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The etiology of iron deficiency anemia during pregnancy among rural mothers in Malaysia Arshad, Fatimah 1984

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THE E T I O L O G Y PREGNANCY  OF I R O N D E F I C I E N C Y  ANEMIA  AMONG R U R A L M O T H E R S  IN  DURING  MALAYSIA  by  B.S., M.S.,  FATIMAH ARSHAD D i p . A g r i c , M a l a y a , 1971 Louisiana State University, Louisiana State University,  A THESIS  SUBMITTED  IN PARTIAL  OF T H E R E Q U I R E M E N T S DOCTOR OF  1973 1975  FULFILLMENT  FOR THE DEGREE  OF  PHILOSOPHY in  THE F A C U L T Y  OF G R A D U A T E  (Department  We a c c e p t to  this  the  of  Food  thesis  required  THE U N I V E R S I T Y  © Fatimah  Science)  as  conforming  standard  OF B R I T I S H  June  STUDIES  COLUMBIA  1984  Arshad,  1984  In p r e s e n t i n g  t h i s t h e s i s i n p a r t i a l f u l f i l m e n t of  requirements f o r an advanced degree a t the  the  University  o f B r i t i s h Columbia, I agree t h a t the L i b r a r y s h a l l make i t freely  a v a i l a b l e f o r r e f e r e n c e and  study.  I  further  agree t h a t p e r m i s s i o n f o r e x t e n s i v e copying of t h i s f o r s c h o l a r l y purposes may department o r by h i s or her  be granted by  the head o f  representatives.  understood t h a t copying or p u b l i c a t i o n of t h i s for financial  gain  s h a l l not be  Department of  FOOD SCf£rVe£  The U n i v e r s i t y of B r i t i s h Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date  z r u i y 3j  mn  my  It i s thesis  allowed without my  permission.  thesis  written  i i  ABSTRACT  This iron  deficiency  Kuala was  Selangor,  to  these  identify mothers.  etiology A the of  thesis  of  total  study. blood  cal  and  of  and  (MCH),  mean c e l l  ment  ova  were and  were  The  second  done  to  purpose  parasite  obtained  were  < 15 n g / m L ) . globin  level  anemic The of  the  with  and of  other food  of  of  the  anemia  the to  were  study among  the  chosen  was by  hematologi-  hemoglobin  were  parametric  food  The  bio-  blood analyzed instru-  socioeconomic  parity,  related  and  Thick  samples  evaluate  (Hb),  hemoglobin  levels.  second  for  analyses  and morphology.  therapy,  belief  first  analysed  Stool  health  were  mean c e l l  ferritin  iron  aspect  investigate  The  were  (MCHC),  was  district  clincis  indices  was  the  on  mothers.  (MCV),  and  interview  to  used.  samples  an i n v e s t i g a t i o n  deficiency  was  parasites.  sanitation  factors. frequency  A listing  interview.  and b i o c h e m i c a l  (Hb < 11 g / d L )  than  were  technique  in  antenatal  volume  malarial  prevalence  less  the  serum f o l a t e  presence  during  these  of  first  iron  among  concentration  infestation  recall,  of  study  mean c e l l  the  the  the  blood  characteristics  The h e m a t o l o g i c a l mothers  of  mothers  Hematological  Interview  compliance  also  detect  cysts.  dietary  The  aspects  aim of  instruments  hemoglobin included  of  attending  methods. (PCV),  pregnant  anemia  samples.  two  prevalence  aspect  378 mothers  of  primary  the  deficiency  volume  The  conditions, 24-hour  confirm  indices  used.  status,  The  and  stool  findings  among r u r a l  Malaysia.  biochemical  chemical  the  Two p a r a m e t r i c  cell  for  anemia  iron  packed  smears  reports  of  and  anemia  10 g / d L  was  findings  indicated  68% w e r e  iron  was used.  lower  that  deficient  (28.6%)  Among t h e  when  anemic  55.1% o f  the  (ferritin the  hemo-  mothers,  37%  i i i  were  also  together were  folate with  some  suspected  biochemical The  deficient.  of  cases  etiology  status,  beliefs,  noncompliance  the mothers  the  wives less  of  the  anemic  mothers  of  lowest  for  to  The to  About  as  by  indicated  were  anemia  4.2% o f  was the  hematological  meet  houses. their  around  the  a  between  present mothers  and  iron  of  the  and  farmers  less  to  The the  money  Indian mothers,  to  requirements.  low  these  less  the  be  in due  occupa-  women.  The  of  (28.0%)  and  on food  The were  Chinese and  anemia  grew  The m a j o r i t y  mothers  farmers  prevalence  but  no  education  Malay  on f o o d ,  of  socioeconomic  between  and  of  could  laborers.  Malays  spent  This  of  the  factors  indicated  among  and  food  status  nonanemic  income  socio-  ownership  economy.  higher  anemic.  related  findings  relationship  compared  compared  spent  The  deficiency  relatively  less  undesirable  occupation,  cash  definite  low  Socioeconomic  anemic  and  of  w h i c h was m a i n l y  on f o o d ,  (19.6%)  The  on f o o d .  and  the wives  nutritional  their  general  was  husbands  mothers  level,  included  and h e a l t h  and m u l t i p a r i t y .  population  generally  anemia  presence  supplements  property  who h a d  Chinese  status,  spent  of  there  to  deficiency  <^ 0 . 0 5 )  more money  The M a l a y  their  gardens  pared  the  (P  the  their  spent  laborers  able  deficiency  deficiency.  education  money  teachers,  Indian  around  of  compared  who  (41.9%).  of  However,  levels  iron  by  ownership  homogeneity  tional  with  differences  background.  iron  infestation  and amount  level,  of  nutritional  was m e a s u r e d  significant  to  poor  parasite  education  folate  iron  indices.  economic  property  of  hemoglobinapathy  possible  including  Therefore,  was  Indians  gardens  and were  did  not  not  have  house.  nutritional  recommended  status  daily  of  dietary  the  study  standard.  population Most  of  was  the  poor  anemic  com-  iv  mothers The  who w e r e  two m a j o r  could  mainly  hemopoietic  be a t t r i b u t e d  vegetable quantity meats,  proteins  to  the  and  diets  less  and  the  vegetables  and  other  was  low,  the  had  nutrients  meats  mothers  of  Indians,  these  or  Chinese  only  lacking  of  meats  of  fish  ate  foods.  way  subnormal  levels  were  nutrient  protein  and  mothers'.  The  while  Malays  a varied  Since  of  the  the diet  iron  adequate  iron  the mothers  complied  by  This  consumed  consumed  large  status  getting  iron.  Indians  and  intake.  amounts  of  was  less  most  by  of  of the  taking  iron  supplements. Only ments.  