FACTORS ASSOCIATED WITH ANAEMIA AMONG PREGNANT WOMEN: A

CASE STUDY OF MANDERA COUNTY REFERRAL HOSPITAL

ABDIRIZAK HAJI MOHAMED

HND -3-2383-1/2014

A RESEARCH PROPOSAL SUBMITTED IN PARTIAL FULFILLMENT FOR

THE REQUIREMENT OF THE CONFERMENT OF THE MASTER’S DEGREE

OF HUMAN NUTRITION AND DIETETICS AT KENYA METHODIST

UNIVERSITY

FEBRUARY 2019
 DECLARATION

I hereby declare that this research is my original work and has not been presented for a

degree in any other university.

Signature………………………………Date……………………………

ABDIRIZAK HAJI MOHAMED

HND -3-2383-1/2014

Supervisors

This research has been submitted for review with our approval as University Supervisors.

Signature………………………………Date……………………………

DR JOYCE MEME

Senior Lecturer

Department of Human Nutrition and Dietetics

Kenya Methodist University

Signature………………………………Date……………………………

DR. MAKOBU KIMANI

MBCHB MPH (UON)

Department of Public Health and Human Nutrition and Dietetics

Kenya Methodist University

ii
 DEDICATION

I dedicate my thesis to my family whose inspiration specially my brother Abdiwahab

Mohamed who helped me financially and encouragements has made me reach this level

of my life.

iii
 ACKNOWLEDGEMENT

I acknowledge with gratitude the support I received from my brother Abdiwahab

Mohamed, who tirelessly encouraged me to complete this work. My mother Fatuma for

her kind support always helped me to finish this project in good time Thanks for your

prayers and encouragement. Many thanks to my supervisors Dr. Joyce Meme and Dr

Makobu Kimani for their continuous assistance during my process.

I wish also to sincerely thank Mandera Hospital staff and management for their support,

encouragement during data collection data not forgetting my research assistant

Abdirahman Sharif. God bless you all.

iv
 LIST OF ABBREVIATIONS

ASAL Arid and Semi-Arid Lands

CDC Centre for Disease Control

HIV Human Immunodeficiency Virus

IDA Iron Deficiency Anaemia

IFAS Iron Folic Acid Supplementation

KAP Knowledge, Attitudes and Practices

KDHS Kenya Demographic and Health survey

KEMU Kenya Methodist University

MOH Minister of Health

WHO The World Health Organization

v
 ABSTRACT

Anaemia is the commonest medical disorder in pregnancy. This is particularly a major

health problem in developing countries, where nutritional deficiency, malaria, worm
infestation are common. Pregnant women and non-pregnant women are mostly affected.
Majority of women have inadequate knowledge on causes of anaemia during pregnancy
and most of mothers know inadequate iron containing diet as the cause of anaemia. The
study sought to examine factors associated with causes of anaemia among pregnant
women in Mandera referral Hospital .The study adopted a descriptive cross sectional
research design. This study was a quantitative method the study target population was
pregnant women in Mandera Referral Hospital. The estimated number of women
pregnancy women aged 15-49 is estimated to be 3651 and they formed the target
population for the study. The study adopted simple random sampling and convenience
sampling techniques. A structured questionnaire were administered to all eligible women
to determine their socio-demographic and KAP on anaemia. The primary data was
collected by the use of the structured questionnaire that has been developed by the
researcher. The data was then presented in frequencies, cross tabulations and diagrams.
Most of the respondent were in their second or other pregnancies as they had been
pregnant before [205, 65.7%] compared to those in their first pregnancy [107, 34.3%] (p
=0.000) while on the stage of their pregnancies, slightly more than half [161, 51.6%]
were in their second trimester compared to 25.3% in their first trimester (p >0.05). Half
of the respondents indicated that they had a total of two pregnancies, 80(25.6%) had three
pregnancies. That majority (68.9%) of the respondents were not aware of iron (p value
<0.05) and further that 44.2% of the respondents knew the sources of iron compared to
55.8 who neither knew or not sure on the sources (P value >0.05). Majority (199, 63.8%)
faced challenges to access and availability of iron rich foods. Most of the women (249,
20.2%) were aware of Vitamin A and further 96.2% were not aware of the various
sources of Vitamin A and these responses were significant at 5%. Majority 46.2% and
42.3% took foods rich in Vitamin A on weekly and daily basis. The interventional
measures to educate the mothers and to initiate importance of iron folic acid supplements.

vi
 DEFINITION OF KEY OPERATIONAL TERMS

Anaemia

Is a haemoglobin concentration below two standard deviations and the

median of a healthy population of the same age with specific reference

mean,

Attitudes

Are emotional, motivational, perceptive and cognitive beliefs that

positively or negatively influence the behaviour or practice of an

individual? An individual’s feeding or eating behavior is influenced by

his/her emotions, motivations, perceptions and thoughts. Attitudes

influence future behavior no matter the individual’s knowledge and help

explain why an individual adopts one practice and no other alternatives.

The terms attitude, beliefs and perceptions are interchangeable

Knowledge

In this proposal, it refers to an individual’s understanding of anaemia,

including the intellectual ability to remember and recall food- and

nutrition-related terminology, specific pieces of information and facts

Practices

Is defined as the observable actions of an individual that could affect

vii
 his/her or others’ nutrition, such as eating, feeding, washing hands, cooking

and selecting foods. Practice and behavior are interchangeable terms,

although practice has a connotation of long-standing or commonly

practiced behaviour.

Public Hospitals

A public hospital or government hospital is a hospital which is owned by a

government and receives government funding

viii
 TABLE OF CONTENTS

DECLARATION........................................................................................................................... ii

DEDICATION.............................................................................................................................. iii

ACKNOWLEDGEMENT ........................................................................................................... iv

LIST OF ABBREVIATIONS ...................................................................................................... v

ABSTRACT .................................................................................................................................. vi

LIST OF TABLES ..................................................................................................................... xiii

LIST OF FIGURES ................................................................................................................... xiv

CHAPTER ONE ........................................................................................................................... 1

INTRODUCTION......................................................................................................................... 1

1.1 Background to the Study....................................................................................................... 1

1.2 Statement of the Problem ...................................................................................................... 4

1.3 Justification of the Study ...................................................................................................... 5

1.4 The Purpose of Study ............................................................................................................ 7

1.5 Objectives of the Study ......................................................................................................... 7

1.5.1 Main Objective................................................................................................... 7

1.5.2 Specific Objectives ............................................................................................ 7

1.6 Research Questions ............................................................................................................... 8

1.7 Hypothesis............................................................................................................................. 8

1.8 Significance of the Study ...................................................................................................... 8

ix
 1.9 Limitation of the study .......................................................................................................... 9

1.10 Delimitation of the study .................................................................................................. 10

CHAPTER TWO ........................................................................................................................ 11

LITERATURE ANALYSIS ....................................................................................................... 11

2.1 Introduction ......................................................................................................................... 11

2.2 Global and National Prevalence of Anaemia ...................................................................... 11

2.3Nutritional Causes of Anaemia ............................................................................................ 15

2.3.1 Iron deficiency ................................................................................................. 15

2.3.2 Folate deficiency .............................................................................................. 16

2.3.3 Vitamin B-12 deficiency .................................................................................. 18

2.3.4 Vitamin A......................................................................................................... 19

2.4 Maternal Knowledge on Anaemia ...................................................................................... 20

2.5 Practice of Intake of iron rich foods among pregnant women ............................................ 22

2.6 Theoretical Framework ....................................................................................................... 24

2.6.1 Health Belief Model ......................................................................................... 25

2.6.2 Transtheoretical Model (TTM) ........................................................................ 27

2.6.3 Theory of Reasoned Action/ Theory of Planned Behavior .............................. 28

2.6.4 Social Cognitive Theory .................................................................................. 30

2.6 Conceptual Framework ....................................................................................................... 32

CHAPTER THREE .................................................................................................................... 33

x
RESEARCH METHODOLOGY .............................................................................................. 33

3.1 Introduction ......................................................................................................................... 33

3.2 Study Design ....................................................................................................................... 33

3.3 Study Site ............................................................................................................................ 33

3.4 Target population ................................................................................................................ 35

3.5 Sampling Technique and Sample Size Determination........................................................ 35

3.5.1 Sampling Technique ........................................................................................ 35

3.5.2 Sample Size Determination.............................................................................. 36

3.6 Data Collection Tool ........................................................................................................... 37

3.7 Data Collection ................................................................................................................... 37

3.8 Data Analysis and Presentation .......................................................................................... 38

3.9 Ethical Considerations ........................................................................................................ 38

CHAPTER FOUR ....................................................................................................................... 40

DATA ANALYSIS AND INTERPRETATION ....................................................................... 40

4.1 Introduction ......................................................................................................................... 40

4.2 Response Rate ..................................................................................................................... 40

4.3 Bio Data of the Respondents............................................................................................... 40

4.4 Pregnancy Responses .......................................................................................................... 42

4.5 Diet Rich in Iron Intake .................................................................................................... 44

4.8 Cross tabulations ................................................................................................................. 50

xi
CHAPTER FIVE ........................................................................................................................ 54

DISCUSSIONS, CONCLUSION ANDRECOMMENDATION ............................................ 54

5.1 Introduction ......................................................................................................................... 54

5.2 Discussions ......................................................................................................................... 54

5.3 Conclusions ......................................................................................................................... 56

REFERENCES ............................................................................................................................ 58

