Assessment of Knowledge, Attitude and Practice Levels Regarding Anaemia Among Pregnant Women in Putrajaya, Malaysia

MATERIALS AND METHODS

Sampling and study location: A cross-sectional study was performed at four government health clinics in Putrajaya, namely, Precinct 9, Precinct 11, Precinct 14 and Precinct 18, from September, 2016 to April, 2017. The study sample consisted of 370 pregnant women aged between 21-44 years old who visited the government health clinics in Putrajaya for the first time during the current pregnancy. The survey employed a random sampling method. The sample size calculation was performed according to the total number of new antenatal cases registered at government health clinics in Putrajaya using a 95% confidence level and 5% margin of error⁹.

Ethical approval: This study was approved by the Ministry of Health, Malaysia [Reference No. NMRR-15-2138-28447(IIR)] and the Research Ethical Committee of Universiti Kebangsaan Malaysia (Reference No. UKM PPI/111/8/JEP-2016-274). Written consent was also collected from the respondents prior to commencement of the research.

Questionnaires: The questionnaires were administered in the Malay language. A standardized questionnaire was used to collect data on the participants’ socio-demographic profiles, which included age, ethnicity, educational level, occupation and household income. Antenatal characteristics were also included in the questionnaire and comprised week of gestation, number of children and haemoglobin level. There were 19 questions on knowledge, 17 questions on attitude and 13 questions on practices related to anaemia, its common cause, signs and symptoms and treatment and prevention. Frequency analysis was calculated for each question for the knowledge, attitude and practices sections using percentages of correct versus incorrect answers in the knowledge section (true/false), positively versus negatively answered questions in the attitude (agree/disagree) and practice sections (yes/no). If an answer in the knowledge section was correct, it was scored as 1 and 0 if incorrect. Good responses in the attitude section were scored as 1 and poor responses were scored as 0. Positive answers were scored as 1 and negative answers were scored as 0 for the practice section. The overall knowledge, attitude and practice sections of the respondents were assessed using sum score outcome, which is classified into three categories: good, moderate and low. A score of 50% and below was ranked as low level, 51-69% was categorized as medium level and 70% and above was rated as a good level¹⁰. The questionnaire was piloted with 38 respondents for acceptability and consistency. The knowledge and attitude sections were developed by reviewing the literature and were tested for reliability using Cronbach’s alpha. Both the variables were measured at 0.82 and 0.72, respectively, indicating an acceptable internal consistency of the scale item¹¹. The developed practice section from the literature review was tested for reliability using the Kuder-Richardson Formula 20 (KR20) and measured 0.80, which is in the acceptable range¹². As the consistency and validity of the study questionnaire were stabilized, the instrument was made available for data collection.

Blood sampling: Trained medical personnel at the respective health clinics took the blood samples of the respondents. The Sysmex Haematology Analyser (Sysmex Europe GmbH, KX-21N^TM) was used to measure the Full Blood Count (FBC) in unit g dL^–1. Blood samples were taken from the subject's venous line in the cubital fossa (front of the elbow). The results of the analysis evaluated the status of haemoglobin, which was divided into a normal group (Hb>1 g dL^–1) and an anaemia group (Hb<11 g dL^–1).

Data analysis: All data from this study were analysed using the Statistical Package for Social Sciences (SPSS) version 23.0 (SPSS Inc., Chicago, IL, USA). Descriptive statistics, such as frequency, mean, standard deviation and percentage, were used to describe socio-demographic characteristics, antenatal characteristics and blood test values. Based on stem and leaf plot analysis, the data of the knowledge score were not normally distributed, while the attitude and practice scores were normally distributed. Therefore, both parametric tests (independent t-test and one-way ANOVA) and non-parametric tests (Mann-Whitney and Kruskal-Wallis test) were used to compare the differences between groups. Pearson correlation and Spearman's rank correlation coefficient were used to evaluate the relationship between the study variables. Statistical significance was set at p<0.05.

RESULTS AND DISCUSSION

Socio-demographic and antenatal characteristics: The socio-demographic characteristics of the study respondents are presented in Table 1. The sample population included 370 pregnant women who visited four government health clinics in Putrajaya. The majority of the respondents (38.4%) were between 31-35 years of age with a mean age of 30.2±4.2 years. The respondents in this study comprised of Malays (90.8%), Chinese (5.4%), Indians (3.2%) and other ethnic groups (0.6%). Most of the respondents were Malaysian Higher School Certificate (STPM)/diploma holders (45.1%), followed by degree holders (24.9%) and Malaysian School Certificate (SPM)/Malaysian Certificate of Education (MCE) holders (24.6%); only 5.4% held a master’s degree.