levels  taken  predicted presence iron  one  was  long by  of  was  no  of  studied  was m i n o r  The third  were  in  the  problems,  to  this  since  k i l l  for  Indians  (2.1  the  longer  The  years). the  between  parasite  parasite  the  these  supplements  had  with  area.  visits,  presence  in  Deworming  of  were  therapy  attitude of  food and  the  not was  towards beliefs.  anemia.  The  population  measures  of  children  and  examples  hemo-  status,  infestation  control  larvae  iron  economic  infestations  adequate  mosquito  of  race,  and  supple-  improvement  clinic  color  iron  the  Compliance  of  taking  of  these spraying  surveilance  area.  the  Malays  for  the  study  pregnancies.  stool  reasonably in  that  including  frequency  association  of  mothers.  stage,  towards  possible  variables  practised  majority  highest  cantly  of  compliance was  worm and m a l a r i a l  insecticides  practices  of It  by  gestation  problem  parasites  found.  enough  health  of  effect  a number  tablets, There  of  third  No d e f i n i t e  globin been  about  mothers duration  (3.3 The  from  years),  average  Malay  (70%)  were the  last  followed  duration  mothers  between  (2.7  by  to  years)  present  the  between  their  first,  pregnancies  Chinese  (2.8  pregnancies  compared  second  to  the  was  years)  was  or  and  signifi-  Chinese  and  y  Indian mothers duration  (2.0  between  pregnancy.  b y many  of  A  hierachy  analysis. order  of  protein The  Only  that  anemia The  towards  of two  that by  that  interval family  was  ranked  variables  the  duration  average  relative  odds  average  duration by  significantly  shorter  between previous  planning  was  not  and  practised  of  of  half. of  were  20  logistic  detected.  pregnancies  two v a r i a b l e s  by  relative g protein  one y e a r odds  regression  They were  for  intake  and  were  between pregnancies  pregnancy The  the  between  these  duration  by  is  calculated.  decreases  will  dietary  0.6  dietary  in  showing  the  protein  decrease  the  risk  of  is  0.7  risk  0.7. of  this  improvement  nutritional  and  family  to  the  problem  overcome  factors  an i n c r e a s e  findings the  shorter  had  mothers.  for  the  mothers  significant  The  odds  and  indicated  causal  approximately  indicating of  anemic  intake.  increasing  anemia  This  magnitude,  relative  The a n e m i c  pregnancies  present  the  years).  of  study the  planning of  iron  have  significant  mother's services  health have  deficiency  practical  status. to  be  anemia.  The  implications existing  evaluated  and  improved  vi  TABLE  OF  CONTENTS  Page ABSTRACT  i i  TABLE  vi  OF C O N T E N T S  LIST  OF T A B L E S  xii  LIST  OF F I G U R E S  xvi  LIST  OF A P P E N D I C E S  xviii  ACKNOWLEDGEMENTS CHAPTER  CHAPTER  xix  1.  INTRODUCTION  I  A.  Background  1  B.  Statement  C.  Hypotheses  3  2.  R E V I E W OF L I T E R A T U R E  6  A.  Description  B.  C.  and Need of  Problem  of  Iron  1.  Definition  2.  Prevalence  3.  Hematological  4.  Folate  5.  Evaluation  6.  Iron  7.  Physiological  1.  Mother  2.  Work  Deficiency  Anemia  6 6  of  anemia and  6  biochemical  aspects  of  10 iron  anemia  and  14 hemoglobinopathies  hemodilution  Effects and  status  of  Iron  Deficiency  Anemia  fetus  Aspects  ..  17 19 21 21  capacity  Nutritional  7  status  deficiency  Detrimental  2  23 of  Iron  Deficiency  Anemia  24  v i i  Page  D.  1.  Iron  balance  2.  Absorption  of  iron  25  3.  Evaluation  of  diet  26  4.  Sociocultural  influences  (a)  Cultural  Practices  (b)  Dietary  patterns  (c)  Dietary  beliefs  (d)  Socioeconomic  Intervention  Definition  2.  Types  3.  iron  (b)  Parenteral  on n u t r i t i o n  27 27 29  and  taboos  29  factors -  31  Iron  Supplementation  ....  supplementation  33 33  iron  with  iron  34 supplements  Measures of compliance characteristics Health iron  problems  35  and  demographic 36  related  to  ingestion  of  supplements  37  (c)  Educational  (d)  Patient-physician  (e)  Presence  of  cultural  (f)  Duration  of  therapy  (g)  Patient's Related  32 32  iron  Compliance  Health  24  supplements  Oral  (b)  E.  of  (a)  (a)  pregnancy  Techniques  1.  of  in  background  of  in  patient  ....  relationship  Accessibility  of  health  2.  Environmental  sanitation  39 40  Iron  1.  37 38  beliefs  comprehension  Factors  the  of  the  therapy  Deficiency  Anemia  ...  40  ..  41  care and  41 disease  control  ..  42  viii  Page  3. CHAPTER  (a)  Sewage  disposal  (b)  Parasite  and water  infestations  -  supply  43  hookworm and m a l a r i a  Multiparity  44 45  3.  M E T H O D S AND P R O C E D U R E S  47  A.  Description  47  B.  Choice  C.  Parametric  of  Area  and D e s c r i p t i o n Instruments  the  Study  1.  Objective  2.  Study  of  Subjects  and Measurements  in  measures  (b)  Hematological  and  (c)  Collection  stool  Subjective  of  55  Collection  of  blood  samples  55  biochemical  analyses  ...  samples  of  57 questions  on  compliance  i r o n supplements Degree of understanding of supplements  57 on  Measurements  of  compliance  (iii)  Health problems tablets  associated  of  the  use 57  (ii)  Formulation  55 56  measure  Formulation with (i)  (b)  Used  53  (a)  (a)  52  59 with  iron 61  demographic  and  health  questions  62  (1)  Socioeconomic  status  (ii)  Parity  (iii)  Medical  (iv)  S a n i t a t i o n , water p a r a s i t e problems  62 62  history  63 supply  and 63  ix  Page  (c)  CHAPTER  Assessment  of  nutritional  (i)  The  24-hour  (ii)  Food  (iii)  Presence  (d)  Pretesting  (e)  Training  frequency  and  of  of  63  recalls  63  tabulations  food  coding  64  beliefs of  interview  65 questions  65  interviewers  Available  4.  Coding  5.  Statistical  4.  RESULTS  AND D I S C U S S I O N  70  A.  General  Demographic  70  B.  Differential  3.  records  67  data  67  analysis  68  Characteristics  diagnosis  Hematological  of  iron  deficiency  anemia  indices  Hemoglobin  (b)  Packed  (c)  Mean c e l l v o l u m e ( M C V ) , mean c e l l h e m o g l o b i n (MCH), mean c e l l h e m o g l o b i n c o n c e n t r a t i o n (MCHC) a n d t o t a l r e d  cell  (Hb) volume  blood  count  Blood  morphology  Biochemical (a)  Iron  (b)  Folate  (TRBC)  indices  status  .  