Exploring the perspective of young adults about anaemia prevention; the contributions of knowledge about at-risk groups and consequences of anaemia

Globally, anaemia is estimated to affect more than three persons in every ten individuals, with developing countries accounting for > 80% of the global anaemia burden [1, 2]. In most sub-Saharan African countries, anaemia is a moderate or severe public health problem [3]. In Ghana, the prevalence of anaemia has been estimated among different sections of the population; 42% among women of reproductive age [4, 5], 13%—50% among adolescents [6, 7], 49%—66% among children under 5 years [5, 8], and 39% among the elderly [8, 9]. In a previous study that involved a cohort of university students, anaemia prevalence was estimated to have increased from 20% to 45.1% over the course of one academic year [10]. That study therefore found anaemia to be a moderate public health problem, at the beginning of the academic year, but anaemia prevalence progressed to a severe public health challenge among students during the latter parts of the second semester. Most of the previous anaemia-related studies in literature have focused on assessing anaemia and risk factors of anaemia [5, 11, 12]. However, there is scanty primary research exploring the perceptions of individuals on anaemia and what their knowledge of predisposition factors to the condition are [13]. This is in spite of the fact that anaemia is endemic in Ghana, and that misconceptions and/or poor knowledge about anaemia may be a hindrance to the successful implementation of any anaemia control strategies [14].

The aim of this study, therefore, was to explore the perceptions of young adults about anaemia and how perceptions and knowledge are interlinked. We sequentially employed both quantitative and qualitative data collection approaches to explore the perceptions of young adults about anaemia as a means of triangulating the data to increase scientific rigour as well as the generalizability of the study findings. Whereas the qualitative data collection enabled us to explore the perceptions of these young adults about anaemia, the quantitative data was used to establish relationships between the knowledge about causes of anaemia, consequences of anemia, and individuals at-risk of anaemia as well as the preventive measures students adopt to curb anaemia.

Anaemia is estimated to roughly affect one-third of the world’s population and has consistently remained a global health concern [2]. In sub-Saharan Africa, anaemia is a moderate to severe public health problem in most countries [3]. According to a study undertaken by Wiafe and associates in 2021, adolescents in Ghana had less knowledge about iron deficiency anaemia (IDA) or the causes, consequences, and prevention of IDA. Additionally, the Wiafe et al. study also demonstrated that fewer adolescents were knowledgeable about iron-rich food sources or factors that might improve/inhibit iron absorption from diet [17]. Previously, we also showed that anaemia prevalence in a cohort of university students more than doubled in an academic year [10]. The present study therefore employed a mixed-methods approach to model the relationship between tertiary students’ knowledge about individuals at risk of developing anaemia, risks associated with anaemia, causes and consequences of anaemia, and anaemia prevention strategies. Our structural equation modeling demonstrated that students’ knowledge of at-risk groups and the consequences of anaemia significantly influences the preventative strategies that may be adopted to mitigate anaemia. Furthermore, knowledge about the consequences of anaemia significantly positively mediates the impact of knowledge about the at-risk groups on the preventive strategies when considering anaemia from the perspective of our tertiary students’ cohort.