Table 1:	Socio-demographic and antenatal characteristics of study respondents (n = 370)

Since Putrajaya is a Federal Government Administrative Centre, a majority of the respondents were government employees (64.3%) and the others were housewives (17.8%) followed by private-sector employees (17.8%) and self-employed (2.2%). The household income of the respondents was divided into four categories with a mean of RM5277.2±2420.8. Most of the respondents (58.6%) had a household income between RM3001 and RM6000, followed by 19.2% with a household income below RM3000. More than half of the respondents (57.0%) were in the first trimester, while the others had a gestational week indicating the second trimester (38.1%) and third trimester (4.9%), with a mean of 15.5±6.2 weeks of gestation. The majority of the respondents (52.4%) had one to two children (with a mean of 1.4±1.2). The mean haemoglobin level was 12.1±4.8 g dL^–1 and three-fourths of the respondents were not anaemic.

Assessment of knowledge on anaemia: Table 2 describes the responses to the individual knowledge questions by the respondents.

Table 2:	Respondents responses to knowledge questions on anaemia during pregnancy (n = 370)

A total of 64 respondents (17.3%) answered all the questions of knowledge correctly and scored 19, which was equivalent to 100%. This indicates that the knowledge of those respondents in relation to anaemia was at a high level. Questions 1 and 2 pertained to the definitions of anaemia and most of the respondents were able to answer these two questions correctly, at 89.2 and 81.1%, respectively. Based on this high percentage, the respondents of this study already knew the definition of anaemia. For question 4, 67% of the respondents were under the assumption that worm infection can cause anaemia. For question 6, more than half of the respondents (51.1%) did not know that a duration in the gap between pregnancies of less than two years is among the causes of anaemia during pregnancy. In addition, there were several aspects of knowledge regarding anaemia that were answered correctly by more than 85% of respondents. This can be observed for questions 7 and 8, with the percentage of those who answered correctly being relatively high, at 85.1 and 89.5%, respectively. From these results, it was seen that respondents’ knowledge and awareness on the signs and symptoms of anaemia was at a good level.

In addition, knowledge concerning risk of anaemia reflected different percentages. For example, for questions 9 and 10, only 69.5 and 67.6% of the respondents, respectively, were aware of the risk that anaemia holds for the expectant mother and child. Questions 11, 12, 13, 14, 15 and 16 showed percentages ranging from 75.4-93.8% for questions assessing the knowledge of the respondents regarding diet for treatment or prevention of anaemia. The answers to question 11 indicate that majority of the respondents (93.8%) were aware that one means of prevention of anaemia is through the intake of a diet rich in iron during pregnancy. Based on question 13, 75.4% of the respondents knew that meat from animal sources is rich in iron, while for question 15, only 75.9% of the respondents knew that the intake of citrus fruits like lemons assist the absorption of iron. Questions 17, 18 and 19 indicate that most of the respondents (87.6, 92.2 and 96.5%, respectively) recognized another aspect of treatment of anaemia besides diet modification, with correct answers.

Assessment of attitude on anaemia: Responses to the attitude statements are reported in Table 3. The high percentage recorded for question 1 (87.8%) indicates the respondents were aware that anaemia is a serious health problem and this is illustrated in question 6, which found that a total of 85.4% of the respondents agreed that treating anaemia during pregnancy is beneficial for the baby. However, question 2 obtained a lower score, whereby 49.4% of the respondents agreed that all pregnant women would have anaemia and similarly, for questions 7 and 9, 48.6% of the respondents believed that it is impossible to prevent anaemia during pregnancy and 48.3% of the respondents agreed that anaemia is difficult to treat. Question No. 2, 7 and 9 showed that most of the respondents believed that anaemia is a common health problem experienced by all pregnant women and that it is neither preventable nor treatable. Furthermore, 51.5% of the respondents (question 3) believed that anaemia causes the pregnancy to be challenging. This is because anaemia causes pregnant women to be too tired to work, as stated in question 4 and 84.3% of the respondents agree with this statement.