73 73  (a)  (d) 2.  the  from medical  66  3.  1.  data  dietary  intake  73 (PVC)  77  77 84 86 86  status  88  Hemoglobinopathies  93  Page  C.  Causal 1.  2.  Factors  Socioeconomic  To  Iron  Deficiency  Anemia  ....  status  93 97  (a)  Education  97  (b)  Occupation  99  (c)  Ownership  (d)  Cash  property  101 104  status  107  Daily  dietary  (i)  Malay  (ii)  Chinese  diet  110  Indian  diet  112  (iii) (b)  Food  (c)  Nutrient  (d)  of  economy  Nutritional (a)  3.  Leading  pattern  of  the  three  races  ...  diet  107 108  beliefs  113  intake  114  (i)  General  nutrition  114  (ii)  Dietary  analysis  116  The  relationship  and  iron  of  deficiency  Iron  supplementation  (a)  Availability  (b)  Compliance  of  with  nutritional  status  anemia  and 121 125  supplements  125  iron  125  (1)  Measures  of  (ii)  Association deficiency  supplements  compliance of  compliance  125 to  iron 127  xi  Page  (iii)  Other  factors  associated  with  compliance  129  (a)  Ethnic  origin  (b)  Cash  (c)  Problems  (d)  Frequency  129  economy  131  with  iron  of  visits  supplements to  the  ...  health  centre  4.  Health  5. CHAPTER  5.  6.  Gestation  (g)  Stool  (h)  Food  Gestation  (c)  Environmental  The  towards  iron  tablets  stage  of  stage  133 135  color  135  belief  137 137  health on f i r s t  center  139  visit  139  sanitation  141  (i)  Water  supply  141  (ii)  Sewage  (iii)  Worm i n f e s t a t i o n  144  (iv)  Malaria  145  disposal  142  Multiparity priority  ranking  145 of  significant  causal  of i r o n d e f i c i e n c y anemia R E C O M M E N D A T I O N S TO O V E R C O M E T H E P R O B L E M OF ANEMIA  factors  IRON  149  155  CONCLUSIONS  CITED  ....  factors  (b)  Suggestion REFERENCE  (f)  Accessibility  DEFICIENCY CHAPTER  Attitude  (a)  (d)  133  (e)  related  131  159 for  future  studies  163 165  x i i  LIST  OF  TABLES  Table  1  2  Page  The p r e v a l e n c e o f a n e m i a i n t h i r d t r i m e s t e r o f pregnancy i n d i f f e r e n t population groups, expressed a s p e r c e n t o f p o p u l a t i o n w i t h l e s s t h a n 11 g / 1 0 0 mL Hemoglobin c a n be  values  considered  hematological 3  4  status  of  antenatal clinic Lumpur, M a l a y s i a 5  6  7  to  iron  and  deficiency  271  pregnant the  of  women  attending 13  women a t t e n d i n g  Maternity  Hospital,  o f 2 8 0 p r e g n a n t women a t t e n d i n g K u a l a Lumpur, M a l a y s i a  hemoglobinopathies  in  18  Distribution  9  Some d e m o g r a p h i c c h a r a c t e r i s t i c s o f s t u d y the d i s t r i c t of Kuala Selangor, Malaysia  11  12  13  of  occupation  in  Kuala  Selangor, 51  Selangor,  1980  ....  population  71  and  nonanemic  mothers  with  PCV,  MCV,  78  attending Selangor, 78  MCV, MCH, MCHC, a n d TRBC v a l u e s o f m o t h e r s a t t e n d i n g the a n t e n a t a l c l i n i c s i n the s u b d i s t r i c t s of Kuala Selangor, Malaysia  a n d TRBC b e l o w t h e s t a n d a r d v a l u e s G e o r g e ( 1 9 8 3 ) a n d WHO ( 1 9 7 2 )  52  at  (Hb) l e v e l s of mothers a t t e n d i n g the h e a l t h the d i s t r i c t of Kuala Selangor, Malaysia . . .  P e r c e n t packed c e l l volume (PCV) of mothers the h e a l t h centers i n the d i s t r i c t of Kuala Malaysia  Anemic  16  Peninsular  Health i n d i c a t o r s for the d i s t r i c t of Kuala Selangor S t a t e and P e n i n s u l a r M a l a y s i a  Hemoglobin centers in  the  Kuala 15  8  10  anemia  associated  of 276 p r e g n a n t K u a l a Lumpur  at  8  8  Serum f e r r i t i n s t a t u s the antenatal c l i n i c , The i n c i d e n c e Malaysia  which  exist,  values  Hemoglobin l e v e l s antenatal clinic, Folate  below  ....  MCH,  recommended  82  MCHC  by 83  x i i i  Table  14  Page  Morphological mothers  15  16  findings  Iron status levels  of  Iron  of  by  of  the  thin  blood  smears  of  status  ferritin  85 mothers  determined  by  serum  ferritin 87  anemic  and  nonanemic  mothers  measured  values  Folate  18  Serum f o l a t e  19  S i x t e e n cases of suspected hemoglobinopathy based h e m a t o l o g i c a l a n d b i o c h e m i c a l i n d i c e s a n d some associated demographic f a c t o r s  21  22  status  of  87  17  20  the  levels  of  by  anemic  23  Education  of  24  The e d u c a t i o n studied  The  and  mothers  anemic  ...  92  on 94  and 95  indices  of  16  mothers 96  mothers  in  the  three  racial  mothers  and  occupation  husbands  levels  of  98  the  339  mothers  categories  of  of  between  spouses  prevalence  respondents'  house  land  of  anemia  and  spouses of  102  Ownership  28  The f r e q u e n c y o f f o o d p u r c h a s e p e r week and i n M$ s p e n t o n f o o d p e r w e e k p e r h o u s e h o l d  the  The mean amount h o u s e h o l d among  person  frequency  and  100  27  29  of  among t h e  89  100  relationship  occupations  groups  98  levels  Occupational  the  racial  and nonanemic  H e m a t o l o g i c a l and b i o c h e m i c a l suspected of hemoglobinopathy of  26  mothers  Prevalence of hemoglobinopathy total population studied  Education levels categories  25  324  studied  340 m o t h e r s  of cash spent per month the three r a c i a l groups pattern  of  the  three  per  studied  ....  103  amount „ 106 in  a  30  Food  races  31  N u t r i e n t i n t a k e of 340 mothers a t t e n d i n g the h e a l t h centers i n the d i s t r i c t of Kuala Selangor, Malaysia . . .  106 109  115  xiv  Table  Page  32  Suggested  33  The  34  Nutrient  35  Prescriptions  36  dietary  dietary  Iron  intake  intakes  intakes of  of  of  for  anemic  anemic  iron  supplementation  pregnant  women i n  and nonanemic  and  nonanemic  Malaysia  mothers  ...  mothers  126  among  the  three  racial  groups 37  38  39  40  41  42  126  The e f f e c t hemoglobin  of compliance change  Association origin  of  Association economy  of  with  iron  supplements  on 128  compliance  characteristics  with  ethnic 130  compliance  characteristics  with  cash 132  The a s s o c i a t i o n to i n g e s t i o n of  of compliance with i r o n supplements  The a s s o c i a t i o n o f number center with compliance  of  problems  related 132  visits  to  the  health 134  The a s s o c i a t i o n compliance  of  43  The  association  of  gestation  44  The  association  of  compliance  45  The a s s o c i a t i o n  attitudes  towards  of  food  iron  tablets  with 134  stage  belief  with and  with stool  compliance  ....  