APPENDICES ............................................................................................................................. 65

APPENDIX I: CONSENT FORM ........................................................................................... 65

APPENDIX II: RESEARCH QUESTIONNAIRE ................................................................... 66

APPENDIX III: APPROVAL LETTERS ................................................................................ 75

xii
 LIST OF TABLES

Table 4.1: Bio Data of the Respondents ....................................................................................... 40

Table 4.2: Pregnancy Responses................................................................................................... 42

Table 4.3: Iron Intake .................................................................................................................... 44

Table 4.5: Intake of Vitamin A ..................................................................................................... 46

Table 4.6: Folate or Folic Acid ..................................................................................................... 47

xiii
 LIST OF FIGURES

Figure 2. 1: Conceptual Framework ..................................................................................32

Figure 4.3: The sources of iron and Percentage .................................................................45

Figure 4.4: Knowledge of health problems associated with lack of enough folate/folic

acid in the diet ...............................................................................................49

xiv
 CHAPTER ONE

INTRODUCTION

1.1 Background to the Study

Anaemia is one of the world’s most widespread health problems. (Khadija, 2006) It

affects more than 2 billion people worldwide –one third of the world’s population – and

is a significant public health problem throughout the developing world. In almost all

developing countries, between one-third and one half of the female and child populations

are anaemic. Anaemia is the commonest medical disorder in pregnancy. This is

particularly a major health problem in developing countries, where nutritional deficiency,

malaria, worm infestation is common. Pregnant women and non-pregnant women are

mostly affected. Chronic anaemia, especially when associated with severe micronutrient

deficiencies, may affect women and children at school performance and attendance and

physical work capacity. Iron deficiency is the most common nutritional deficiency and

global burden of the disease. Nutritional anaemia are by far the most common type of

anaemia worldwide and mainly include iron, folate and vitamin B12 deficiencies

(Khadija, 2006). The causes of anaemia include genetic factors, nutritional deficiencies,

and infectious agents of the nutritional causes of anaemia, iron deficiency is probably the

most common and important because the physiological changes associated with

1
pregnancy exert a demand for additional iron needed for transfer to the foetus (James et

al, 2003)

The World Health Organization (WHO) estimated that in developing countries,

prevalence rates in pregnant women are commonly in the range of 40 to 60 percent.

Around half of those with anaemia, are suffering from iron deficiency anaemia. Folate

deficiencies and other causes account for the major proportion of the remaining anaemia.

Maternal anaemia in pregnancy is commonly considered a risk factor for poor pregnancy

outcome and can result in complications that threaten the life of both mother and foetus.

Current knowledge indicates that iron deficiency in pregnant is a risk factor for preterm

delivery subsequent low birth weight and possible inferior neonatal health. The

importance of this is to have of information to adoption of a positive attitude and

practices in nutrition most causes of anaemia are nutrition related. Previous study done in

India found that lower knowledge and Attitude Practice about anaemia in pregnant

women increased risk ‘five times’ and the worse practice about prevention of anaemia in

pregnant women increased anaemia risk ‘six times’ so the potential risk factors that

indicated to increase anaemia were knowledge and practices about anaemia in pregnant

mothers. Infections, including malaria, hookworm and other helminths are also involved

in the pathogenesis of anaemia in pregnancy. Pregnant women are particularly

2
susceptible to malaria in endemic populations and often have higher prevalence as well as

severity including anaemia. Anaemia may worsen the squeal of postpartum hemorrhage

and predispose to puerperal infection both of which are leading causes of maternal

mortality in developing countries inadequate consumption of fruits and vegetables and

food from animal sources among pregnant women are some of the common factors that

contributes to under nutrition and thus iron deficiency anemia and may also result to poor

birth outcome (Hassan et al., 2013; Nutrition & Health in developing Countries, 2008).

Majority of women have inadequate knowledge on causes of anaemia during pregnancy

and most of mothers know inadequate iron containing diet as the cause of anaemia.

Regarding the knowledge on sources of rich iron containing foods, most of women in

ASAL regions and in slum regions characterized with low socioeconomic status are not

aware of the that green leafy vegetables, meat, fish, egg are good sources of iron. Most

women in the ASAL regions have no access to fresh supply of green vegetables and

heavily rely on meat for iron. Coupled by their inadequate knowledge of proper and

adequate nutrition have increased their risk of developing anaemia. However, early

detection and effective management of anaemia can contribute substantially to reduction

in maternal mortality. To carry out nutrition education on consumption of healthy foods

during pregnancy and strengthen supplementation of iron and folate in pregnant women

3
this will expect to reduce mortality of anaemia and other micronutrient, low birth weight

among women.

1.2 Statement of the Problem

Worldwide, iron deficiency is the most cause of anaemia in pregnant women. The

prevalence of anaemia in Kenya is moderate high and pregnant women have a poor

nutritional status and anaemic Pregnant women attending antenatal clinics are routinely

put on iron supplementation despite of this the burden of disease remains high and

related foetal, maternal mortality and morbidity in Kenya due to low knowledge of

anaemia and type of foods they consume (WHO and CDC, 2008).Many households in

Mandera county are vulnerable to food and nutrition insufficient , poverty , illiteracy ,

and drought have lead minimal access to essential services to the majority of the

inhabitants of the county .Also problems are driven, at least by lack of access to quality

maternal health services, including ante-natal, delivery, and post-natal services long

spans of marginalization, weak health systems, lack of accountability and negative

cultural and religious practices.

Maternal anaemia in pregnancy is commonly considered a risk factor for poor pregnancy

outcome and can result in complications that threaten the life of both mother and foetus.

Current knowledge indicates that iron deficiency in pregnancy is a risk factor for preterm

4
delivery subsequent low birth weight and possible inferior neonatal health. The

prevalence of moderate anaemia is 54% in Kenya, while almost 70% of pregnant women

in Kenya are anaemic and the need to evaluate the factor associated causes anemia in

pregnant women and their knowledge about good diet intake . Most of the studies done in

Kenya have sought to determine the prevalence of anaemia and none has been done to

and did not ascertain the KAP on anaemia among women e.g. Khadija (2006) study

done on prevalence conducted in Kakamega put prevalence of anaemia in pregnancy at

25.7%.Sawe, (2001) conducted in Kericho District had prevalence of anaemia in

pregnancy at 24.5% Currently, there is no study which has been done to assess the

knowledge and practices of nutritional causes of anaemia among women in northern part

of Kenya. This study will seek to determine the factor associated with anaemia among

pregnant women attending Mandera Referral Hospital in Mandera County.

1.3 Justification of the Study

In Africa, the prevalence of anaemia in pregnancy is estimated to be between 35% and

75% as compared to the developed countries where prevalence is almost 15% (WHO,

2010). The burden of disease is heavy and more so in Sub Saharan Africa women have

additional needs of iron requirements from puberty to menopause, a total of an estimated

5
58.27 million (WHO, 2010) women worldwide are anemic during pregnancy. Lack of

knowledge about anaemia and its consequences may lead high morbidity and maternal

mortality among women pregnant, and pregnant women have a poor nutritional status

then that lead to anaemic. Ministry of Health has laid out policy on Iron

supplementation to all women attending antenatal clinic and this can be effectively done

if the knowledge and practices of nutritional anaemia among women is well documented.

The micronutrient deficiencies and anaemia remain as major concern for pregnant

women; this will leads to reduced mental capacity, poor physical performance, and

fatigue during pregnancy. This study will go a long way into obtaining information

relating to anaemia in knowledge and practices among pregnant women in the Mandera

Referral Hospital where micronutrient deficiency shows very high due to lack of

knowledge and poor practice among pregnant women at Mandera Referral County

Hospital, hence it will help in paving the way forward towards objective intervention

measures among women in Mandera county. There is a need to carry out to identify key

challenges and gaps in giving knowledge and positive attitude, thus the aim of the study

is to determine the Nutritional causes of anaemia among pregnant women attending in

Mandera Referral Hospital.

6
1.4 The Purpose of Study

The aim of the study is to identify factor associated causes of anemia in pregnant women in

Mandera county using by enhancing the give power to facts of good intake foods rich in

nutrients. The purpose of the study is to help the health providers to improve on service

delivery to prevent the cause anaemia in pregnant women and to provide awareness towards

anaemia and look for ways of intervention.

1.5 Objectives of the Study

1.5.1 Main Objective

To examine the factors associated with anaemia among pregnant women, a case of

Mandera County Referral Hospital.

1.5.2 Specific Objectives

1. To determine the socio demographic characteristics of pregnant women attending

Mandera County Referral Hospital.

2. To determine the intake of dietary iron among pregnant women attending

Mandera County Referral Hospital.

3. To examine the intake of dietary folate among pregnant women attending

Mandera County Referral Hospital.

4. To examine the intake of dietary vitamin A among pregnant women attending

Mandera County Referral Hospital.

7
1.6 Research Questions

1. What are the socio demographic characteristics of pregnant women attending

Mandera County Referral Hospital.?

2. What is the intake iron among pregnant women attending Mandera County

Referral Hospital.?

3. What is the intake folate among pregnant women attending Mandera County

Referral Hospital.?

4. What is of intake of Vitamin A among pregnant women attending Mandera

County Referral Hospital.?