Table 3:	Respondents responses to attitude questions on anaemia during pregnancy (n = 370)
*A/SA: Agree/Strongly agree, UD: Undecided, DA/SDA: Disagree/Strongly disagree

More than half (55.5%) of the respondents stated that anaemia also complicates the birthing process.

Question 8 states that the duration of the gap between pregnancies is important to prevent anaemia and 61.9% of the respondents agreed with this statement. For question 10, more than half (70.0%) of the respondents stated that it is difficult to prepare food that is rich in iron and 62.7% of the respondents believed that it is important for pregnant women to eat as she desires during pregnancy, even though the food may be low in iron (question 11). This belief will influence the intake of healthy nutrition during pregnancy and consequently will affect the intake of important nutrients such as iron.

In addition, a small percentage of the respondents (20.3%) believed that iron tablets will not cause the baby in the womb to increase in size, while 37.0% of the respondents believed otherwise and 42.7% were undecided for question 14. This shows that this belief is still held by the respondents and may influence the pattern of consuming iron tablets. However, a majority of the respondents (85.4%) agreed that the consumption of iron tablets daily is important for pregnant women with anaemia, as shown in question 13 and 77.9% of the respondents agreed that pregnant women should take iron tablets even if they adopt a balanced diet during pregnancy (question 16). Thus, most of the respondents agreed on the importance of iron tablets for pregnant women to meet their iron needs during pregnancy. For the treatment of anaemia, most of the respondents (85.1%) believed that the combination of iron supplementation and a balanced diet during pregnancy can treat anaemia as stated in question 12. In addition, the statement that pregnant women should undergo regular medical examinations during pregnancy was agreed to by 82.1% of the respondents (question 15). Only 45.5% of the respondents stated that it is possible for them to have anaemia. Nonetheless, a high sense of self-assurance among the respondents indicates that they may not experience anaemia.

Assessment of practice on anaemia: Practices towards anaemia were assessed by asking the thirteen questions shown in Table 4. A majority of the respondents, 69.5%, changed their normal dietary patterns during pregnancy, as they were more concerned about the intake of healthy food and 72.4% were not vegetarian during pregnancy. For question 3, only 26.8% of the respondents did not experience vomiting in their first trimester of pregnancy and 73.2% experienced otherwise. Vomiting during early pregnancy can lead to a lack of nutritious food intake, especially food that contains iron. More than three-quarters of the respondents (77.3%) answered positively for question 4, which meant that they did not have pica during pregnancy. Pica is the intake of a non-food substance that contains no nutrients such as soil, clay, lime, soap and ice¹³. Question 5 showed that 54.9% of the respondents were not practising food taboos during pregnancy. Food taboos are practised by certain races in relation to pregnancy and may also influence the pattern of food intake by pregnant women. Based on a study in Mali, Africa, egg was avoided during pregnancy because it was believed to cause malaria, while meat was avoided because it was believed to make the baby heavier and may cause difficulty during the birthing process¹⁴.

Table 4:	Respondents responses to practice questions on anaemia during pregnancy (n = 370)

Eggs are a rich source of folic acid, while meat is a source of iron. Both nutrients are important in the formation of red blood cells and less intake will cause anaemia.

A high percentage of the respondents, above 90%, correctly answered the questions on the practice of anaemia in question 6 and 8. For question 6, 97.6% of the respondents ate meat, poultry or fish as part of their diet daily during pregnancy. Question 8 concerns the intake of green leafy vegetables in their daily diet during pregnancy and it was agreed by more than 90% of the respondents. This kind of food contains a high iron content and it needs to be consumed daily during main meals to meet iron needs during pregnancy. In addition, question 7 also focused on diet during pregnancy and 84.1% of the respondents answered positively that they do consume citrus fruits or fruit juice daily during the main meal during pregnancy. This type of food contains high levels of vitamin C and helps with the absorption of iron^15. More than half of the respondents (57.3%) practice good habits, whereby they refrain from coffee or tea during the main meal during pregnancy. This is because tea and coffee can obstruct the absorption of iron¹⁶.

The result of question 10 indicates that 64.6% of the respondents did not miss meals during pregnancy. A majority of the respondents (83.5%) used cooking utensils made of iron during cooking and this can help to increase their iron intake. A total of 60.0% of the respondents took iron tablets daily on their own initiative before they were registered at a health clinic (question 12). Additionally, 69.5% of the respondents (question 13) reported that they were not taking any supplements or traditional medicine during pregnancy.