color  compliance  with  iron  47  138  The a s s o c i a t i o n first  visit  to  of  anemia w i t h  health  Worm i n f e s t a t i o n a m o n g groups as i n d i c a t e d by i n the s t o o l  48  The  49  Average the  association  last  duration to  136 136  supplements 46  122 123  supplements record  117  of  stage  the  on 140  101 m o t h e r s i n t h e t h r e e racial the presence of ova and c y s t s 144  age w i t h  between  present  gestation  centre  number  of  pregnancies  pregnancy  in  each  pregnancies and d u r a t i o n race  146 from 146  XV  Table  50  Page  Gravida  and  parity  status  of  the  anemic  and  nonanemic  mothers 51  The  148  outcome  factors district  of of  of  logistic  anemia Kuala  among  regression  analysis  the  pregnant  Selangor,  Malaysia  mothers  of in  causal the 150  xv i  LIST  OF  FIGURES  Figure  1  2  3  Page  Proposed  factors  women i n  Malaysia  Cumulative  frequency  concentration in  of  Kuala  Cumulative  of of  6  Map o f study  the  in  pregnant  hemoglobin concentration pregnancy i n different  distribution  subjects Lumpur,  frequency  Map s h o w i n g territories  anemia  9  from  of  the  Malaysia  the  location  hemoglobin  three  racial  •  distribution  volume of s u b j e c t s from K u a l a Lumpur, M a l a y s i a 5  to  4  Frequency d i s t r i b u t i o n i n the t h i r d trimester population groups  groups 4  contributing  11 of  three  packed  racial  cell  groups  in 12  of  Malaysia  and  adjacent 48  Peninsular  Malaysia  showing  location  of  the  site  7  Map o f  8  Flow  9  C u m u l a t i v e f r e q u e n c y d i s t r i b u t i n g body w e i g h t s o f 314 mothers from the three r a c i a l groups a t t e n d i n g the antenatal c l i n i c s at the d i s t r i c t of Kuala Selangor, Malaysia  72  Frequency d i s t r i b u t i o n of hemoglobin mothers a t t e n d i n g the h e a l t h centers of Kuala Selangor, M a l a y s i a  74  10  11  12  the  49 study  diagram  of  area a  showing  sampling  the  health  centers  50  day  54  levels at the  o f 332 district  Frequency d i s t r i b u t i o n of hemoglobin c o n c e n t r a t i o n of 332 m o t h e r s f r o m t h e t h r e e r a c i a l g r o u p s a t t e n d i n g the antenatal c l i n i c s i n the d i s t r i c t of Kuala Selangor, Malaysia Frequency d i s t r i b u t i o n of 332 m o t h e r s a t t e n d i n g t h e district  of  Kuala  packed health  Selangor,  c e l l v o l u m e (%) centers i n the  Malaysia  76  of 79  xvii  Figure  13  Page  The c u m u l a t i v e f r e q u e n c y d i s t r i b u t i o n o f p a c k e d c e l l v o l u m e (%) o f 3 3 2 m o t h e r s f r o m t h e t h r e e racial groups attending the antenatal c l i n i c s i n the district of  14  15  16  Kuala  18  Malaysia  80  F r e q u e n c y d i s t r i b u t i o n of serum f o l a t e i n 293 m o t h e r s from the three r a c i a l groups a t t e n d i n g the a n t e n a t a l c l i n i c s i n the d i s t r i c t of Kuala Selangor, Malaysia The c u m u l a t i v e f r e q u e n c y d i s t r i b u t i o n o f d a i l y intake of d a i l y p r o t e i n intake of mothers from three races attending the antenatal c l i n i c s i n d i s t r i c t of Kuala Selangor, M a l a y s i a The  percentage  intake 17  Selangor,  below  of  the  mothers Malaysian  in  each  race  suggested  with  daily  90  protein the the 118  nutrient intake  The two m a j o r c a u s a l f a c t o r s o f anemia (shown d a r k e r a r r o w s ) as p r e d i c t e d by the outcome of logistic regression analysis  ....  119  by the  O u t l i n e of program on f a m i l y p l a n n i n g and n u t r i t i o n a l improvement based on c h i l d w e i g h i n g a c t i v i t y  152  153  xviii  LIST  OF  APPENDICES  Page  Appendix  A.  Definitions  of  terms  used  for  the  purpose  of  the  study  177  Appendix  B.  A brief  Appendix  C.  Detailed chosen  Appendix  D.  description  descriptions  for  Antenatal for  the  of  the  of  the  three  179 subdistricts  study  attendance  years  Malaysia  1982  181 in  and  Kuala  Selangor  District  1983  183  Appendix  E.  Interview  format  (English)  184  Appendix  F.  Interview  format  (Malay)  199  Appendix  G.  Problems and  Appendix  H.  Code  incurred  laboratory Book  during  data  collection  -  field 213 216  xix  ACKNOWLEDGEMENTS  I help and  am g r e a t l y  and its  guidance  which  presentation.  Supervisory Powrie  indebted  and  have I  Committee: Dr.  N.  to  my s u p e r v i s o r , contributed  am a l s o Dr.  Waxier  very  C.J.G.  for  Dr.  J .  Vanderstoep  greatly  to  this  grateful  MacKenzie,  their  help  and  to  the  Dr.  B.  for  thesis  other  research  members  Morrison,  constructive  his  Dr.  criticism  of  my  W.D. of  this  thesis. During research other  the  in  course  Malaysia,  people.  I  Community  Health,  Institute  of  wish  Centers  in  like  to  acknowledge  help  of  Mr.  appreciated.  R.  I  my s t u d y  was  to  UBC a n d  in  a variety  of  the  Medicine,  area  for  the mothers  Sizto  in I  their for  computing  thank  Mrs.  P.  staff  and  of  ways  members  and  at  the  analysis  at  in  Kebangsaan  Malaysia  for  the  Health  I would  is  patience  of  Malaysia,  this  her  of  Department  staff  in  this  a number  cooperation.  participation  for  by  Kebangsaan  statistical  Quay  conducting  the medical  help  their  and  while  Universiti  Research Malaysia,  research  Also,  helped  at  acknowledge  Faculty  Medical  the  of  also  study.  The  greatly typing  this  thesis• I  would  educational Lastly, ment.  like leave  to and  thank  Universiti  financial  many  thanks  to  T o my s o n ,  Azlan,  I  support  my h u s b a n d dedicate  of  the  Nik  for  this  granting  me  project. his  thesis.  support  and  encourage-  1  CHAPTER  A.  Background  Iron mothers was  due  to  in the  1982).  that  the  1964).  The  ~&12 a r e  of  up  to  deficiency  in  is  tropical  tropics  A similar  reported  anemia  developing  estimated  50% o f  were of  Malaysia  iron,  (Tee  two  of  et  importance  deficiency  is  (Baker,  hemoglobin  level  point  signifying  observed level  (Tee  et  pregnancy,  anemic  condition  lassitude,  of  iron  1930).  