1.7 Hypothesis

H0: Pregnant women in Mandera County have no knowledge, attitudes and practices of

anaemia

H1: Pregnant women in Mandera County have knowledge, attitudes and practices of

anaemia

1.8 Significance of the Study

The findings of the study are significant to many stakeholders. It will provide the

common causes of anaemia such as parasitic infestations such as malaria and hookworm,

8
the predisposing factors, age, low socioeconomic status, and illiteracy which was critical

in anaemia preventions, the level of knowledge and practices in nutritional causes of

anaemia among pregnant women. It will also provide key information to other

researchers and academicians by providing the KAP on the nutritional causes of anaemia

in Kenya, since few studies have been carried out in Mandera Referral County Hospital

and this will improve the information to the researchers and the government which has

been advocating and providing free iron supplementation to the pregnant women in

Kenya (KDHS, 2008/2009).

The study may provide key information to the mothers on the importance of the intake of

iron supplementation during their pregnancy period as well as the sources of folate and

iron and this would contribute to their overall wellbeing through intake of adequate of

iron and folic nutrients. This may help the residences in observe healthy living so as to

reduce the burden of the disease among pregnant women through their knowledge.

1.9 Limitation of the study

The study was limited to pregnant women attending Mandera Referral Hospital. The

study foresaw challenges during data collection due to the security reasons that have

affected the region. The region is also characterized with high illiteracy rates among

women and this posed challenges in data collection.

9
1.10 Delimitation of the study

To overcome the aforementioned challenges, the researcher used research assistant who

administered the questionnaire using the local dialect to overcome the language and

illiteracy barrier. The data collected at the healthcare facility where security is provided

10
 CHAPTER TWO

LITERATURE ANALYSIS

2.1 Introduction

This section reviews literature related to factors contributing to prevalence of anaemia

among pregnant women. The literature review was collected from different sources

books, document analyzed from hospital, journals and internet. The global prevalence of

anaemia among pregnant women is 55.9%, anaemia as particularly prominent in South

Asia. In nutrition, anaemia is one of India’s major public health problems. The

prevalence of anaemia ranges from 33% to 89% among pregnant women. In sub-Saharan

Africa the causes of anaemia during pregnancy are multifactorial. They include an iron-

and folate deficient diet and infections such as malaria, hookworm, and increasingly

human immunodeficiency virus (HIV).

2.2 Global and National Prevalence of Anaemia

Globally, the prevalence of anaemia fell by 12% between 2005 and 2011– from 33% to

29% in non-pregnant women and from 43% to 38% in pregnant women, indicating that

progress is possible but presently insufficient to meet these goals. It is therefore urgent

that countries review national policies, infrastructure and resources and act to implement

strategies for the prevention and control of anaemia (Morris et al 2009). In 2003, the

11
World Bank rated anaemia as the eighth leading cause of disease in young girls and

women in the developing world (World Bank, 2003). According to World Health

Organization- World Health Statistics (2005), the average prevalence of anaemia in the

world is 41.8%. Many studies show that anemia in pregnancy is globally common but

Africa and Asia bear the greatest burden (WHO, 2005). In Africa and South East Asia,

the prevalence is estimated at 57.1% and 48.2% respectively. This is twice as common as

in America and Europe where prevalence is estimated at 24.1% and 25.1% respectively.

Sub -Saharan Africa bears the major burden of disease. Prevalence of anaemia in

pregnancy in Nigeria is between 30-40%. In Ethiopia, overall prevalence of anemia was

found to be 41.9% with urban areas having a prevalence of 35.9% compared to the rural

population at 56.8% (WHO, 2005)

12
Figure 2.1: Worldwide Prevalence of anaemia 1993-2005

Source: WHO Global Database on Anaemia (2008)

In 2006, a study carried out on selected countries in South Eastern Africa showed a

prevalence of 58%, 76%, 75.6% and 74.4% in Mozambique, Rural Zaire, Coastal Kenya

and Tanzania respectively (Jane et al, 2007).

In Malawi, between July 2007 and June 2008, a study done on the urban population on

women attending antenatal clinic at St. Elizabeth Hospital in Blantyre, 57.1% were found

to be anaemic. According to James et al,(2008), in Kenya, a study on prevalence

conducted in Kakamega put prevalence of anemia in pregnancy at 25.7%. Another one

13
conducted in Kericho District had prevalence of anemia in pregnancy at 24.5%.

According to The Global Micronutrient survey done in May to October 2009, prevalence

of moderate anemia in pregnancy was 54% in Kenya, while almost 70% of pregnant

women in Kenya were moderately anemic. This is despite routine supplementation with

iron for all pregnant women attending antenatal clinics (James et al, 2008). Seventeen

percent of Ethiopian women in the reproductive age group are anemic, and 22% of these

women are currently pregnant. Despite its known effect on the population, very few data

are available in this area (EDHS 2011)

According to Sari et al, (2001) on a prospective study on severe anemia in pregnancy was

done in Kisumu District and it studied prevalence and risk factors of the respondents

who developed obstetric complications, 22% were found to be anemic. Poor pregnancy

care, illness during pregnancy, socioeconomic conditions of the mother and the sanitary

conditions of the household among other things also significantly increased prevalence of

anemia in their subjects. A study done in Kilifi District, 10% of women booked for

antenatal care had severe anemia (Hb<7g/dl) with 76% having Hb ,11g/dl and the main

causes for the anaemia were reported as iron deficiency often exacerbated by hookworm

infestation, malaria, folate deficiency and HIV infection (Sari et al, 2001).

14
2.3Nutritional Causes of Anaemia

2.3.1 Iron deficiency

Iron is a necessary basic of haemoglobin, the oxygen carrying pigment in the blood. Iron

is normally obtained through the food diet and by recycling iron from old red blood cells

and in the absence of the required iron blood concentrations, blood cannot carry oxygen

effectively and hence normal functioning of every cell in the body was affected. It is

estimated that a median amount of 840-1210 mg of iron needs to be absorbed over the

course of the pregnancy. When the iron needs of pregnancy are not met, maternal

haemoglobin falls below 11 g/dl. When the haemoglobin level is below 10 mg/dl

(haematocrit under 33%), iron deficiency is suspected (Brabin et al, 2008).

Nutritional iron deficiency is the most common deficiency disorder in the world,

affecting more than two billion people worldwide, with pregnant women at risk. Despite

the lack of stringent criteria, problems with definitions and lack of substantial supportive

data, in sub-Saharan Africa anaemia during pregnancy is most often believed to result

from nutritional deficiencies, especially iron deficiency (Brabin et al, 2008).

WHO (2005), data show that iron deficiency anemia (IDA) in pregnancy is a significant

problem throughout the world with a prevalence ranging from an average of 14% of

15
pregnant women in industrialized countries to an average of 56% (range 35–75%) in

developing countries.

In some instances, poor absorption of iron is aggravated by dietary contents. For

example, diets rich in phytates and phenolic compounds prevent absorption of iron,

thereby contributing to the anemic condition. Nutritional iron deficiency rarely occurs by

itself; rather, it occurs in the presence of other nutritional deficiencies, although this fact

is frequently overlooked. For example, deficiency of micronutrients such as folic acid,

vitamins A, B12, riboflavin, and copper increase the risk of anemia because these

micronutrients play important roles in hemopoietin (Brabin et al, 2008).

When an iron deficient woman becomes pregnant, her need for iron will increase

dramatically. Pregnancy is a setting where the normal physiological demands for iron

display an extraordinary increase of such a magnitude, which has not recognized in other

physiological situations.

2.3.2 Folate deficiency

Folate plays a crucial role in the one-carbon metabolism for physiological nucleic acid

synthesis and cell division, regulation of gene expression, amino acid metabolism and

neurotransmitter synthesis. During pregnancy, increased folate intake is required for

rapid cell proliferation and tissue growth of the uterus and the placenta, growth of the

16
fetus and expansion of the maternal blood volume. Folate requirements are 5-to 10-fold

higher in pregnant than in non-pregnant women, therefore pregnant women may be at

risk for folate deficiency (Cook, 2004).

As a consequence of folate deficiency, homocysteine accumulates in the serum and is

found to be associated with an increased risk in cardiovascular disease, late pregnancy

complications such as pre-eclampsia and neural tube defects around the time of

conception. The recommended folate intake for pregnant women is 400μg/day. Folate

deficiency is a serious problem that affects women worldwide. This deficiency is caused

primarily by inadequate dietary intake (Cook, 2004). Typical folate intakes are

suboptimal in the diets of many women of childbearing age, and folate intake is further

limited by cooking losses and poor bioavailability estimated to be from 50% to 82%.

Fortification of grains with folic acid has increased folate intake in several developed

countries. Folate deficiency can also be a consequence of medical conditions that

increase the need for folate or result in increased excretion of folate, including pregnancy,

lactation, alcoholism, malabsorption, kidney dialysis, liver disease, certain anemia’s and

medications that interfere with folate metabolism (Cook, 2004). Folate deficiency is

associated with several health risks. Over folate deficiency leads to megaloblastic

anemia. Suboptimal preconception folate intake increases risk of clinical spontaneous

17
abortion, preterm birth, low birth weight and neural tube defects. Digestive disorders

such as diarrhea, loss of appetite and weight loss can occur with folate deficiency, as can

weakness, sore tongue, headaches, heart palpitations, irritability, forgetfulness and

behavioural disorders (IOM, 2003)

2.3.3 Vitamin B-12 deficiency

Vitamin B12 deficiency occurs in 10– 28% of uncomplicated pregnancies. Vitamin B12

can only be obtained from animal products. More than 1000 μg of vitamin B12 is stored

in fertile women eating a mixed diet. At term, foetal vitamin B12 stores should be 25–50

μg. 20% of women show a physiological drop in vitamin B12 levels during pregnancy,

with lowest levels reached at third trimester. Maternal vitamin B12 determines foetal

vitamin B12 levels. During pregnancy, vitamin B12 is transferred from mother to foetus

by active transport across the placenta into foetal circulation which results in foetal serum

level being double that of maternal serum levels.