Our study found a disconnect between what the students knew about anaemia and what they did in terms of nutritional choices. Overall, 85.5% of our cohort could correctly identify that anaemia had to do with low levels of blood or haemoglobin concentration. In the focus group discussion, participants were able to identify low energy, easy fatigability, increased heart rate, and changes in physical appearance such as paleness, and yellowish colouration of the eye as potential symptoms of anaemia. These symptoms of anaemia as espoused by our student cohort are consistent with scientific data on symptoms of anaemia [18, 19]. Further, although the majority of the participants knew that increasing vegetable intake could potentially prevent anaemia, this knowledge did not actualize in these students as less than half of the students indicated including vegetables in their diet during their stay on campus. It is instructive to note that during the FGD, the participants suggested economic constraints as a potential cause of anaemia. For example, participants overwhelmingly agreed that the high economic cost of living and poverty makes it difficult to patronize vegetables while on campus. This supports the findings from a multi-national study that showed weak preferences, poverty, and relatively high food prices were important constraints in attaining healthy eating standards in sub-Saharan Africa [20]. In agreement with previous reports, food insecurity precipitated by weak finances, and the financial constraint inherent in higher education make these students prone to unhealthy lifestyle choices. Previous studies have found prevalence of food insecurity to be as high as 44% [21], 39% [22], 38 – 48% [23, 24], respectively among students from University of California, Lebanon, and Australian universities, and therefore suggest a more global problem in the tertiary setting. Furthermore, although our cohort unanimously agreed that regular intake of balanced meals was an important preventive strategy to deal with anaemia, over two-thirds (73.5%) indicated skipping meals while on campus. When the issue of meal skipping was explored during the focus group discussion, the reasons offered for skipping meals were multi-factorial and included demands on time in view of academic work and the high cost of living that make it untenable to routinely eat three-square meals per day. As evidenced in the thematic analysis of the FGD, the students knew that eating a balanced diet that includes meat, egg, vegetables, and fruits, as well as food supplementation was important for anaemia prevention and that failure to routinely take balanced meal would negatively affect academic performance (64.0%). However, the realities on campus are such that they skip meals, and are not able to routinely afford three square meals and thereby predisposing them to anaemia in spite of the knowledge. In support of the link between food insecurity and anaemia predisposition, a synthesis of the literature through a meta-analyses by Moradi and colleagues demonstrated a significant positive association between anaemia or iron deficiency anaemia and food insecurity among various age groups [25]. It is also instructive to note that comparatively, a higher proportion of females (vs males, p = 0.007), or participants ≥ 40 years old category (vs lower age groups, p = 0.017) indicated regular inclusion of vegetables in their diets. This is suggestive that being female or older was associated with increased healthy eating choices. Although the reason(s) why higher proportion of females saw the importance of vegetables in the diet were not readily apparent, the fact that females generally are responsible for cooking in the traditional Ghanaian family settings, as well as the nutritional education females receive during antenatal clinic visits [26, 27] might be plausible explanations for the observations reported herein.

Noteworthily, about two-thirds of our study cohort could identify potential adverse consequences of anaemia on pregnancy outcomes such as intra-uterine death (63.5%), low birth weight (65.4%) as well as impaired mental (61.8%) and physical (72.6) development of children in agreement with published data [28, 29]. Although this finding is at variance with a previous qualitative study in Ghana where participants were unable to connect anaemia to adverse birth outcomes [13], we believe the differences might stem from the fact that our participants were individuals with tertiary level education (who might have had a higher chance of exposure to anaemia-related literature) whereas < 5% of the Awuah et al., study participants had tertiary level education. In view of these anaemia-induced adverse intra-pregnancy outcomes, as indicated by our study cohort, it was not surprising that more than six-out-of-ten of our study cohort could correctly identify pregnant women, and adolescent females as groups, particularly at high risk of developing anaemia. When participants were asked for clarifications as to why these reproductive aged women were particularly at high risk, FGD participants unanimously opined that the demands of menstruation and pregnancy make these individuals prone to higher anaemia prevalence. These suppositions are in agreement with findings of previous studies that demonstrated that menstruation [30], women of reproductive age [4], and pregnancy [31] are significant determinants of anaemia. Surprisingly however, less than half of our study cohort (42.5%) agreed that shorter inter-pregnancy interval (defined in this study as inter-pregnancy intervals < 18 months) was a significant risk factor for anaemia in reproductive aged women. Even when asked whether ensuring ≥ 18 months inter-pregnancy intervals or preventing teenage pregnancies could be important anaemia prevention strategies in women, only about one-third of the cohort (36.1% and 30.6% respectively) agreed. This contrasts with established scientific data that demonstrate that both teenage pregnancies and shorter inter-pregnancy intervals are each independently associated with adverse maternal and perinatal outcomes [32‐34]. Taken together, these findings, therefore demonstrate a lack of comprehensive understanding of the multi-dimensionality of factors that could put an individual at a higher risk of anaemia.

