CONCEPTS OF ANEMI A AMONG LOW I NCOME NI CARAGUAN W OMEN
Rit a L. Ailinger1 Jean B. Moor e2 Lisa Paw losk i3 Lidy a Rut h Zam or a Cor t és4 Ailinger RL, Moore JB, Pawloski L, Cort és LRZ. Concept s of anem ia am ong low incom e nicaraguan wom en. Rev Lat ino- am Enfer m agem 2009 m ar ço- abr il; 17( 2) : 147- 52.
Anem ia is a com m on healt h pr oblem am ong w om en t hr oughout t he w or ld, how ev er , t her e has been m inim al research on wom en’s concept s of anem ia. The purpose of t his st udy was t o exam ine concept s of anem ia in low incom e Nicar aguan w om en. A qualit at ive design w as used. Audio- t aped open- ended int er view s in Spanish w it h 14 w om en w er e used t o obt ain dat a. Tapes w er e t r anscr ibed and cont ent analyzed. The findings indicat e t hat few of t he w om en had biom edically accurat e concept s of anem ia, such as t hat it w as due t o lack of iron from poor eat ing. Ot hers held folk m edical beliefs including hom e rem edies, for exam ple drinking t he m ilk of a m are or beet j uice and eat ing cer t ain foods such as bean soup. Most of t he w om en did not know any sym pt om s of anem ia and a few r epor t ed t hat it can dev elop int o leuk em ia. These concept s of anem ia ar e inst r uct iv e for nurses w orking w it h pat ient s from Nicaragua and w ill be useful in developing nursing int ervent ions t o alleviat e t his public healt h pr oblem .
DESCRI PTORS: anem ia; Nicar agua; Lat in Am er ica
CONCEPTOS DE ANEMI A ENTRE MUJERES NI CARAGÜENSES DE BAJA RENTA
La anem ia es un problem a de salud com ún ent re las m uj eres alrededor del m undo, sin em bargo, se han realizado pocas invest igaciones sobre los concept os de anem ia ent re las m uj eres. El propósit o de est e est udio fue exam inar los concept os de anem ia en m uj eres Nicaragüenses de baj os ingresos económ icos. La invest igación fue de orden cualit at iv a. Par a la r ecolección de dat os, se r ealizar on ent r ev ist as sem iest r uct ur adas, gr abadas en cast ellano, con 14 m uj er es. Las cint as gr abadas fuer on t r anscr it as y se r ealizó un análisis de cont enido. Los r esult ados indican que pocas m uj eres poseen conocim ient os biom édicos sobre anem ia, por ej em plo, la ingest ión de alim ent os pobres en hierro. Ot ras expresaron creencias populares, com o rem edios caseros, ingest ión de leche de yegua o j u go de r em olach a y cier t os alim en t os com o sopa de j u días. La m ay or ía de las m u j er es n o con ocía n in gú n sínt om a de anem ia y pocas relat aron que creían que est a enferm edad podría t ransform arse en leucem ia. Est os concept os de anem ia son inst r uct ivos par a las enfer m er as que t r abaj an con pacient es en Nicar agua y ser á de m ucha ut ilidad par a desar r ollar int er venciones de enfer m er ía par a aliviar est e pr oblem a de salud pública. DESCRI PTORES: anem ia, Nicar agua, Am ér ica Lat ina
CONCEI TOS DE ANEMI A ENTRE MULHERES NI CARAGÜENSES DE BAI XA RENDA
A anem ia e um pr oblem a de saúde com um ent r e as m ulher es de t odo a m undo int eir o, m as t em hav ido um m ín im o de in v est igação sobr e os con ceit os de an em ia en t r e as m u lh er es. O obj et iv o dest e est u do foi o de analisar os conceit os de anem ia em m ulheres nicaragüenses com baixos rendim ent os. Foi ut ilizado um desenho q u alit at iv o. Par a a colet a d e d ad os, en t r ev ist as sem i- est r u t u r ad as f or am con d u zid as, áu d io g r av ad as em espanhol para 14 m ulheres. As fit as foram t ranscrit as e t ornou- se um a análise cont eúdo. Os result ados indicam que poucas m ulher es possuem conhecim ent o biom édico pr eciso sobr e anem ia, t al com o ingest ão de alim ent os pobr e em fer r o. Out r as m ant iver am out r as cr enças popular es incluindo r em édios caseir os, ingest ão de leit e de égu a ou su co de bet er r aba e cer t os alim en t os com o sopa de f eij ão. A m aior ia das m u lh er es n ão con h ecia nenhum sint om a de anem ia e poucas r elat ar am que pode pr ogr edir par a leucem ia. Est es conceit os de anem ia são esclar ecedor es par a os enfer m eir os que t r abalham com doent es na Nicar água e que ser á m uit o út il par a desenv olv er int er v enções de enfer m agem par a m inor ar o pr oblem a de saúde pública.