Vitamin B12 deficiency can cause anencephaly (the absence of a brain, which causes a

fetus to die a few hours after birth). Shoran et al. (2009) found very low vitamin B12

levels in 3 anencephalic mothers compared with controls; this may be due to the fact that

vitamin B12 is involved in the metabolism of neural tissue. Pathological changes that

18
occur due to vitamin B12 deficiency are demyelination, axonal degeneration, and

neuronal death (Shoran et al, 2009)

2.3.4 Vitamin A

Vitamin A deficiency in pregnancy is known to result in night blindness, to increase the

risk of maternal mortality and is associated with premature birth, intrauterine growth

retardation, and LBW. Symptoms of vitamin A deficiency include a variety of eye

symptoms, such as night blindness, exophthalmia (dry eyes, failure to produce tears),

keratomalacia (drying and clouding of the cornea with ulceration), Bitot spots (keratin

debris in the conjunctiva) and photophobia. Follicular hyperkeratosis (excessive

development of keratin in hair follicles), which is also seen with general malnutrition, can

be a manifestation of vitamin A deficiency. Ocular changes can be documented

quantitatively using a dark adaptation test (e.g. the papillary threshold test-PTT) or using

electro-retinography. Change in night blindness is accessed via a simple before (the

intervention) and after (the intervention or treatment) questionnaire (Milman et al, 2003).

A study from Nepal showed that weekly vitamin A supplementation reduced maternal

mortality by 40%. It was also found that the prevalence of iron-deficiency anemia in

pregnancy was reduced from 76% in controls to 69% among those receiving vitamin A

(Milman et al, 2003).

19
2.4 Maternal Knowledge on Anaemia

Maternal knowledge of anemia is important because of its potential to encourage women

to take iron supplements during pregnancy and after childbirth, affecting the iron status of

both the mother and the child. In a small study in southern Israel, the presence of anemia

in infants and level of maternal knowledge were inversely related, with low knowledge of

anemia leading to a 12-fold increase in prevalence of anemia in infants compared to

women with higher levels of knowledge.

According to a study conducted in Uganda by Mbule et al (2012), only 80.9% of the

respondents had ever heard about anaemia. In decreasing frequency, intermittent

dizziness, general body weakness, and persistent fatigue were the top three most

commonly known and recognized symptoms of anaemia by the respondents. Only 45.1%

of the respondents knew at least 3 symptoms of anaemia but knowledge of

anaemia symptoms was not found to be significantly associated with the presence of

anaemia.

Mbule et al (2012), most women are not aware of some negative consequences of

anaemia during pregnancy to both the mother and child. Excessive blood loss

(haemorrhage) was the most widely cited consequence of anaemia.

20
Rajeev Kumar et al (2014) found out that knowledge regarding cause of anemia, sign and

symptoms of anemia, proper diet to prevent anemia was poor. Knowledge regarding

prevention and treatment of anemia, knowledge regarding preventive practice of anemia

was good. The result clearly showed that there was significant association between

women’s education and knowledge regarding cause of anemia, sign & symptoms of

anemia, proper diet to prevent anemia, prevention and treatment of anemia, preventive

practice regarding anemia.

According to Souganidis et al (2012) maternal knowledge of anemia is not protective

against anemia in the mother herself but was found to be protective against anemia in the

child in rural families and of borderline significance in urban families. There are other

factors in addition to maternal knowledge that may play an important role in anemia

among mothers and children. For example, the study also showed an association between

the consumption of fortified milk and availability of improved latrines with anemia. This

study also shows that maternal knowledge of anaemia was associated with the

consumption of fortified milk by the child and iron supplementation during the mother’s

last pregnancy in rural and urban families, but not with the use of deworming medication

in the child. Maternal knowledge of anemia was also significantly associated with

consumption of animal source foods in rural families but not in urban families. Maternal

knowledge of anaemia was associated with the use of iron supplements during pregnancy

21
in both urban and rural areas. In the present study, 85.7% of mothers in urban slums and

84.0% of mothers from rural areas used iron supplementation during their last pregnancy.

Maternal knowledge of anemia was significantly associated with consumption of animal

source foods in rural areas. However, resource-poor settings make increased consumption

of animal source foods a difficult strategy to implement. Household food-processing and

preparation methods such as thermal processing, mechanical processing, soaking,

fermentation, and germination/malting have been shown to enhance the bioavailability of

micronutrients in plant source foods. Therefore, a diet consisting of modified plant source

foods combined with a small portion of animal source foods could be an effective

strategy to improve micronutrient bioavailability and dietary diversity. In Mandera

county micronutrient deficiency is a major contributor to pregnant women anaemia

(KNBS, ICF, 2015)

2.5 Practice of Intake of iron rich foods among pregnant women

Increased consumption of animal source foods is an additional health-related behavior

that could be encouraged by maternal knowledge of anaemia. Benefits of consuming

animal source foods include dietary diversity, relatively higher bioavailable forms of

22
micronutrients, and overall better maternal nutrition affecting both the mother and child

during pregnancy and lactation

According to Nyaruhucha (2009) Passions and dislikes, which refer to a strong desire and

strong dislike respectively for confident food, are common during pregnancy such as

nausea and vomiting These problems may cause not only embarrassment during

pregnancy but also interfere with the dietary intake of the pregnant woman and

sometimes causing serious problems, during pregnant women should know and practice

source of dietary foods contain certain and also health workers to help pregnant women

make a better choice of food during pregnancy. Lack of information among partner and

women are cause to encounter this kind of problems during pregnancy of vomiting and

nausea.

Concerning knowledge of iron rich foods, only a small proportion of pregnant women

could positively identify some food rich in iron in most women. Organ meat and red meat

were rarely known to be rich sources of iron. Pregnant women are supposed to be given

nutrition education as early as possible during pregnancy with ANC visits as the main

channel for this delivery. The low levels of awareness about these aspects can, therefore,

be attributed to low ANC attendance by pregnant women. It is also possible that even if

women attend ANC, nutritional education sessions may not be available. Mwadime et al

23
reported that the workload within health facilities deprives health workers of sufficient

time to carry out meaningful health and nutritional education

Pregnant women may believe there are no advantages in attending ANC in the first

3 months of pregnancy, because ANC is viewed primarily as curative, rather than

preventive. Neema (2013) reported that pregnant women do not have confidence in the

health system because of inadequate services and medicines, which in part contributes to

the high usage (73%) of traditional indigenous medicine as an alternative to ANC in

Uganda. It is possible that such attitudes and misconceptions contribute to the high

prevalence of anaemia among pregnant women. Poverty reduces timely access to

accurate information. Poverty translates into limited access to adequate and nutritious

food at both household and individual levels. Further, foods that are rich in available iron

(red meats, organ meats, fish and poultry) are expensive and not affordable to those in the

lower ranks of society.

2.6 Theoretical Framework

Most funded nutrition education interventions and programs to change behaviors are

based on research and theory-driven models. While theory specifies the variables

affecting the target behavior and the relationships among those variables, it also explains

24
how to intervene to promote behavior change while providing predictability for expected

outcomes.

To date, the nutrition education community has not embraced a single model as the gold

standard for behavior change. The challenge is to integrate distinct constructs from

competing theories into one model that can be empirically tested and refined into a more

comprehensive, tailored theory or set of theories specific to food and nutrition behavior

changes.67 Four behavior change models commonly applied in nutrition include: Health

Belief Model (HBM), the Transtheoretical Model (TTM), Theory of Reasoned Action

(TRA) and the Social Cognitive Theory (SCT).

2.6.1 Health Belief Model

Developed in the 1950's by researchers for the US Public Health Service, the HBM was

designed to explain preventative health behaviors. Originally, the HBM focused on the

associations between health behaviors, practices and utilization of health services but has

since been revised to include health motivation to enable users to distinguish between

illness behavior and health behavior. HBM predicates that health beliefs (perceived

benefits and barriers) and readiness to take action (perceived susceptibility and severity)

determine subsequent health behaviors.

25
The most recent version of HBM consists of 6 constructs: perceived susceptibility,

perceived severity, perceived benefits, perceived barriers, self-efficacy, and cues to

action. Perceived susceptibility is defined as an individual's perceptions of the likelihood

that he/she will experience a condition that will adversely affect his/her health. Perceived

severity is characterized as an individual's beliefs about how extensively the development

of an adverse health condition will affect his/her life. Perceived benefits include an

individual's opinions about how effective the recommended actions will be at preventing

disease or minimizing negative health outcomes. Perceived barriers are those tangible and

psychological costs of taking action, which may impede an individual from taking action.

While an individual may feel threatened by his/her current behavioral patterns (perceived

susceptibility and severity) and may have determined that the benefits of change

outweigh the barriers, he/she must also believe they possess the ability to complete the

behavior (self-efficacy) in order for behavior change to be successful. Finally, internal or

external cues can be defined as those forces which cause or inspire an individual to take

action.

