnancies depletes a woman of her iron stores and hence decreased hemoglobin level. Besides high fertility, the interval between successive pregnancy is also associated with maternal anemia. Minimum of 2-years gap between two successive pregnancies is recommended. In our study, 33% of anemic women had birth interval less than 24 months. Successive pregnancies with short interval leads to depletion of iron stores resulting in anemia.  Study done by Shazley MK among women of reproductive age-group in Alexandria has shown that high parity and short birth intervals are risk factors of anemia.  Our study shows that contrary to public health policies, early marriage and teen pregnancy are still prevalent in tribal groups. Thus, women who became pregnant at or below 20 years constituted 69% of anemics in the study group. A study done among Chenchu tribal group of Andhra Pradesh also revealed similar results.  The prevalence of anemia was 67.5% among tribal women who chewed pan compared to 32.5% among those who do not chew pan. With the absence of this habit, hemoglobin is found to increase in linear regression (P = 0.006). Pan chewing is a socially accepted and widely prevalent habit among tribal women.
Under nutrition and anemia go hand in hand where anemia manifests itself in late stages of malnutrition. Our study revealed higher prevalence of anemia among women who are underweight [Table 2] and [Table 5]. Linear regression for hemoglobin showed that increase in BMI increased hemoglobin.
| Conclusion|| |
In conclusion, the high prevalence of moderate and severe anemia among tribal nonpregnant non-lactating women is a cause for concern. Operational research is needed on how to improve existing supplementary nutrition services. Innovative and culturally sensitive strategies targeting all tribal women are needed to improve the health and nutritional status of young girls by promoting healthy feeding habits.
| Acknowledgement|| |
The authors would like to acknowledge the District Kudumbashree Mission at Wayanad for arranging field visits and for their hospitality. Dr. Ajith, Dr. Sreelal, and Dr. Patrick helped with the data collection. We thank all our study participants for their cooperation.
| References|| |
|1.||Gopalan C. Nutritional Atlas of India. ICMR; Government of India; 1978. |
|2.||UN Report. Health Status of Women. Improving concepts and methods for statistics and indicators on the situation of women. Studies on Methods Series, F. No. 33, 1984. |
|3.||Sharma V, Sharma A. Health profile of pregnant adolescent among tribal population in Rajasthan, India. J Adolesc Health 1992;13:696-9. |
|4.||ICMR. Survey of Living Conditions of Tribals in Port Blair; Review of literature; 1990. |
|5.||Menon KC, Skeaff SA, Thomson CD, Gray AR, Ferguson EL, Zodpey S, et al. Concurrent micronutrient deficiencies are prevalent in nonpregnant rural and tribal women from central India. Department of Human Nutrition, University of Otago, Dunedin, New Zealand. |
|6.||International Institute for Population Sciences (IIPS) and Macro International. 2007. Vol. 1 India: National Family Health Survey (NFHS-3); 2005-06. |
|7.||Bothwell TH. Iron metabolism in man. Oxford: Blackwell Scientific Publications; 1979. |
|8.||Kapoor SK, Kapil U, Dwivedi SN, Anand K, Pathak P, Singh P. Comparison of HemoCue method with cyanmethemoglobin method for estimation of haemoglobin. Indian Pediatr 2002;39:743-6. |
|9.||Agarwal KN, Agarwal DK, Sharma A, Sharma K, Prasad K, Kalita MC, et al. Prevalence of anaemia in pregnant and lactating women in India. Indian J Med Res 2006;124:173-84. |
|10.||Registrar General of India (SRS 2001-2003). |
|11.||World Bank, WHO, UNFPA. Preventing the tragedy of maternal deaths. A report on the International Safe Motherhood Conference Nairobi, Kenya. Geneva: WHO; 1987. |
|12.||Harrison KA. Tropical obstetrics and gynaecology. 2. Maternal mortality. Trans R Soc Trop Med Hyg 1989;83:449-53. |
|13.||Severity of anaemia and operative mortality and morbidity. Lancet 1988;1:1392-3. |
|14.||Park K. Text book of Preventve and social medicine. 2 1st ed. 2011. |
|15.||Murty JS, Ramesh A. Selection Intensities among the tribal population of Adilabad district. Andhra Pradesh. Soc Biol 1978;25:302-5. |
|16.||el-Shazley MK, Ibrahim AG, Masoud GM. Risk factors of anemia among women in the child bearing period and preschool children in Alexandria. J Egypt Public Health Assoc 1996;71:229-41. |
|17.||Sirajuddin. Among the Chenchu tribal group of Achampet taluk of Andhra Pradesh, 1984. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]