DESCRI TORES: anem ia; Nicar água; Am ér ica Lat ina
Disponible en castellano/ Disponível em língua portuguesa SciELO Brasil w w w .scielo.br/ rlae 1
I NTRODUCTI ON
T
h e Wo r l d H e a l t h Or g a n i z a t i o n ( W H O) est im at es t h at an em ia af f ect s ov er 2 billion people w or ldw ide( 1 ). An em ia is a gen er al t er m r efer r in g t o t he condit ion char act er ized by abnor m ally low lev els of healt hy r ed blood cells or hem oglobin. Ther e ar e m ult iple causes of anem ia including genet ic and diet ary fact or s. The m ost com m on inher it ed for m of anem ia is t halassem ia. These form s of anem ia prim arily affect t hose of African, Sout heast Asian, and Medit erranean her it age. Sick le cell anem ia is anot her m or e ser ious inherit ed form of anem ia which affect s t hose of African and Medit er r anean her it age and can lead t o chr onic f at i g u e an d p o t en t i al l y l i f e t h r eat en i n g si ck l e cel l crises. Regarding diet ary causes of anem ia, t he m ost co m m o n k i n d o f a n e m i a i n cl u d e s i r o n d e f i ci e n cy anem ia, how ever, deficiencies of folic acid, B12, and Vit am in C can also lead t o low levels of hem oglobin( 2). These dat a reflect anem ia as m easured by hem oglobin st at u s, of w h ich t h e WHO est im at es t h at 5 0 % ar e caused by ir on deficiency anem ia ( her eaft er r efer r ed t o as anem ia) . Wom en, part icularly pregnant wom en, and childr en ar e m ost at r isk of anem ia w or ldw ide, and t he WHO suggest s t hat 52% of pregnant wom en, 42.3% of all wom en, and 48% of children are anem ic in dev eloping count r ies. I n Lat in Am er ica, anem ia is a huge problem affect ing 19% of t he ent ire populat ion, w i t h t h e m aj o r i t y o f cases af f ect i n g ch i l d r en an d w o m en( 3 ). An em i a ca u sed b y d i et a r y f a ct o r s i s a disease t hat is r eadily pr ev ent able and t r eat able.Co n c e p t s o f d i s e a s e a r e i n f l u e n c e d b y educat ion, econom ics and m ost im port ant ly by cult ure. How p eop le t h in k ab ou t d isease com es f r om t h eir cult ural experience wit h t he disease. When t he concept of a d isease is d if f er en t f or t h e n u r se an d f or t h e pat ient , due t o varying cult ural beliefs, t he incongruit y m ay lead t o m isu n d er st an d in g s, p r ob lem s in g oal set t in g an d n on - adh er en ce t o pr escr ibed r egim en s. The purpose of t his st udy was t o explore t he concept of anem ia in low incom e Nicaraguan wom en in order t o p r ov id e a m or e cu lt u r ally sen sit iv e ap p r oach t o anem ia prevent ion and t reat m ent by nurses and ot her healt h car e pr ov ider s.