While studies in other fields indicate successful prediction of behavior change using this

model, a review of research reveals limited usefulness of the model in the nutrition

26
education arena, specifically relating to obesity. One limitation of the model, health

behaviors do not always coincide with belief, as people's actions often contradict their

personal beliefs. This model also fails to account for the other variables outside of beliefs

that often impact behavior, including culture, economic constraints, and previous

experiences. As these factors may greatly influence decision making in the target

population of this dissertation, the applicability of this model may be limited

2.6.2 Transtheoretical Model (TTM)

The core of the TTM, stage of change proposes that behavior change is a continual

process with five unique stages. These stages are precontemplation (unaware a problem

exists and/or not considering changing the behavior), contemplation (thinking about

changing), preparation (planning to change in the immediate future and may have made

small attempts), action (has changed problem behavior in the short term (within the past 6

months), and maintenance (problem behavior changed for at least 6 months).

Composed of both experiential and behavioral processes; the process of change explains

how individuals progress from one stage to the next. The ten methods for movement

include consciousness raising, self-reevaluation, self-liberation, counterconditioning,

stimulus control, reinforcement management, helping relationships, dramatic relief,

environmental reevaluation, and social liberation.

27
According to TTM, individuals base decisions on the pros and cons balance of behavior

change, along with the ten components of the process of change. Individuals in the

precontemplative stage believe fewer positive outcomes and more negative consequences

are related to behavior change, whereas those in later stages believe the reverse is true.

The TTM purports that shifts in the pro/con balance and improvement in self-efficacy

(confidence in performing specific tasks leading to change) must occur in order for

behavior change to take place. Transtheoretical model is one of the most widely used

theoretical models and has been applied to health and nutrition education, specifically in

dietary behavior change, such as dietary fat reductions, " dietary fiber consumption and

fruit and vegetable intake.

2.6.3 Theory of Reasoned Action/ Theory of Planned Behavior

TRA suggests an individual's attitudes and subjective norms determine his/her intention

to perform a particular behavior, which then predicts the likelihood of the individual

engaging in that behavior. Attitude reflects the individual's opinion of the said behavior,

and subjective norms represent the perceived social pressure to perform or not perform

that behavior Because success of explaining actual behavior is dependent upon the degree

28
to which the behavior is under an individual's volitional control, not just behavioral

intention, Ajzen et al. developed the Theory of Planned Behavior (TPB) in 1986 to

predict behaviors over which people have incomplete volitional control.

Developers of TRA added perceived behavioral control as a third predictor of behavioral

intention to represent circumstances outside the individual's control that may affect his

intention and behavior. Believed to have a direct effect on behavior, in addition to its role

imbedded in behavioral intention, perceived behavioral control denotes the perceived

ease or difficulty of performing a particular behavior. TPB asserts that an individual will

use less energy to engage in a behavior when his/her perception of behavioral control is

low, but he/she will expend more efforts when perceived control is high. As a result, a

person's behavior intention along with perceived behavioral control should predict actual

behavior.

Researchers have applied TPB successfully to various behaviors, including condom use,

exercise and nutrition. However, limitations of the model preclude it from being the

main health behavior change model identified with nutritional sciences. First, TPB only

succeeds when some facet of the behavior is not under volitional control. Additionally,

predictability of actual behavior using behavior intent decreases as time passes. Finally

29
and of most concern, researchers have not clearly defined perceived behavioral control,

thus they cannot consistently measure this construct

2.6.4 Social Cognitive Theory

Adapted from Miller and Dollard's Social Learning Theory, Bandura's SCT provides an

expansive model for understanding health behaviors and methods to change them.

Represented as a reciprocal model, SCT is composed of three main components

(individual factors, environmental factors, and behavioral repertoires), which constantly

interact with each other. The constructs of SCT include reciprocal determinism,

behavioral capability, expectations, expectancies, observational learning, reinforcement,

self-efficacy, emotional coping responses, self-control, situation and environment.

Reciprocal determinism asserts that the individual, the environment, and behavioral

repertoire are continually changing and influencing each other. Behavioral capability

results from an individual's training, intellectual capacity and learning style

Self-efficacy is the belief in one's own abilities to perform at task. The construct

"expectations" allows that people can anticipate what will happen in a situation before

they actually experience it. Expectancies can be termed as an individual's incentives to

act. Expectancies differ from expectations, because with expectancies a person places

30
value on a particular outcome. Reinforcements are responses to a person's behavior that

increase or decrease the likelihood of reoccurrence. A person can learn from other people

not only by received reinforcements but also through observational learning, which

occurs when a person watches the actions and outcomes of others' behavior.

Observational learning is most often accomplished by providing a credible role model for

the individual. Emotional coping responses are strategies or tactics that are used by

person to deal with emotional stimuli. When applying SCT, behavior change researchers

should use each of the above constructs, not just one, to empower the individual to

change. As a whole, the constructs allow educators to target both the individual and

his/her environment, focusing on a multidimensional approach to behavior change. Each

construct provides an avenue for improving the circumstances leading to a health-related

behavior.

By providing role models, building behavioral skills and expanding self-confidence (self-

efficacy), along with improving other circumstances in an individual's environment, the

educator. A variety of health and nutrition education interventions employed and

measured various constructs successfully from SCT. Instruments to assess knowledge

and self-efficacy in the interventions; however, were either adopted measures from

previous research or developed prior to the intervention with varying and limited

methodology employed (e.g., content validation, factor analysis).

31
2.6 Conceptual Framework

Independent Variables Dependent Variable

Demographic Factors
• Age
• Marriage
• Education,
• Income

Vitamin A
Anaemia among Pregnant
• Aware of Vit A,
• Aware source of Vit Women
A Intake of Vit A

Personal Factors
• Aware Iron diets,
• Sources of iron
daily intake

Figure 2. 1: Conceptual Framework

32
 CHAPTER THREE

RESEARCH METHODOLOGY

3.1 Introduction

This chapter presents the methodology that was used to address the objectives of the

study. The researcher will address research design to be adopted, respondent’s selection

and sampling, methods employed during data collection, processing and analysis of the

problem encountered.

3.2 Study Design

Cross-sectional descriptive study is preferred for it is used to obtain information

concerning the current status. The purpose of this method is to describe what exist with

respect to situational variable. According to Bryman & Bell, (2003) in descriptive cross-

sectional studies variables of interest in a sample of subjects are tested once and the

relationships between them are determined. Survey strategy is used by a deductive

approach, and it allows one to collect quantitative data, which one can analyze

quantitatively using descriptive and inferential statistics (Saunders et al., 2009)

3.3 Study Site

Mandera County is situated in the former North Eastern Province of Kenya. Its capital is

Mandera. According to Kenya Census, 2009 the county has a population of 1,025,756

33
and an area of 25,797.7 km². It has border Somalia to east and Ethiopia to north. The

county has six sub counties: Mandera South, Mandera West, Mandera East and Mandera

North, Banisa and Lafey.

Mandera County Referral Hospital is a Government health centre located in Bulla Power

Sub-location, Bulla Jamhuri location, Central Division, Mandera East Constituency. It

has a 128 beds and antenatal care (ANC) services and basic emergency obstetric care

Caesarean Section and comprehensive emergency obstetric care , curative in-patient

services curative outpatient services, family planning, growth monitoring and promotion

HIV Counselling and testing immunization integrated management of childhood illnesses

Mandera County Referral Hospital provides health services to its all six sub-counties

Mandera has border with Somalia and Ethiopia. The serves includes referrals and ANC

emergency obstetric from these areas so, due to poor of equipments and unskilled staff at

Mandera County during insecurity and long marginalization and negative , cultural

religious practice discourages deliveries at the hospitals. Mothers living in Mandera

County have the highest mortality rate than other counties of Kenya when compared to

the national average (KDHS2014).

34
3.4 Target population

According to Ngechu (2004) a study population is well defined or specified set of people,

group of things, households, firms, services, elements or events which are being

investigated. The target population refers to the population to which the researcher makes

inferences to this population should theoretically be countable, observable and exist

within a specific time frame. The units of the target population must also be specified

(Groves, Fowler, Couper, Lepkowski, Singer, & Tourangeau, 2009). The target

population simply explained is elements relevant to the research.

The study target population were pregnant women in Mandera County Referral Hospital

the estimated number of women pregnant women aged 15-49 is estimated to be 3651 and

they formed the target population for the study.

3.5 Sampling Technique and Sample Size Determination

3.5.1 Sampling Technique

Sampling techniques provide a range of methods that enable one to reduce the amount of

data needed for a study by considering only data from a sub-group rather than all possible

elements. The study adopted simple random sampling and convenience sampling

techniques. A convenience sampling is available to the researcher by virtue of its

35
accessibility” (Bryman & Bell, 2003). The study selected every third pregnant woman in

the hospital and questionnaire was administered.

3.5.2 Sample Size Determination

Sample size determination is an important and often difficult step in planning an

empirical study. A sample is a subset of a population element, where a population is a

theoretically-specified aggregation of an element. Hence a sample size is a subset of a

population. (Agresti & Finlay, 2009). The study will utilize Fischer’s formula to compute

sample size. According to Fischer et al., (2008) formula, at permissible error of 5% and

prevalence of 50% the sample size was:

𝒁𝟐 𝒑𝒒
𝒏=
𝒅𝟐

Where n= sample size

Z2= Standard error from mean corresponds to 95% confidence interval =1.96, and

is the standard normal deviate (i.e. deviation from the mean in normal distribution

or curve).

p = proportion of the population with the desired characteristics (Prevalence of

anaemia among pregnant in Kenya is at 54%)

q = 1-p =1-0.54=0.46

𝒅 (0.05) = Permissible error in the estimate of P

36
Thus, with permissible error of 5%, the sample size is:

𝟏. 𝟗𝟔𝟐 × 𝟎. 𝟓𝟒 ×. 𝟎. 𝟒𝟔
𝒏=
𝟎. 𝟎𝟓𝟐

𝒏 = 𝟑𝟖𝟏. 𝟕

𝒏 ≈ 𝟑𝟖𝟐

Thus, the sample size of 382 was needed.