in  of  the  during  early  Malaysia  These  on  studies  fetus  infancy  studies  (Tasker  et  of  blood  only  and  folate  (Harrison, pregnancy  and  vitamin of  their  practical  purposes,  has  been used  as  clinical  was  Lourdenadin,  occurrence  a  a  cut-off  symptoms  concentration  on  the mother,  lactation. which  heart  are  1968;  was  were  above  this  1968).  al.,  to  the  No o v e r t  not  a l . ,  anemia  For  hemoglobin  anemia  failure  on severe  of  but  also  symptoms from  of  on  her  the  anorexia,  (Lourdenadin,  1964).  birth  and  weights  1973).  during  1959;  The  can range  lowering  (McFee,  a l . ,  were mainly  since  during  It  antenatal  this  nutrient  pregnant  1959).  attending  anemia et  (WHO,  76% o f  namely  1975).  severity,  breathlessness  anemia  of  Malaysia  puerperium on i t s  Chong  nutrients,  are  Malaysia  hematopoietic  1984;  WHO,  p r o b l e m among  mothers  deficiency  Malaysia.  anemia  depend  levels  A number  iron  et  as  Approximately  1 0 0 mL o f  Chong  health  such  pregnant  a major  women w i t h  labor,  pallor,  effects  reported  in  1984;  effects  fetus,  storage  anemia  a l . ,  1978;  10 g p e r  among p r e g n a n t  Adverse  The  of  a l l  a l . ,  in  public  countries  hemopoietic  lesser low  a major  anemic.  incidence  other  INTRODUCTION  Need  deficiency  in  clinics  and  1.  pregnancy  Reed, cases  1940; of  have  Corke  anemia  been  and among  Bush, pregnant  2  Indian  laborers  rubber  plantations.  focus  brought  by  the  Later,  British  towards  o n u r b a n women a t t e n d i n g  Efforts  were  country  as  suggested 1965;  The  et  a l . ,  incidence  and  levelled  al.,  1984).  off,  its  problem.  Most  of  attending  Lumpur.  It  pregnant  mothers.  is  this  problem  B.  Statement  has  mothers  Lumpur  a  of  been  is  This rural  identify  the  the  the  thesis  a l . ,  1968; this  all  reports  to  hospitals. in  the  treatments  Llewellyn-Jones,  period  pregnant  declined  onwards, mothers  is  s t i l l to  General  is  even  findings  since  high  on anemia were  problem  the  country.  have  the  and  in  started  occurred  outlined  thoroughly  at  studies  it  considerably  studied  clinics  that  the  pregnancy  studies  as  to  to work  and m a t e r n i t y  From  free  to  s t i l l in  et  1958a).  given  India  the  rate  mid-sixties  today  endemic,  and  understand focussed  Hospital  severe  among  it  et  is  the  on in  (Tee  urban Kuala  the  rural  from an i n v e s t i g a t i o n  of  setting.  Problem  the This  possible  that  anemia  antenatal area, rural,  people.  attending  a  be  recent  antenatal  considered of  at  were  Chong  appears  anemia  observed  1979).  mainstay  mothers  in  was  clinics  disorder  throughout  etiology the  1964;  Tasker,  anemia  possible  attending  (Arshad,  1969,  clinics  Therefore,  that  It  causes  although  important  mothers  The  1959;  of  antenatal  probable  southern  mid-sixties,  the  supplementation  antenatal  the  characterize  (Lourdenadin,  iron  attending  to  a whole.  Tasker  routine  made  from  It  with  factors  these  clinics  about  is,  health  is  s t i l l in  the  prevalent district  among of  Kuala  6 0 km f r o m  the  capital  city  agriculture  and  fishing  being  therefore,  contributing centers.  the to  objective anemia  of  among  pregnant  of  Kuala  the  this the  Selangor  chief  study  pregnant  to  3  Some o f Malaysia (Ong,  are  1974;  factors  demographic to  defective  are  food  above mentioned outlines The Kuala  ejt a l . , of  the  intake  1.  Selangor,  was  conducted  Selangor,  dietary  additional  information  C.  were  in  anemia.  at  health  blood  and  this  this  of  status, practices vitamin  causal  with  and  iron  model  is  relationship  of  the  also  thesis. centers  the  in  the  involved  analyses,  records  associated  The m o d e l  collection  stool  a  in  multiparity  with  expected  in  from medical  involved  the  with  Data  and  cultural  explicit  reported  Malaysia.  recall,  more  three  pregnancy  Other  characteristics  factors  in  socioeconomic  sanitation,  illustrates  study  anemia  1964).  include  assumptions  causal  to  infestation  Lourdenadin,  compliance  model  the  interview,  379 m o t h e r s  and  probable  research  parasite  importance  these  of  contributing  environmental  This  scope  1968;  equal  To m a k e  Figure  factors  nutrition,  background,  supplements. shown i n  probable  Chong  that  regards  the  and  district personal  collection  subjects.  of  of  A total  of  probable  causes  of  The  hypotheses  study.  Hypotheses The v a r i a b l e s  anemia  from which  outlined several  in  Figure  hypotheses  1 highlight could  be  the  drawn.  null  are: There mothers 1.  will  with  be no  respect  to  Socioeconomic education,  2.  significant  Demographic  the  difference  following  status  —  occupation,  cash  anemic  and  nonanemic  characteristics: available  ownership  characteristics  between  —  of  age,  for  food  property. race.  (cash  economy),  (2)  NUTRITION FACTOR Food i n t a k e - P r o t e i n , Iron Absorption of iron •  (3) (1)  ANEMIA SOCIOECONOMIC FACTOR Age, Race, R e l i g i o n , Education, Occupation, Cash economy, P r o p e r t y , Cultural practices  -  SUPPLEMENTS Compliance  -  Iron  -  Folate Hemodilution Hemoglobinapathies  -  Standards  Effects  HEALTH FACTOR A c c e s s i b i l i t y to C l i n i c s Pregnancy Stage Environmental sanitation P a r a s i t e - m a l a r i a and hookworm Parity  Note:  The  scope  of  this  Figure  1.  study  is  Proposed  (1),  (2),  factors  (3).  contributing  to  anemia  in  pregnant  women i n  Malaysia.  5  3.  Nutritional other  4.  status  nutrients;  Parasite  —  dietary  serum  infestation  intake  folate  —  and  presence  of  energy,  protein,  serum f e r r i t i n of  malarial  and  iron  and  levels. hookworm  parasites» 5.  Sanitation  6.  Parity  7.  —  —  drinking  number  of  waste  pregnancies  miscarriages,  duration  Observance  iron  to  water,  and number  between  and v i t a m i n  disposal. of  children,  —  compliance  pregnancies. supplements  with  prescriptions. 8.  