BACKGROUND
I n t h e p a st f i v e y e a r s, f e w st u d i e s h a v e explored differing concept s of anem ia and none have
t arget ed Nicaraguan wom en. I n a m aj or eight - count ry q u a l i t a t i v e st u d y t h a t w a s co n d u ct e d i n Bo l i v i a , Burkina Faso, Guat em ala, Honduras, I ndia, I ndonesia, Malawi and Pakist an, wom en’s percept ions of anem ia w er e ex p lor ed . Th e p u r p ose of t h at st u d y w as t o i d e n t i f y t h e b a r r i e r s a n d f a c i l i t a t o r s o f i r o n su pplem en t at ion f or pr egn an t w om en . Th e au t h or s found t hat t he wom en did not know t he t erm anem ia alt h ou g h t h ey w er e aw ar e of t h e sy m p t om s. Th ey described headache, dizziness, paleness, “ t hin blood”, or “ w eak blood”. Abou t 5 0 % of t h e w om en st u died t hought t hat t he sym pt om s of anem ia w ere a healt h priorit y, while t he rest did not . The wom en at t ribut ed t he sy m pt om s t o poor diet and half of t hem link ed t h e sy m p t om s t o h ar d w or k . I n Hon d u r as, an em ia was linked t o sleeping in excess. I n t he Lat in Am erican count ries of Guat em ala, Honduras and Bolivia, wom en k n ew t h at an em ia cou ld h av e ser iou s ou t com es for t he m ot her and baby. Percept ions about t reat m ent of a n e m i a i n c l u d e d n u t r i t i o u s f o o d , v i t a m i n s a n d m edicat ion. Hom e rem edies ut ilizing herbs and plant s w er e u sed in Hon d u r as an d Boliv ia. Belief s ab ou t t ak ing ir on included fear s t hat t he ir on “ m ay cause t oo m uch blood or a big baby” or spot s on t he baby’s face or ot her harm t o t he baby( 4).
I n t heir report on t he underst anding of anem ia a m o n g Pu e r t o Ri ca n p a r e n t s l i v i n g i n H a r t f o r d , Co n n e ct i cu t , t h e r e se a r ch e r s f o u n d t h a t p a r e n t s associat ed anem ia wit h diet , heredit y and act ivit y but w er e u n su r e ab ou t it s g r av it y. Th ey d escr ib ed t h e sy m pt om s as w eak ness and lack of appet it e. Som e Puert o Rican parent s not ed t hat anem ia could devlop int o leukem ia if it was not t reat ed and t hey t reat ed it wit h egg m ixed wit h grape j uice or m alt s( 10).
I n t h e o n l y r e c e n t s t u d y o n a n e m i a i n Nicar agua, t he inv est igat or s found t hat 3 5 % of t he adolescent girls who had anem ia were pregnant , had in t est in al par asit es or w er e sm ok er s. How ev er, t h e aut hors did not exam ine t he concept of anem ia( 11).
I n s u m m a r y, s t u d i e s o f w o m e n i n b o t h d ev el o p i n g a n d d ev el o p ed co u n t r i es sh o w ed t h a t w om en held a variet y of concept s about anem ia and it s t r eat m ent , including folk beliefs and biom edicine. I n t h is st u d y, w e d escr ib e t h e con cep t s of an em i a f r o m t h e em i c p er sp ect i v e i n l o w i n co m e w om en in t h e Nicar ag u an cap it al of Man ag u a. Th e r esear ch q u est i on s w er e: ( 1 ) How d o l ow - i n com e Nicar ag u an w om en d escr ib e som eon e w it h an em ia an d ( 2 ) Wh at r em ed i es d o t h ey u se t o t r eat t h e p r ob lem ?
METHODS
Desi g n
Th i s s t u d y u s e d a q u a l i t a t i v e d e s i g n t o e x a m i n e t h e co n ce p t s o f a n e m i a i n l o w i n co m e Nicar agu an w om en .