3.6 Data Collection Tool

Various techniques could be used to gather primary data for descriptive research. These

include personal interviews, self -administered surveys, postal surveys, telephonic

surveys and observation (Roberts-Lombard, 2006). A structured questionnaire survey

was used to collect primary data. A structured questionnaire was administered to all

eligible women to determine their socio-demographic and knowledge about the sources

iron and challenges in terms of access and availability diet rich iron.

3.7 Data Collection

The primary data was collected by use of the structured questionnaire that was developed

by the researcher. It captured the knowledge of anaemia and practices foods that are rich

in iron. The research questionnaires were administered by the researcher as most of the

women in the Mandera County were informally educated and needed assistance in filling

37
the questionnaire. Data was collected during the months of October and November 2016,

total of the 382 of whom were contested structured questions only 312 provided their

responses translated to 81.7% and this attributed to high illiteracy rates and some of the

respondents did not understand the importance of the study. Further, there was the aspect

of language barrier of which most of the respondents only speak Somali and thus

translating the question to the local dialect presented challenges.

3.8 Data Analysis and Presentation

The data were then presented in frequencies, cross tabulations and diagrams as necessary.

A descriptive analysis included measures of central tendency like the mean, measures of

variability like standard deviation and range and univariate analysis. Inferential analysis

was carried out using chi square test to determine significant association between the two

variables.

3.9 Ethical Considerations

The KeMU Ethical research committee approved the study undertaking upon researcher’s

fulfilment of the necessary requirements. An introduction letter was provided by the

University marked to the study Hospital to enable the researcher undertake the study.

Confidentiality and privacy of the information obtained from the respondents was assured

by not including any form of identity on the data collection tools. Written informed

38
consent was sought from the patient after clear explanation on the purpose of the study

and participation in the study was on voluntary basis. Completed data collection tools

were kept in a place accessible only to the principal researcher.

39
 CHAPTER FOUR

DATA ANALYSIS AND INTERPRETATION

4.1 Introduction

This chapter presents statistical summary and results from empirical analysis and the

interpretations of the statistical inferences derived from the compiled data as the

researcher strives to accomplish the objective of the study

4.2 Response Rate

The targeted sample size was 382 of whom were given self-administered structured

questions of whom 312 provided their responses and this translated to 81.7%. The

researcher used drop and pick technique.

4.3 Bio Data of the Respondents

Table 4.1: Bio Data of the Respondents

Variable Responses Frequency Percent

Age bracket Less than 20 years 34 10.9

Between 21-30 years 76 24.4

Between 31-40 years 126 40.4

More than 40 years 76 24.4

40
Marital status Single 24 7.7

Married/cohabiting 243 77.9

Divorced/ Separated 33 10.6

Widow 12 3.8

Highest level of Primary level 127 40.7

education achieved Secondary level 63 20.2

University level 12 3.8

Postgraduate 12 3.8

None 42 13.5

College level 56 17.9

Average monthly Less than Ksh 30, 000 151 48.4

income Between Ksh 31,000-60,000 121 38.8

Between Ksh 61,000-90,000 35 11.2

More than Ksh 90,000 5 1.6

From the responses in Table 4.1, most of the respondents were between 31-40 years

[40.4%] compared to 24.4% who were between 21-30 years. On their marital status, the

study found that most of the respondents [243, 77.9%] were either cohabiting or married

as opposed to those who were in single motherhood [24, 7.7%] and those who were either

41
divorced or separated constituted 10.6%. Approximately 190[60.9%] of the respondents

had less than secondary level education and this indicated that the illiteracy level in the

county is high. The last query concerned the monthly income of the respondents. It was

established that majority [151, 48.4%] of the respondents had an average income of less

than Ksh 30,000 while 121[38.8%] indicated that they earned between Ksh 31,000-

60,000 and thus most of the women could afford balanced diet.

4.4 Pregnancy Responses

Table 4.2: Pregnancy Responses

Variable Responses Chi Square Sig. (2-

Frequency Percent Value tailed)

Have you ever been Yes 205 65.7 30.782 .000

pregnant before No 107 34.3

Stage of your First Trimester 79 25.3 47.096 .000

pregnancy Second
161 51.6
Trimester

Third Trimester 72 23.1

Number of One pregnancy 69 22.1 143.718 .000

42
pregnancies had Two pregnancies 156 50.0

before Three
80 25.6
pregnancies

More than four

7 2.2
pregnancies

The Table 4.2 presents the summary of the responses provided by the women on their

state of pregnancy. Most of the respondent were in their second or other pregnancies as

they had been pregnant before [205,65.7%] compared to those in their first pregnancy

[107,34.3%] (p =0.000) while on the stage of their pregnancies, slightly more than half

[161,51.6%] were in their second trimester compared to 25.3% in their first trimester (p

<0.05) while half of the respondents indicated that they had a total of two pregnancies,

80(25.6%) had three pregnancies. A significant p value of 0.005 was obtained and this

indicated consistency in the responses provided.

43
4.5 Diet Rich in Iron Intake

Table 4.3: Responses on the Awareness and Frequency of Intake of Iron Rich Foods

Variable Responses Chi Sig.

Square (2-

Frequency Percent Value tailed)

Aware of iron Yes 215 31.1 44.628 .000

No 97 68.9

Know the sources of iron Yes 138 44.2 17.154 .000

No 82 26.3

Not sure 92 29.5

Intake frequency iron rich Daily 74 23.7 94.872 .000

foods Weekly 130 41.7

Monthly 96 30.8

Never 12 3.8

Challenges in terms of access Yes 199 63.8 23.705 .000

and availability of iron rich No

113 36.2
source of iron

44
Table 4.3 shows the responses on the awareness and frequency of intake of iron rich

foods whereby majority (68.9%) of the respondents were not aware of iron (p value

<0.05) and further that 44.2% of the respondents knew the sources of iron compared to

55.8 who neither knew or not sure on the sources (p value >0.05). On the frequencies, the

respondents took the iron rich foods, it was established that majority (130, 41.7%)

indicated they took them weekly compared to 30.8% who cited they took them on

monthly basis. It was established majority (199, 63.8%) faced challenges to access and

availability of iron rich foods and thus the need for IFAS or other iron rich supplements.

Figure 4.1: The sources of iron and Percentage

45
Among the sources of iron both animal and plant based sources that the respondents

indicated they knew about, it was established that 35.3% cited eggs compared to 28.5%

who indicated vegetables as the sources of iron. 19.9% indicated meat as a source of iron

as presented in the Figure 4.3. The responses were significant at 5% as p value obtained

was <0.05.

Table 4.4: Intake of Vitamin A

Variable Responses Chi Square Sig. (2-

Frequency Percent Value tailed)

Aware of Vitamin A Yes 249 20.2 110.885 .000

No 63 79.8

Aware of sources of Yes 300 3.8 265.846 .000

Vitamin A No 12 96.2

Intake frequency of Daily 132 42.3 67.385 .000

those foods Weekly 144 46.2

Monthly 36 11.5

Challenges in terms of Yes 230 73.7 70.205 .000

46
access and availability of No
82 26.3
Vitamin A

The Table 4.5 presents the responses on the intake of Vitamin A among the pregnant

women in Mandera Referral County Hospital. Most of the women (249, 79.8%) were not

aware of Vitamin A and further 96.2% were not aware of the various sources of Vitamin

A and these responses were significant at 5%. On the query about frequency of intake of

Vitamin A, it was established that majority 46.2% and 42.3% took foods rich in Vitamin

A on weekly and daily basis. Further, most (230, 73.7%) of the respondents indicated that

they experienced Challenges in terms of access and availability of Vitamin

4.7 Folate or Folic Acid

Table 4.5: Folic Acid Awareness among pregnant women

Variable Responses Chi Sig. (2-

Square tailed)

Frequency Percent Value

Aware of Folate or Yes 224 28.2 59.282 .000

Folic Acid No 88 71.8

47
Types of foods and Fruit 288 92.3 138.481 .000

drinks do you think Green vegetables 123 39.4

are good sources of Milk 89 28.5

folate Fish/Seafood 36 11.5

Meat 78 25

Breakfast cereals 8 0.025

Bread 39 12.5

Health problems are Arthritis 39 12.5 4.459 .000

associated with lack Neural Tube Defects

200 64.1
of enough (e.g. spina bifida)

folate/folic acid in Goiter (enlarged

73 23.4
the diet thyroid gland)

Approximately 72% the respondents who indicated that they were not aware of folate or

folic acid compared to 28.2% who indicated that they were aware. Among the foods, the

respondents were aware or knew as good sources of folate, 92.3% indicated fruits

compared to 39.4% who indicated green vegetables while 28.5% indicated milk.

Assessing knowledge of health problems are associated with not having enough

48
folate/folic acid in the diet, majority (64.1%) indicated Neural Tube Defects (e.g. spina

bifida) compared to 23.4% who said Goiter (enlarged thyroid gland). All the responses

were significant at 5% level

Figure 4.2: Knowledge of health problems associated with lack of enough folate/folic

acid in the diet

49
4.8 Cross tabulations

Cross tabulations are simply data tables that present the results of the entire group of

respondents as well as results from sub-groups of survey respondents. The Tables that

follows presents the cross tabulation between social demographic data and awareness of

iron, folic acid vitamin A.