Taken together with previous studies on anaemia [13, 35], our present study is suggestive that poor knowledge or incomplete knowledge about anaemia is an entrenched public health problem that requires a multi-sectorial stakeholder engagement to evolve a holistic public health campaign to increase chances of making any meaningful impact. Bearing in mind that our cohort was young adults who might be in the process of making reproductive choices, it will be interesting to study the lifestyle and dietary choices these young adults consider appropriate in preventing anaemia in the unborn. This would be a worthwhile study considering that less than half of our study cohort agreed that inadequate meat (31.3%) or fish intake (36.2%), road traffic accidents (37.5%) or poor hygiene (40.9%) could potentially cause anaemia (Supplementary Table ST2). If the causative agents of anaemia are poorly understood and/or not appreciated by these tertiary students (some of who were postgraduate students), we postulate a graver anaemia knowledge among individuals with only secondary education or no formal education in the communities. This poor understanding might provide insights as to why anaemia has been consistently a moderate-to-severe public health problem in most sub-Saharan African countries. We propose that a national multi-sectorial stakeholder engagement involving the Ghana health services, the ministry of health, the ministry of education and the national commission for civic education (NCCE) as well as sponsors from the media landscape should be convened to formulate anaemia sensitization strategies, and educational campaigns to tackle the persistent public health threat posed by anaemia. Since the NCCE is the legal body mandated to take policy issues to the grassroots, we consider their involvement to be a priority policy consideration since it would provide an avenue to engage the public through indigenous dialect to help address misconceptions as well offer comprehensive holistic knowledge on anaemia to the populace. It has been noted that the success of policy implementation is greatly influenced by the knowledge of the recipients and the adequacy of collaboration between stakeholders [36]. Additionally, such undertakings should be backed by the needed socioeconomic and macroeconomic empowerment from governments to improve living standards to increase chances of success since social determinants of health are an important consideration in dealing with anaemia [37‐39]. In view of our finding of food insecurity among our student cohort, and the reported adverse consequences of food insecurity among tertiary students such as poor mental health [40, 41], and poor academic performance [40], these public health campaigns should consider financial aid and other support systems that could potentially improve food security in tertiary settings.

Our structural equation modeling provided some clarifications about the underlying relationship among the constructs used to explore students’ knowledge about anaemia. Specifically, our study found that knowing the causes of anaemia did not significantly associate with either knowledge about the consequences of anaemia or the knowledge about preventive strategies that could be adopted to prevent anaemia. However, knowledge about individuals at-risk of anaemia was significantly positively associated with preventive strategies that could be employed to curb anaemia. Additionally, knowledge about individuals at-risk of anaemia was significantly positively associated with knowledge about the consequences of anaemia. Importantly, our findings suggest a potential mediating influence of knowledge about the consequences of anaemia on the significant positive association between knowledge about at-risk groups and preventive measures that could be adopted to mitigate anaemia. The fact that simply knowing about anaemia did not significantly associate with the other constructs suggests a possible complex, non-linearity of relationships between the constructs. Taken together, we propose that any public health campaign seeking to address anaemia in sub-Saharan should adopt the complex adaptive systems (CAS) thinking approach [42, 43] given the plausible inter-relating personal, political and socio-economic factors that may cumulatively impact policy outcomes. Such a CAS approach would be invaluable in unearthing potential feedback loops (positive and/or negative), as well as factors that may cross multiple domains and stimulate consensus building among stakeholders to ensure success with policy implementation.

Although this study employed qualitative and quantitative data collection processes to increase the rigour of the study outcomes, we acknowledge some limitations. Our sampling frame covered only tertiary students which might have introduced an element of selection bias in view of the fact that educational attainment is an important consideration in the social determinants of disease conditions [39, 44]. The present study employed convenience sampling technique in which only students who agreed to participate were recruited; this might have likely introduced participation bias in the data presented herein. Additionally, our study is a one-centre study that involved only students from the University of Cape Coast and may not necessarily be generalizable to other tertiary institutions across the country since the dynamics differs across the country. Furthermore, in view of the exclusion of students on the distance learning mode from the study, we acknowledge that the findings may not reflect the experiences and anaemia knowledge among such students considering that food insecurity issues may not be as pronounced among such students. In spite of these limitations, we are of the opinion that since the University of Cape Coast is an equal access university and admits students from all across the 16 regions of Ghana, and the fact that the sampling cut across colleges offering health and non-health related programmes, our data provides an approximation of the anaemia knowledge base among young adults in Ghana.