Set t in g
The st udy was conduct ed in Nicaragua, which h as a p op u lat ion of 5 . 4 m illion an d is t h e secon d poor est count r ies in t he Am er icas, w it h a per capit a incom e of $ 8 5 0 per y ear. The lit eracy rat e is 6 8 % . The infant m ort alit y rat e is 35.50 per 1,000 birt hs( 12). The set t ing for t his research was a com m unit y t hat w as pr ev iously a squat t er set t lem ent , m ade up of people f leein g ear t h qu ak es, h u r r ican es an d w ar. Recent ly, m any people w ho live t her e hav e had t he land deeded t o t hem by t he st at e. Few hom es hav e el ect r i ci t y. Th e h o u ses ar e ap p r o x i m at el y 1 5 f eet square and are const ruct ed of scrap wood, cardboard an d t in . For t h e last t h r ee y ear s, t h er e h as b een
p ot ab le w at er a cou p le of h ou r s a d ay. Th e m ost c o m m o n h e a l t h p r o b l e m s a r e d i a r r h e a , a c u t e respirat ory infect ions( 13) and undernut rit ion in girls( 14). The first aut hor has worked for 13 years, t wo w eek s a y ear, as a t each er of U. S. st u den t s doin g t heir com m unit y healt h/ vulnerable populat ions nursing c l i n i c a l c o u r s e i n t h e c o m m u n i t y. A s a n u r s e -ant hropologist , fluent in Spanish, she had undert aken ex t ensiv e par t icipant - obser v at ion in t he cont ex t t hat in f or m ed t h e p r esen t st u d y. Th e secon d an d t h ir d aut hor s hav e done ex t ensiv e r esear ch on anem ia in Nicaraguan adolescent girls( 15- 16). The fourt h aut hor is a nat iv e Nicar aguan nur se.
Sam ple an d Pr ocedu r e
A pur posiv e sam ple of four t een w om en w as inv it ed t o par t icipat e in t h e st u dy. Th e w om en h ad been at t ending m icro- credit m eet ings for t he previous m ont h. Like t heir neighbors, t hey were all low- incom e. The w om en’s m ean age w as 35 (SD= 8 . 6 ) and t heir m ean num ber of children was four (SD= 1.6) . The first aut hor had est ablished rapport w it h t he w om en over t he years, t hey m et t he st udy crit erion of low incom e, an d t h ey w er e w illin g t o be in t er v iew ed. I n div idu al in t er v iew s w er e con d u ct ed in a sm all r oom in t h e com m unit y ’s nur sing clinic.
Th e w o m en w er e f i r st g i v en a n i n f o r m ed consent in Spanish, w r it t en at t he fift h gr ade lev el, ex plain in g t h e st u dy ’s pu r pose an d t h e con f iden t ial and volunt ary nat ure of t heir part icipat ion. There were n o r ef u sals t o par t icipat e. Appr ov al t o con du ct t h e st udy w as obt ained fr om a Unit ed St at es univ er sit y h u m a n su b j e ct s r e v i e w b o a r d a n d t h e sch o o l o f nursing in Managua t hat m anages t he clinic. Using an int er v iew schedule w it h open- ended quest ions about a n e m i a , t h e f i r st a u t h o r i n t e r v i e w e d t h e w o m e n i n d i v i d u a l l y i n Sp a n i sh , a n d t a p e r e co r d e d t h e i r r esponses. The quest ions included:
- How does anem ia dev elop? - What are t he sym pt om s?
- What hom e rem edies do you use for it ? - What ot her t reat m ent s are used?
- What can happen t o som eone wit h anem ia? I d e n t i f i ca t i o n n u m b e r s w e r e u se d o n t h e t ap es; n o n am es w er e u sed . Tr an scr i p t i o n o f t h e int er v iew s was done by a nat iv e speaker.
r elat ion sh ip s( 1 7 ). Su b seq u en t ly, t r an scr ip t ion s w er e an aly zed u sin g lat en t con t en t an aly sis. Cat eg or ies em er ged fr om t he dat a as a r esult of t his induct iv e process. The cat egories were abst ract ed int o t hem es, “ an abst ract ent it y t hat brings m eanings and ident it y t o a recurrent experience”( 18). Qualit at ive analysis was assist ed by t he use of The Et hnograph ( Ver sion 5.0) soft ware. Dat a were analyzed in Spanish t o conserve t he cont ext ual language prior t o t ranslat ing t he t hem es int o English.
RESULTS
Dev elopm en t of An em ia
W h e n t h e w o m e n w e r e a sk e d a b o u t h o w anem ia develops, t hey responded wit h t he t hem es of poor eat ing and lack of v it am ins. For ex am ple, one wom an report ed We have t his habit in Nicaragua, also because
of t he povert y, t hat we dedicat e ourselves t o filling our st om achs,
wit hout looking at all t he foods t hat m ake us well, we only fill our
st om achs wit h beans and rice. Anot her said it is a lack of iron
due t o bad eat ing and inst ead of drinking j uice, one drinks coffee
and it ’s not good it t akes away t he vit am ins. Anot her wom an
said t hat anem ia develops because t hey don’t get vit am ins and
iron t hat is prim ary t o prot ect t he blood. One of t he wom en
offered t hat anem ia is due t o t he wom an being deficient in
iron, a hum an m ust look for foods t hat cont ain iron so t hey w on’t
get anem ia. None of t he wom en different iat ed t he various
t y pes of anem ia.