Mean scores of KAP, according to socio-demographic and antenatal characteristics: Comparisons of the knowledge score, according to the socio-demographic and antenatal characteristics as presented in Table 5, were analysed using the Mann-Whitney and Kruskal-Wallis tests, while the attitude and practice scores were analysed using an independent t-test and ANOVA. The median of the total knowledge score was 84.2 and mean scores for attitude and practice were 72.4±6.7 and 69.9±13.1, respectively. All the respondents were in the category reflecting a good level of knowledge and attitude but a moderate level for practice regarding naemia. The mean score for knowledge was significantly higher among respondents in the second trimester compared to those in first trimester (p<0.05) but no significant difference was seen between the third trimesters with the other two groups. According to the number of children, mean knowledge of nutrition for respondents with three or more children was higher compared to those without any children. However, no significant difference was observed between the group with 1-2 children and the other two groups. Attitude, the attitude score was higher in the working subjects (p<0.05) compare to those who are not working. There was no significant difference in practice score based on sociodemographic and antenatal characteristics (p>0.05).

The finding of this study revealed that gestational week and number of children contributed to the knowledge level about anaemia among respondents, while the level of education contributed to the attitude level. This finding is similar to the study by Daba et al. ¹⁷ among pregnant women, which indicated that there was a strong correlation between the number of children and the knowledge of mothers (p<0.001). Meanwhile, according to Manaf et al.¹⁸, gestational stage (p<0.05) was significantly associated with the knowledge score of pregnant mothers. Results of the present study are consistent with Baby et al.¹⁹ who reported that there was no significant difference in knowledge score among the education levels of 50 antenatal mothers.

Table 5:	Comparison of knowledge, attitude and practice score according to selected socio-demographic and antenatal characteristics
1Kruskal-Wallis test, 2Mann-Whitney test, 3ANOVA test, 4Independent t-test, a,bDifferent alphabets on the same column indicates a significant difference (p<0.05)

Table 6:	Correlation coefficient between knowledge, attitude and practice scores
**Significantly correlated at p<0.01, aSpearman correlation, bPearson correlation

Relationship between knowledge, attitude and practice: Results in Table 6 indicate that knowledge has a significant positive relationship and moderate level with attitude (r = 0.317, p<0.01) but no significant relationship with practices (r = 0.007, p>0.05). Thus, the higher the level of knowledge of respondents, the better their attitude; however, knowledge does not influence the respondents concerning their practices regarding anaemia. The result of this study also demonstrates that attitudes have a significant positive and moderate relationship with practices (r = 0.330, p<0.01). Attitude towards anaemia can improve practice among respondents in this study.

CONCLUSION

This study provides information related to the level of knowledge of anaemia among pregnant women. A quarter of the respondents were identified as anaemic. The median score for knowledge of anaemia among respondents was higher than the mean score for attitude and practice. This study also revealed that gestational week and number of children contributed to the knowledge level of anaemia among respondents, while level of education contributed to the attitude level. Knowledge scores did not correlate with practice but significantly correlated with attitude. In addition, the attitude score also significantly correlated to the practice of the respondents.

Increasing the level of awareness of anaemia among pregnant women is seen as an important step in improving the level of their attitude toward anaemia. A positive attitude regarding anaemia influences the high levels of knowledge and good practice towards anaemia, as attitude was significantly correlated with knowledge and practice. The results of this study can help identify specific areas of health education that can be developed for pregnant women concerning anaemia to ensure the mother’s health is at an optimal level during pregnancy.

SIGNIFICANCE STATEMENT

This study found that level of knowledge, attitude and practice regarding anaemia among pregnant women can be of use to the Health Ministry of Malaysia and health-related agencies as they identify specific areas of health education to be developed for pregnant women pertaining to anaemia. This study will help the researcher to uncover the critical areas of anaemia issues faced by pregnant women that many researchers were not able to explore. Thus, a new theory on the factors that may contribute to anaemia disease among pregnant women may be developed.

ACKNOWLEDGMENT

This study was supported by the Faculty of Science and Technology, Universiti Kebangsaan Malaysia. The authors would like to express appreciation to the Health Department of the Federal Territory Kuala Lumpur and Putrajaya for granting permission to conduct this research, Universiti Kebangsaan Malaysia for their support and most importantly to all pregnant women from the health clinics in Putrajaya, Malaysia for their cooperation and commitment as respondents throughout the study.