Cultural iron  The Appendix  beliefs  food  intake,  compliance  characteristics  with  prescriptions.  definitions A.  —  of  terms  used  in  the  text  of  this  thesis  are  given  in  6  CHAPTER  A.  Description  1.  of  Iron  Deficiency  deficiency  anemia  concentration  is  below  the  to  of  iron,  a  deficiency 1972).  The  term  representative  group  differences  normal  of  in  different  Gam  eit  race  a l . ,  standard  has  standard  or  blood  and  Next  to  origins  hemoglobin  level  iron  of  of  their  the World  Health and  an  et  done  or  also  in  a  where  a l . ,  which  hemopoiesis population deficiency to  e_t a l . , Thus,  for  in  a given  hemoglobin  individual (Baker,  is is  In  pregnant  from  excluded.  exist  1978;  due  1981;  derived  among  Beaton,  a different  population.  used  et  for  reported  1965).  a  Some  people 1974;  arbitrary  Malaysia, women i s  the  10 g m / d L  of  1968).  on anemia  third  nutrient  likely  anemia  due  to  to  Some e x a m p l e s  (WHO,  (WHO)  1968),  (Jackson 1984).  in  trimester  most  Organization  a l . ,  for  were  each  increased  1978).  Burma  normal  (Dallman  a l . ,  Chong  condition  anemia  second  are  Africa  (Tee  et  studies  deficiency,  (Baker,  Malaysia  level  normal  They  West  hemoglobin  for  prevalent  1973),  persons  determined  experience  Venezuela,  healthy  1973;  is  a  hemoglobin"  be  (Ong,  as  required  to  women i n  pregnancy.  nutrient  ethnic  Prevalence  they  that  McDonough  The m a j o r i t y  cause  LITERATURE  Anemia  defined  level  "normal of  or  is  1974;  above  2.  nant  R E V I E W OF  Definition  Iron  WHO,  2.  pregnancy of  pregnancy.  requirement  show e v i d e n c e  folate of  at of  deficiency  studies  collaborative  done  (Sood  et  and Latham,  1982;  Mathan  these  a l . ,  this iron  in  studies  preg-  is  be-  stage  of  deficiency. also  on anemia  1975; et  with  This  could  studies  India  The women i n  dealt  be include  Mexico,  Poland,  Yusufji  et  1979)  and  a l . , were  selected  a l . ,  at  7  clinics or  mainly  urban.  Table  The  1.  prevalence  The h e m o g l o b i n  frequency  distribution  Hematological  Some  of  are  mean c e l l  the  the  (MCHC)  values  indicating (1983)  as  iron  (International a  should  reported  be  that  PCV  the  form  to  (Hb),  hemoglobin blood  have  determine  (MCH),  cells are  packed  determined for  (TRBC).  expected  and J a c o b s , been  set  by  the  to  compared  is  essential  techniques  to  Dacie  in to  any  determine  and L e w i s  lower  diagnosis than  The  of  the  criteria  and  George  for  differential  diagnosis  of  iron  of  a l . ,  electronic  iron  1981).  counters  laboratory  they  dealing  with  PCV,  MCV, It  This  information  since  The  et  useful  practical  1967).  underestimate  anemia  of  method  Hb m e a s u r e m e n t s  of  diagnosis  be  (1974).  a measure  differential  the  studies  sensitive  important  In  hematology,  as  a n d MCV a r e  (Graitcer  by  in  not  and  (PCV),  hemoglobin  b y WHO ( 1 9 7 2 )  is  fast  deficiency volume  1980).  that  an a c c u r a t e ,  iron  cyanmethemoglobin  standardization  described  use  in  cumulative  mean c e l l  assume  increasing  of  cell  of  PCV  shown  rural  aspects  Richards  standard  cases  in  are  number  The  anemic  as  countries  either  2.  be  as  and were  2).  indicators  anemia  strata  shown  utilized  red  hemotological  used  are  hemoglobin  1981;  committee  Standard  of  total  Table  these  biochemical  blood  should  in  (Figure  methods  deficiency  common r e f e r e n c e  anemia. TRBC  and  these  shown i n  anemia  mean c e l l  (Figueroa,  Hemoglobin  of  and  (MCV),  socioeconomic  estimations  measurements  deficiency,  normal  of  standard  volume  concentration  low  curves  3.  anemia  iron  representing  provide  deficiency  has  test.  valuable anemia.  would as  has the  lead Hb,  total to it  MCH a n d  in  gives  anemia.  The d e t e r m i n a t i o n information  and  been  us  but  deficiency  made MCV,  MCH,  use  TRBC of  MCH  the  L o w M C H a n d MCV  compared  8  TABLE  1.  The  prevalence  of  anemia  different  population  with  less  than  Geographical  area  in  third  groups,  11 g / d L  as  Population  trimester  expressed  cited  by  Anemic  as  Baker  of  pregnancy  percent  of  and DeMaeyer,  %  1979.  References  Poland  Urban  21.8  WHO,  1968  Venezuela  Urban  37.0  WHO,  1968  Latin  Mixed  26.5  Cook  et  Israel  Rural  47.0  WHO,  1968  Mexico  Rural  26.6  WHO,  1968  America  a l . ,  1971  Southern  India  Urban  57.4  Yusufji  Northern  India  Rural  80.0  WHO,  Burma  Urban  82.0  Aung-Than-Batu 1976  Malaysia  Urban  43.8  Tee  TABLE  2.  in  population  et  a l . ,  1973  1968  et^ a l . ,  et  a l . ,  1984  Hemoglobin values below which i r o n d e f i c i e n c y anemia c a n be c o n s i d e r e d t o e x i s t , and a s s o c i a t e d hematological v a l u e s (WHO, 1 9 7 2 j G e o r g e , 1 9 8 3 ) .  Normal  values  for  adult  women  Blood  indices  Pregnant  Hb  (g/dL)  10-11  12-16  PCV  (%)  30-33  36-46  MCH  (pg)  MCHC  (g/dL)  MCV  (fL)  TRBC  (lxl0 /L)  26 32-36 75 9  3.3  Non  pregnant  26-32 32-36 77-91 4.2-5.4  HMmogtobm grami/100 ml  Figure  2.  HMmoglabin grams/100 ml  Frequency d i s t r i b u t i o n of hemoglobin concentration i n the t h i r d t r i m e s t e r of pregnancy i n d i f f e r e n t ^population groups (Baker and DeMaeyer, 1979).  10  to  normal  be  a  values  characteristic  folate  and  (Dallman, g/dL  B^2  1983).  spherocytosis  and  cell  at  Maternity  findings  of  better  3).  This less  Using purposes,  the  This  in  4.  normal  iron Most  characterized  range  for  as  deficiency. other  taken  It  anemias,  by n o r m a l  MCHC i s  that  deficiency.  of  or  to  microcytosis  be is  Bj^  and  also  example MCH  present  found  folate  for  between  the  in  could  elevated  H i g h MCHC i n d i c a t e s  than  (37%)  the  Malaysia  and  the  than was  g/dL  Malays 11.0  of  Irael  g/dL,  reduced was  anemia  32  to  36  and  is  a  presence  of  deficiency  used  as  an  of  less this  prevalence (47%)  (57.4%),  Malaysians  as  as  is  cited  the  half  11.0  Malaysian  Table  India  by  (22.8%)  Baker  of  group with 1.  (80%)  a  clinic The  cut-off  when  anemic the  anemia. for of  comparative women  those  The and  and  was  women w e r e  g/dL  comparable  shown i n  northern  Using  indicator  than  antenatal  Chinese  Indians.  almost  hemoglobin  e_t a j ^ . , 1 9 8 4 ) .  the  43.8% o f  of  the  (Tee  of  by  in  curves  attending  of  high  India  the  Lumpur,  concentration  and  mothers  status  proportion 10.0  frequency  hematological  less  moderately  situation  Kuala  that  of  cumulative  pregnant  the  prevalence  Folate  and  276  that  than  than  the  Hospital,  southern  much h i g h e r  A  of  minor.  macrocytosis  hemoglobin  Venezuela  anemia  are  4 show  hemoglobin  hemoglobin  43.8%.  iron  volumes  indicate  generally  (Table  thalassemia  L o w MCHC m e a n s  not  3 and  packed  value  of  indicative  1984).  Figures  the  is  The n o r m a l  indicator  (Khalid,  of  2)  deficiency,  1982).  (George,  useful  in  (Table  was  reported  prevalence  Burma  and DeMaeyer  (82%)  of was  (1979).  Status  is  possible  Hb v a l u e s  are  where  the  low while  percentage other  of  PCV  is  greater  indices  are  normal.  than  This  is  11  hemoglobin concentration (g/dO  Figure  3.  Cumulative frequency d i s t r i b u t i o n of hemoglobin concentration of subjects from the three racial groups i n K u a l a Lumpur, M a l a y s i a (Tee e t a l . , 1984) .  12  packed cell volume (%)  Figure  4.  Cumulative frequency d i s t r i b u t i o n of packed of s u b j e c t s from the three r a c i a l groups i n Lumpur, M a l a y s i a (Tee e t a l . , 1 9 8 4 ) .  c e l l volume Kuala  13  TABLE  Racial  group  3.  Hemoglobin l e v e l s antenatal clinic,  Number  o f 2 7 6 p r e g n a n t women a t t e n d i n g K u a l a Lumpur (Tee e t a l . , 1 9 8 4 ) .  Hemoglobin  of  subjects  Mean  (+SD)  % < 10  (g/dL) g/dL  % < 11  g/dL  Chinese  104  11.48  (+1.8)  17.3  30.8  Malays  109  11.15  (+1.5)  20.2  47.7  63  10.51  (+1.7)  36.5  58.7  276  11.13  (+1.7)  22.8  43.8  Indians A l l  races  Numbers  in  parentheses  are  standard  deviations.  14  indicative  of  this.  the  For  blood in  samples  iron  logical Baker  are  would  The  quantification  serum f o l a t e  gives  higher  used. green  leafy  status  is  vegetables  folate  vegetables  subjects (Table using  studied  4).  A  5 ng/mL  a  by  lower as  low  et  in  3 ng/mL  cited  Baker  5.  Evaluation  The most serum  ferritin  1974;  Addison  serum f e r r i t i n  recent using et  a l . ,  method  when  not  red  microbio-  cell  1961; folate  usually assay  is  intake  of  uncommon  their  of  less  than  3 ng/mL  (1984)  were  considered  value  of  58.8% o f  folate  for  recent  dietary  46  level  folate (AH  percent  denoting  using  serum,  folate  the  61% o f  was  1982). lower  the  deficient  deficiency  eit a _ l . ,  folate  reported  Folate  normal  limit  of  (1979).  status of  and  determination  levels  the  expected  Herbert,  dietary  value  confirming  radioimmune 1972  by  determination  is  all  morphology.  done  between  a cut-off  and DeMaeyer  iron  blood  1966;  as  Burma was  of  It  of  deficient  is  recent  confirm  are  microbiological  by  to  minimal.  al.  cut-off  reported by  folate  been used  deficiency as  is  prevalence  the  occur  supplements.  serum  cut-off Tee  influenced  the  (Herbert,  the  of  Using  results  cells  B^2  blood  when  intake  deficiency.  casei  the  serum f o l a t e  or  have  in  in  folate  to  limits  folate  necessary  examinations  and  cell  directly  have  folate  megaloblasts  in  are  hypochromic  Red  subjects  Several  of  1984).  normal  these  or  Variations  than  and  contrast,  Lactobacillus  (Khalid,  values  Folate  In  methods  histological  Microcytic  anemias.  1959).  other  diagnosis,  necessary.  utilizing  e_t a l . ,  and  show m a c r o c y t o s i s  actual assay  deficiency  differential  deficiency  subjects  and  folate  is  assay  Jacobs that  iron  deficiency  (Barnett et  it  a l . , allows  e_t a l . ,  1972).  is  1978;  by  measuring  Miles  An advantage  evaluation  of  iron  et of  a l . , the  status  15  TABLE  4.  Folate  status  antenatal Lumpur,  Racial  group  Number  of  clinic  Malaysia  271 at  (Tee  women a t t e n d i n g  Maternity  e_t a l . ,  Mean  Hospital,  the  Kuala  1984).  Serum f o l a t e  of  subjects  pregnant the  (+SD)  Median  (ng/mL) Range  % < 3  ng/mL  Chinese  104  4.70  (+5.06)  3.15  0.3-30  45.2  Malays  101  3.30  (+3.83)  2.48  0.1-30  66.3  66  2.47  (+2.44)  1.60  0.3-14  77.3  271  3.64  (+4.19)  2.40  Indians A l l  races  Numbers  in  parentheses  are  standard  deviations.  0.1-30  60.9  16  within or  the  normal  excess.  Cook  et  It  a l . ,  range,  is  an  1974;  In Malaysia, to  differentiate  as  indicator  Lipschitz a number  iron  (1982)  Khalid  (1984)  15 n g / m L  11.0  in  ng/mL  values value Malays  Malaysia  (Table  among of  used  the  21.9  and  „ . , Racial  5).  Indians  group  5.  used as  Tee  There  three  ng/mL  TABLE  by  of  racial  et  body  a l . ,  conditions iron  1974;  stores and  threshold  the  lower  for  value  normal  (1984),  the  significant  groups.  w h i c h was  „ , Number  of  In  a  in  et  used  a l . ,  while  value  was  ferritin  women s h o w e d higher  were  study  ferritin  (ng/mL)  Mean  (+SD)  Median  Range  0-180  Malays  103  11.09  (+ 8 . 8 )  9.0  67  12.61  (+15.3)  280  15.69  (+19.0)  are  Tee  12 n g / m L ,  Ferritin  of  13.5  parentheses  1979;  a  mean  than  the  5).  (+25.3)  in  ones.  significantly  21.86  Numbers  ferritin  differences  110  races  deficiency  and F i n c h ,  serum  median  The C h i n e s e  iron  1972).  value.  Chinese  A l l  (Cook  Serum f e r r i t i n s t a t u s o f 280 p r e g n a n t attending the antenatal c l i n i c , Kuala M a l a y s i a (Tee et a l . , 1984).  subjects  Indians  either  from normal  the  a l .  of  Jacobs,  values  subjects  were  ferritin  (Table  in  threshold  deficient  and Dallman  as  of  et  of  (1984)  conducted  well  standard  women Lumpur,  % < 12  ng/mL  40.9  68  61.2  8.6  0-165  62.7  11.0  0-180  53.6  deviations.  0-  17  In another ferritin  in  hemoglobin here  is  their  the  than  earlier  than  12 g / d L  determination  serum f e r i t i n  nutrition  studies  method  established,  are  is  assay  status  of  Malaysia,  the  10 n g / m L .  