Sy m pt om s of An em ia
Mo s t o f t h e w o m e n d i d n o t k n o w a n y sy m p t o m s o f a n em i a . Sev er a l m en t i o n ed l a ck o f appet it e, one r epor t ed dizziness and w eak ness, and anot her said t he ey es becom e y ellow .
Hom e Rem ed ies
Wh en t h e w o m en w er e ask ed w h at h o m e r e m e d i e s t h e y u se d f o r a n e m i a , t h e i r r e sp o n se s evolved int o t he t hem e of eat ing cert ain foods. Alm ost half of t he wom en m ent ioned bean soup as a rem edy for anem ia. Ot her s m ent ioned dr inking t he m ilk of a m ar e, eat ing gour d seeds, beet j uice, or ange j uice, carrot j uice, eat ing fruit , m eat w hen you can and if you can’t
eat m eat , drink m ilk because it is cheaper. Several report ed
using car ao w hose scient ific nam e is Cassia gr andis.
The fruit s of t his t ree have a kind of m olasses t hat is also used t o allev iat e r espir at or y illnesses. Guapinol ( scien t if ic n am e Hy m en ea cou r bar i) w as also u sed, as w ell as Cuculm eca ( scient ific nam e Sim ilax spp) , w h i c h i s a k i n d o f l i q u o r t h a t h a s a n a l g e s i c pr oper t ies( 1 8 ).
Ot h er Tr eat m en t s
Seeking car e at t he local public healt h clinic w as anot her t hem e in t he w om en’s r esponses. Go t o
t he clinic and t hey give you m edicine t hat com es from anot her
count r y w as t he response of one w om an. A couple of
ot her wom en said when you go t o t he clinic t hey give you vit am ins t hat ar e like ir on.
Effect s of anem ia
Most of t he w om en did not k now w hat can h a p p e n t o so m e o n e w i t h a n e m i a . H o w e v e r, t w o w om en r epor t ed t hat it can develop int o leukem ia.
DI SCUSSI ON
Th e f i n d i n g s of t h i s st u d y u n d er scor e t h e p l u r a l i t y o f a n e m i a c o n c e p t s a m o n g t h e s e l o w in com e w om en . Som e of t h e b elief s an d r em ed ies w er e f r o m t h e f o l k sy st em , w h i l e o t h er s w er e i n l i n e w i t h t h e b i o m e d i ca l m o d e l , su ch a s a n e m i a d e v e l o p i n g f r o m p o o r n u t r i t i o n . Th e Ni ca r a g u a n w o m e n ’ s co n ce p t s w e r e n o t d i ssi m i l a r f r o m t h e per cept ion s of an em ia h eld by w om en in t h e Lat in Am er i can co u n t r i es i n t h e ei g h t - co u n t r y st u d y o r b y t h e Pu er t o Ri ca n p a r en t s i n Ha r t f o r d , CT. For e x a m p l e , sy m p t o m s o f d i zzi n e ss, w e a k n e ss a n d eat in g poor ly w er e m en t ion ed in sev er al st u dies of Lat in Am er ican r espondent s and, alt hough t he hom e r e m e d i e s s o m e t i m e s d i f f e r e d , t h e i r u s e w a s p r o m i n en t i n t h e g r o u p s st u d i ed . Ri ce an d b ean s w e r e m e n t i o n e d a s a r e m e d y i n t h e L a t i n o r esp on d en t s; h ow ev er, b ean sou p w as m or e of t en n ot ed by t h e Nicar agu an w om an .
t h e s e w o m e n h a v e , n u r s e s c a n a d j u s t t h e i r co m m u n i ca t i o n t o i n cl u d e t h e co n ce p t i n h e a l t h t each in g.