Cross tabulations of Age and Nutrients Awareness

Table: 4.8.1: Age Bracket and Nutrient Awareness

Aware of micronutrient iron Chi-

Square
Age bracket Yes No Total
Less than 20 years 26 8 34 1.057a .788
Between 21-30
52 24 76
years
Between 31-40
86 40 126
years
More than 40
51 25 76
years
Aware of Vitamin A
Less than 20 4.785a .188
28 6 34
years
Between 21-30
54 22 76
years

50
 Between 31-40
104 22 126
years
More than 40
63 13 76
years
Aware of Folate or Folic
Acid
Less than 20 years 25 9 34 8.196a .042
Between 21-30
55 21 76
years
Between 31-40
81 45 126
years
More than 40
63 13 76
years
Total 224 88 312

Table: 4.8.2: Age Bracket and nutrient awareness

Aware of micronutrient Chi-

iron Square
Yes No Total
Marital Single 17 7 24 .683a .877
status
Married/cohabiting 168 75 243
Divorced/ Separated 21 12 33
Widow 9 3 12
Aware of Vitamin A
marital status Single 17 7 24 1.921a .589
Married/cohabitin
195 48 243
g
Divorced/
28 5 33
Separated

51
 Widow 9 3 12
Aware of Folate or Folic
Acid
marital status Single 16 8 24 3.027a .387
Married/cohabiting 174 69 243
Divorced/
27 6 33
Separated
Widow 7 5 12
Total 224 88 312

Table: 4.8.3 Education Level and Awareness

Aware of micronutrient
called iron
Highest level of education you have
achieved Yes No Total
Primary level 79 48 127 8.375a .137
Secondary level 51 12 63
University level 8 4 12
Postgraduate 8 4 12
None 27 15 42
College level 42 14 56
Aware of Vitamin A
Primary level 94 33 127 7.292a .200
Secondary level 51 12 63
University level 11 1 12
Postgraduate 12 0 12
None 35 7 42

52
 College level 46 10 56
Aware of Folate or Folic
Acid
Primary level 92 35 127 9.562a .089
Secondary level 49 14 63
University level 8 4 12
Postgraduate 12 0 12
None 29 13 42
College level 34 22 56
Total 224 88 312

53
 CHAPTER FIVE

DISCUSSIONS, CONCLUSION ANDRECOMMENDATION

5.1 Introduction

The chapter presents summary of the study findings and the conclusions arrived at. The

chapter also gives recommendations and the suggestions for further study. The discussion

is guided by the study objectives

5.2 Discussions

Majority (68.9%) of the respondents were not aware of iron (p value <0.05) and further

that 44.2% of the respondents knew the sources of iron compared to 54.8% who neither

knew or not sure on the sources (p value >0.05). this agreed with Brabin et al, (2008) who

noted that most of women in developing countries especially in the marginalized areas

were not aware of iron. On the frequencies, the respondents took the iron rich foods, it

was established that majority (130, 41.7%) indicated they took them weekly compared to

30.8% who cited they took them on monthly basis. It was established majority

(199,63.8%) faced challenges to access and availability of iron rich foods and thus the

need for IFAS or other iron rich supplements. most of the women (249,79.8%) were

aware of Vitamin A and further 96.2% were aware of the various sources of Vitamin A

and these responses were significant at 5%. On the query about frequency of intake of

54
Vitamin A, it was established that majority 46.2% and 42.3% took foods rich in Vitamin

A on weekly and daily basis. Further, most (230, 73.7%) of the respondents indicated that

they experienced challenges in terms of access and availability of Vitamin A. the study

agrees with Milman et al, (2003) who noted that weekly vitamin A supplementation

reduced maternal mortality by 40% and further most women may not know they have

deficiency of the vitamin and presented in this study.

Approximately 72% the respondents who indicated that they were aware of folate or folic

acid compared to 28.2% who indicated that they were not aware. Among the foods, the

respondents were aware or knew as good sources of folate, 92.3% indicated fruits

compared to 39.4% who indicated green vegetables while 28.5% indicated milk.

Assessing knowledge of health problems are associated with not having enough

folate/folic acid in the diet, majority (64.1%) indicated Neural Tube Defects (e.g. spina

bifida) compared to 23.4% who said Goiter (enlarged thyroid gland). All the responses

were significant at 5% level. Though few studies have assessed the folate knowledge,

Cook (2004) indicated that Folate requirements are 5-to 10-fold higher in pregnant than

in non-pregnant women, therefore pregnant women may be at risk for folate deficiency,

and from this study, it is evident that women from Mandera community have little

knowledge and their practice is sub optimal on it and thus they may be suffering from its

deficiency.

55
5.3 Conclusions

Most of the respondent was in their second or other pregnancies as they had been

pregnant before compared to those in their first pregnancy .On the stage of their

pregnancies, slightly more than half were in their second trimester compared to a quarter

in their first trimester That majority of the respondents were aware of iron and further

that less than half of the respondents knew the sources of iron compared to more than half

who neither knew or not sure on the sources. Majority faced challenges to access and

availability of iron rich foods and thus the need for IFAS or other iron rich supplements.

Knowledge on anemia: Majority of the pregnant women do not have any knowledge on

anemia and its effects in pregnancy, which influences the importance to which they attach

to the supplements.

Most of the women were not aware of Vitamin A and further some of them were aware

of the various sources of Vitamin A and these responses were significant at 5%. Majority

they don’t take foods rich in Vitamin A on daily basis. Most respondents who indicated

that they were not aware of folate or folic acid compared to 28.2% who indicated that

they were aware. Among the foods, the respondents were aware or knew as good

sources of folate, most indicated fruits compared to a third who indicated green

vegetables while 28.5% indicated milk

56
5.4 Recommendations

1. Health professionals at the health facility should sensitize pregnant women on the

need to continuously take the supplements throughout pregnancy. To ensure that

the pregnant women actually take the supplements, education on anemia in

relation to pregnancy should be done. Training to the health professionals and

community health workers in regard to anemia, nutrition during pregnancy and

counseling skills to be applied when they come in contact with the mothers.

2. Education on anaemia prevention should be emphasized in the community level

in order to encourage dietary modifications and promote environmental control of

infections contributing to anaemia. This needs to be carried out on a continuous

basis and integrated with other ongoing community health programmes.

3. Subsequent studies should be undertaken by the Ministry of Health (MoH) and

other research bodies on the iron/folate supplementation program for the

improvement of maternal health and on dietary adequacy

57
 REFERENCES

Brabin C. Katai E, Kaplan B, Raick Y, Cohen Y, Neri A, FriedmanJ. (2008). Community

screening to reveal iron deficiency in healthy menstruating women inIsrael

suburbs. EurJObstetGynecolReprodBiol; 67:21-5.

C.N.M. Nyaruhucha. (2009) Food cravings, aversions and pica among pregnant women

Central Statistics Agency. Ethiopia Demographic and Health Survey. Addis Ababa,

Ethiopia: Central Statistics Agency; 2011.

Cook NR, (2004) Plasma folate, vitamin B-6, vitamin B-12, and risk of breast cancer in

pregnant women. Am J Clin Nutr87: 734–743.

Harrison KA, Rossiter CE. Maternal mortality. Br J ObstetGynaecol 2005; 83:449-53.

Hassan et al., 2013; Nutrition & Health in developing Countries, 2008

Holliday, RoseAnna Boyle, "Anemia Prevention: Development of a Theory-Driven

Nutrition Education Measurement Instrument" (2011). Doctoral Dissertations.

AAI3464374.

https://opencommons.uconn.edu/dissertations/AAI3464374

in Dar es Salaam, Tanzania. Tanzania Journal of Health Research, Vol. 11, No. 1,

January 2009 29

58
IOM. (2003). Iron deficiency anemia: recommended guidelines for the prevention,

detection, and management among U.S.children and women of childbearing

age. Washington DC: National Academy Press.

James, V., Jones, K., Turner, E. And Sokol, R. (2003). Statistical analysis of

inappropriate results from current Hb screening methods for blood d donors.

Transfusion; 43: 400–404

Jane K. John, B., Mahshid, L., Nita, D., Karita, S. and Megan, D. (2007). Current

progress and trends in the control of vitamin A, iodine and iron deficiency.

The micronutrient report; pp 1-65

Jane, B., Michael, B. And Klaus, K. (2007). The guidebook. Nutritional Anemia. Sight

and Life Press. pp 1-11

John, B., Mahshid, L., Nita, D., Karita, S. and Megan, D. (2001). Current progress and

trends in the control of vitamin A, iodine and iron deficiency. The

micronutrient report; pp 1-65

Kenya Demographic and Health survey (2014), North Eastern: Key Indicators from the

2014 KDHS. pp. 17-18

Kenya National Bureau of Statistics (KNBS) and ICF Macro. (2015). Kenya

59
 Demographic and Health Survey 2014 Key Indicators. Calverton Maryland: KNBS

and ICF Macro.

Khadija K. (2006). Iron requirements in normal pregnancy as assessed by serum ferritin,

serum transferrin saturation and erythrocyte protoporphyrin determinations.

British Journal of Obstetrics and Gynaecology; 90:101-7.