For exam ple, a num ber of t he wom en t hought t hat bean soup was good for anem ia. I n realit y, bean sou p is m ade fr om local bean s t h at ar e soak ed for several hours t hen boiled in t he sam e wat er in which t hey are soaked. While beans are a significant source of ir on , t h is cook in g p r ocess m ay act u ally lead t o incr ease in t he r isk for ir on deficiency. The soak ing pr ocess allow s f or t an n in s f ou n d in t h e sk in of t h e beans t o be released in t he soaking wat er. Consum ing t annins wit h iron lim it s t he bioavailabilit y of iron and u l t i m a t e l y d e c r e a s e s a b s o r p t i o n o f i r o n , t h u s i n cr ea si n g r i sk f o r i r o n d ef i ci en cy a n em i a . W h en m ot h er s w er e ask ed ab ou t d iscar d in g t h e soak in g wat er and using new wat er for boiling, m ost felt t hat t his would cause t he soup t o be less palat able and, in a co m m u n i t y w h er e w a t er i s sca r ce, m u ch m o r e difficult t o pr epar e. Thus, a few w om en appear ed t o u n d er st an d t h e con n ect i on b et w een d i et an d i r on d ef icien cy an em ia, b u t w ou ld also n eed ad d it ion al h ealt h edu cat ion con cer n in g pr ocessin g t ech n iqu es. This educat ion could be com plicat ed by t he issue of palat abilit y, cost of ingr edient s, and per sonal eat ing p r ef er en ces.
No one m ent ioned t hat dr ink ing coffee w it h m eals, a com m on p r act ice in Nicar ag u a an d ot h er La t i n A m e r i c a n c o u n t r i e s , i n t e r f e r e s w i t h i r o n absorpt ion. This is not surprising given t he educat ional lev el of t h e par t icipan t s an d t h e st r on g pr ef er en ce for coffee wit h all m eals. However, t his also present s an opport unit y for educat ion. There was no reference eit her t o eat ing foods r ich in Vit am in C t o incr ease
i r o n a b so r p t i o n . Al l o f t h e se p r a ct i ce s a r e v i t a l co n si d er a t i o n s w h en d o i n g h ea l t h ed u ca t i o n w i t h p e o p l e i n La t i n Am e r i ca o r w i t h La t i n Am e r i ca n im m igrant s t o t he U.S.
Sev er al Nicar aguan w om en m ent ioned going t o t he public healt h cent er t o get a pr escr ipt ion for vit am ins and iron t o t reat anem ia, however, prevent ing t h e p r ob lem w as n ot as r ead ily n ot ed . Dev elop in g leukem ia as a consequence of unt reat ed anem ia was not ed by several of t he Nicaraguan wom en, j ust as it had been by t he Puert o Rican parent s in t he Hart ford st u dy. Th e beliefs con cer n in g gr eat er con sequ en ces of lon g- t er m ir on deficien cy an em ia w er e r oot ed in l o ca l b e l i e f sy st e m s o r l a ck o f h e a l t h e d u ca t i o n concer ning t he causes and consequences of anem ia. This research ident ified som e specific cult ural b e l i e f s t h a t n u r s e s n e e d t o b e a w a r e o f w h e n in t er act in g w it h t h eir Nicar agu an or Lat in - Am er ican im m igrant client s. Nurses can incorporat e t he cult ural beliefs t hat m ay m it igat e t he anem ia, such as eat ing foods rich in iron ( e.g. beans, m eat , and m ilk) , while e d u c a t i n g c l i e n t s a b o u t a n e m i a p r e v e n t i o n a n d t r eat m en t . Clin ician s m u st also b e aw ar e of local p r o ce ssi n g t e ch n i q u e s, co st s a n d a v a i l a b i l i t y o f ingr edient s, and a gener al under st anding about food p r ef er en ces an d accessi b i l i t y t o m ak e u sef u l an d r eason ab le r ecom m en d at ion s.
Fu t u r e r e se a r ch sh o u l d f o cu s o n a n e m i a p r ev en t ion t h r ou g h ed u cat ion , esp ecially ed u cat ion a b o u t n u t r i t i o n a n d o t h er f a ct o r s co n t r i b u t i n g t o an em ia. Fu r t h er st u dies on an em ia per spect iv es of w om en in ot h er cou n t r ies w ou ld also be h elpf u l t o c l i n i c i a n s w o r k i n g i n t h o s e c o u n t r i e s o r w i t h im m igr ant s fr om t hose count r ies.
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