Mandera County Integrated Development Plan 2013-2017

Mbule MA, Byaruhanga YB, Kabahenda M, Lubowa A. Determinants of anaemia

among pregnant women in rural Uganda. Rural and Remote Health (Internet)

2013; 13: 2259.

Available: http://www.rrh.org.au/articles/subviewnew.asp?ArticleID=2259 (Acce

ssed 7 February 2016)

Milman N, Rosdahl N, Lyhne N, Jorgensen T, Graudal N. (2003). Iron status in

Danishwomen aged 35-65 years. Relation tomenstruation andmethodof

contraception.Aca ObstetGynecolScand; 72:601-5.

Milman.Brabin L, Verhoeff FH, Kazembe P, Brabin BJ, Chimsuku L, Broadhead R.

2003)Improving antenatal care for pregnant adolescents in southern Malawi.

ActaObstetGynecolScand 2008; 77:402-9.

60
Morris P. Boulton, F., Nightingale, M. and Reynolds W. (2009). Improved strategy for

screening prospective blood donors for anaemia. Transfusion Medicine; 4: 221–

225.

Morris, S., Ruel, M., Cohen, R., Dewey, K., de la Briere, B. and Hassan, M.

(2009).Precision, accuracy, and reliability of haemoglobin assessment with

use of capillary blood. American Journal of Clinical Nutrition; 69 (6):1243–1248

Rajeev Kumar Yadav, M.K Swamy, Bijendra Banjade (2014). Knowledge and Practice

of Anemia among pregnant women attending antenatal clinic in Dr. Prabhakar

Kore hospital, Karnataka-A Cross sectional study.

Robert M. Groves , Floyd J. Fowler Jr., Mick P. Couper James M. Lepkowski , Eleanor

Singer , Roger Tourangea Survey-Methodology-Robert-M-Groves/

Roberts-Lombard, (2006). Exploring the relationship between trust, commitment and

customer loyalty through the intervening role of customer relationship

management (CRM) in hospitals. African Journal of Marketing Management Vol.

3(8), pp. 207-218, August 2011

Romslo, I., Haram, K., Sagen, N. And Augensen, K. (2003). Iron requirements in

normal pregnancy as assessed by serum ferritin, serum transferrin saturation

61
 and erythrocyte protoporphyrin determinations. British Journal of Obstetrics and

Gynaecology; 90:101-7.

Sari M, dePee S, Martini, E., Herman, S., Bloem, M. and Yip, R. (2001). Estimating the

prevalence of anaemia: a comparison of three methods. Bulletin World Health

Organization; 79: 506–511.

Saunders M. Puolakka, J., Janne, O., Pakarinen, A., Jarvinen, P. And Vihko, R. (2009).

Serum ferritin as a measure of iron stores during and after normal pregnancy with

and without iron supplement. ActaObstetricia ET Gynecologica Scandinavica;

95:43-51.

Sawe, F. (2001). Kericho CLinic-Based ART Diagnostic Evaluation (CLADE): Design,

Accrual, and Baseline Characteristics of a Randomized Controlled Trial

Conducted in Predominately Rural, District-Level, HIV Clinics of Kenya

Scholl TO, Hediger ML, Fischer RL, Shearer JW. (2002). Anemia vsiron

deficiency:increased risk of preterm delivery in a prospective study. Am J

ClinNutr; 55:985-8?

Shoran M.,Jahr, J., Lurie, F., Driessen, B., Davis, J., Gosselin, R. and Gunther, R. (2009).

The HemoCue®, a point of care B-haemoglobin photometer, measures

62
 haemoglobin concentrations accurately when mixed in vitro with canine plasma

and three hemoglobinbased oxygen carriers (HBOC). Journal of Anaesthesia; 49

(3):243–248

Souganidis Taylor, D., Mallen, C., McDougall, N. And Lind, T. (2012). Effect of iron

supplementation on serum ferritin levels during and after pregnancy. British

Journal of Obstetrics and Gynaecology; 89: 1011-7.

Souganidis, E. S., Sun, K., de Pee, S., Kraemer, K., Rah, J.-H., Moench-Pfanner, R., …

Semba, R. D. (2012). Relationship of maternal knowledge of anemia with

maternal and child anemia and health-related behaviors targeted at anemia among

families in Indonesia. Maternal and Child Health Journal,16(9), 1913–1925.

http://doi.org/10.1007/s10995-011-0938-y

The prevalence of anaemia in women: a tabulation of available information. Geneva,

World Health Organization, 2002 (WHO/MCH/MSM/92.2).

WHO and CDC. (2008). Assessing the iron status of populations. Report of a joint

World Health Organization/Centers for Disease Control and Prevention

technical consultation on the assessment of iron status at the population

63
 level. Geneva, Switzerland: World Health Organization and Centers for Disease

Control and Prevention: pp1-30.

WHO and CDC. (2008). Worldwide prevalence of anemia 2009 to 2005 Global data base

on anemia. pp 1-17

WHO Global Database on Iron Deficiency and Anaemia, Micronutrient Deficiency

Information System. Geneva, World Health Organization (to be published).

64
 APPENDICES

APPENDIX I: CONSENT FORM

My name is Abdirizak Haji Mohamed, a master student in Kenya Methodist University.

I’m undertaking a study on the factors leading to anaemia among pregnant women in

Mandera county .The aim of this survey is to determine the knowledge of anaemia and

nutritional causes of anaemia among pregnant women in Mandera Referral County

Hospital. I wish to request for your voluntary participation and consent in regard to this

study

• You are free to choose either to participate or decline to participate.

• There will be no payment for those who choose to participate.

• Information given was treated with utmost confidentiality and was used for the

purpose of the study only.

• No names will be used to identify you and the information gathered will help

enhance better understanding of the study topic.

• You may refuse to answer any question or withdraw from the study at any time.

• There will no alteration of data during analysis and after the study; the researcher

will give feedback to the hospital for necessary action.

65
Having read and understood the above information and that the study is voluntary,

confidentiality and anonymity are guaranteed, I do hereby accept to participate in this

research study.

Participant’s sign……………………………… Date…………………………..

Principal researcher’s sign……………………… Date……………………………

APPENDIX II: RESEARCH QUESTIONNAIRE

Demographic Information

1. What is your age bracket?

Less than 20 years [ ]

Between 21-30 years [ ]

Between 31-40 years [ ]

More than 40 years [ ]

2. What is your marital status?

Single [ ]

66
 Married/cohabiting [ ]

Divorced/ Separated [ ]

Widow [ ]

3. What is the highest level of education you have achieved?

Primary level [ ]

Secondary level [ ]

University level [ ]

Postgraduate [ ]

None [ ]

4. What is your average monthly income?

Less than Ksh 30, 000 [ ]

Between Ksh 31,000-60,000 [ ]

Between Ksh 61,000-90,000 [ ]

More than Ksh 90,000 [ ]

67
5. Have you been pregnant before

Yes [ ]

No [ ]

6. What is the stage of your pregnancy?

First Trimester [1Months-3Month]

Second Trimester [3Month-6months]

Third Trimester [6Month-9Months]

7. If yes, to the above question, how many previous pregnancies have you had?

One pregnancy [ ]

Two pregnancies [ ]

Three pregnancies [ ]

More than four pregnancies [ ]

68
INTAKE OF IRON

8. Are you aware of micronutrient called iron?

Yes [ ]

No [ ]

Don’t know/ Not Sure [ ]

9. Do you know the sources of iron?

Yes [ ]

No [ ]

Don’t know/ Not Sure [ ]

If yes, which are the sources of iron both animal and plant based sources?

Fruit [ ]

Vegetables [ ]

Eggs [ ]

69
 Meat [ ]

Salt [ ]

Milk [ ]

10. What is your intake frequency of those foods?

Daily [ ]

Weekly [ ]

Monthly [ ]

Never [ ]

11. Do you have any challenges in terms of access and availability of iron rich

source of iron?

Yes [ ]

No [ ]

Don’t know/ Not Sure [ ]

INTAKE OF VITAMIN A

70
12. are you aware of Vitamin A

Yes [ ]

No [ ]

Don’t know/ Not Sure [ ]

13. are you aware of sources of Vitamin A

Yes [ ]

No [ ]

Don’t know/ Not Sure [ ]

14. What are the main sources of Vitamin A?

Fruit [ ]

Green vegetables [ ]

Orange vegetables [ ]

Yellow vegetables [ ]

Tomato [ ]

71
 Dairy products [ ]

Liver [ ]

Fish [ ]

Fortified cereals [ ]

15. What is your intake frequency of those foods?

Daily [ ]

Weekly [ ]

Monthly [ ]

Never [ ]

16. Do you have any challenges in terms of access and availability of iron rich

source of iron?

Yes [ ]

No [ ]

Don’t know/ Not Sure [ ]

72
INTAKE OF FOLATE

17. Are you aware of Folate or Folic Acid?

Yes [ ]

No [ ]

Don’t Know/Not sure [ ]

18. Which types of foods and drinks do you think are good sources of folate?

Fruit [ ]

Green vegetables [ ]

Milk [ ]

Fish/Seafood [ ]

Meat [ ]

Breakfast cereals [ ]

Bread [ ]

73
19. Which health problems are associated with not having enough folate/folic

acid in the diet? (More than one answer can be ticked)

Arthritis [ ]

Neural Tube Defects (e.g. spina bifida) [ ]

Goitre (enlarged thyroid gland) [ ]

Mental retardation [ ]

74
APPENDIX III: APPROVAL LETTERS

75
76
77
78
79