Some o f  these  (George  al.,  hemoglobin  not  a l . ,  biopsies,  and  is  to  a need of  it  is  et  adequate  can be been  been  found  to  1975).  It  a  procedure  safer  study  other  the  et  to  assess  levels  1980).  concentration  is  be  on  Burks  applied  to  a  also  useful  1979;  compared  effect  diseases  a very  a l . ,  has  and has et  assay  (Segall  Serum f e r r i t i n  effect  less  women i n  the  women The  and  iron  of had  inference  other status  of  women.  The  Tsung  on pregnant  were  higher  mentioned  pregnant  done  sera  values  that  indices  study  with  superior less  a  liver  serum  tool  et  Once  a l . ,  large  other method  traumatic  when employed  of  epidemiological  number  methods (Cook  compared  and  the  of in  to  samples. assessing  bone  iron  1979;  marrow  mothers.  There  possibility  concentration  iron  this  and F i n c h ,  on pregnant  disease  ferritin  1976).  in  (Addison  of et  the a l . ,  1972).  6.  Iron  Deficiency  Hematological consequence  of  a  deficiency  could  identified  almost  1972).  Its  South East  15%  (Maclver, The  Table  6.  also  highest  and  and  Hemoglobinopathies  or  hemoglobinopathies,  disorders  dehydrogenase in  Anemia  a l l  of  lead  The  to  races  incidence  Asia.  the  red  cell  anemia.  throughout is  in  carrier  in  as  thalassemia,  gene  the  and  world  (Ratten  Mediterranean  these  a  glucose-6-phosphate  The a - t h a l a s s e m i a  several  rate  enzyme,  such  countries  has  Beischer,  countries, may be  been  as  India high  as  shown  in  1976).  incidence There  is  of  hemoglobinopathies  an i n c i d e n c e  28% o f  in  the  Peninsular heterozygous  Malaysia  is  thalassemia  traits  18  TABLE  6.  The i n c i d e n c e o f h e m o g l o b i n o p a t h i e s in Peninsular Malaysia, (George, 1983).  Hemoglobinopathies  Percentage  Normal  64  a-Thalassemia Thalassemia Homozygous  2  (a  + trait)  26  1 trait  2  Thalassemia  2  (a+)  1  Others  7 Total  (categorized  as  Homozygosity  for  (Maclver, The  such  low as  is  iron that  normal film  is  are  well  features  a  women w i t h as  8 to  2)  and  1% o f  common c a u s e  the of  homozygous  thalassemia.  intrauterine  death  MCHC v a l u e s  shows  abnormally  sized  Occasional  target  around  symptomatic  to red  are  states. are  thalassemia slight  (Maclver,  minor  1976).  Mild  11 g / d L .  anemia  or  heterozygous anemia  Under  commonly  is  common  condition  occurs  with  in  of  Hb  levels  g/dL.  deficiency  in  thalassemia  m e a n Hb o f  pregnancy, 9  of  established  T h e MCV a n d MCH v a l u e s and  1 and  a-thalassemia  hematological  non-pregnant  as  a-thalassameia  100  1976).  thalassemia  stress  (%)  The m a i n  typically  minor. moderate blood  cells  markedly  or  low  Also  in  point in the  hypochromia  cells  or  nucleated  reduced of  iron  both  thalassemia  distinction deficiency  latter or  in  pale  case  but  the  are  may  the  and  two  often  peripheral  erythrocytes,  anisopoikilocytosis erythrocytes  between  minor  with  blood some  ovalocytosis.  be p r e s e n t .  The  iron  19  status iron  determined  deficiency  (Maclver, The  prevalence (1964)  Malaysian  7.  is  compared  to  blood  volume  in  and  an  Tasker  1967;  number  bone marrow  is  de  a l . ,  et  Chesley, placental increase  and  increase  in  of  to  in  levels  are  thalassemic  usually  low  in  subjects  by Ong  studies  (1973);  on anemia  in  preg-  6%.  physiological  changes  the  circulating  second  by  increases  the  the  mother,  blood.  3 6 t h week  of  and MacDonald,  1965).  trimester.  During  the  or  remains  of  Blood  1980;  last  one  pregnancy  The g r e a t e s t  slightly  during  red  resulting increase  rises changes  until  as  Chesley,  increase several  stable  occur as  They  are  The  (Pritchard, 1980;  in  in  in  to  cells  resulting  and MacDonald, an red  term  well  delivery.  pregnancy  blood  (Pritchard  the  as  of  in  in  weeks (Lund  1965).  thus  unit  amount  (Pritchard  accelerated  pregnancy.  during  their  Pritchard,  circulating  These  1 to  state  Manson, is  in  reported  50% g r e a t e r  either  1966),  fetal  in  1967;  the  gradually  during  occurs  40  However,  1972). and  from  hyperplastic  volume.  initially  elevated  (1958b)  certain  volume  Erythropoiesis  Leeuw  serum i r o n  hemodilution  Donnovan,  the  and Donnovan,  which  and  nonpregnant  occurs  pregnancy  increased  or  or  hemoglobinopathies  produces  the  Lund  plasma  of  approximately  1972;  of  normal  Physiological  results  volume  are  ferritin  women r a n g e d  Pregnancy which  but  serum  1976).  Lourdenadin nant  by  increase cell  volume  (Pritchard meet  maternal also  control  in of  the  the  1962).  The  Wintrobe,  both is  red  only  cell 20  and MacDonald,  requirements  organs  in  whose  anticipation  of  to  1967; and 33%  1980; the  functions of  erythropoiesis  the  blood  during  loss  20  pregnancy in  this  is  complicated  with  definite  increase  normalcy  is  of  towards in  PCV  due  in  state  1968).  from  the  nonpregnant  anemias  in  pregnancy.  second  in the  the  1968)  plasma  and  to  pregnant  The and a  of  is  not  hemodilution  in  opinion  (Committee  and a  discussed  of  lesser  state.  change  There  is  is  a  slight  increase  in  the  1980;  de Leeuw  et  a l . ,  to  the  number  on Maternal  a  hemodilution  slight  as  but  hematologic  physiological  usual  and MacDonald,  a difference  volume  determination  contribution  trimester  (Pritchard  anemia  the  33% P C V  cases during  of  during  Haynes, the  majority  pathological  The  Nutrition, extreme  or  of  drop last 1966).  l o w PCV a n d .  Nutrition,  many  causes.  volume  in  hemoglobin  and  Hb a n d  low  level  1970;  Council  Hb a n d P C V authors  1970;  anemias  in  Thus,  Hb l e s s  occur,  (Committee  pregnancy than  by  in  the  small cell  nonpreg-  drop  to  11  1980;  Nutrition,  absolute  definition  impossible.  anemia  c a n be  the  packed  levels  Food and  and MacDonald,  33% P C V  to  and MacDonald,  becomes  define  and  These  of  expansions  compared  normalcy  36% P C V .  hemodilution  a  of  (Pritchard  (Pritchard  Although of  plasma  lower  plasma  using  less  11 g / d L  1969).  result  pregnancy  purposes,  30% P C V  in  hemoglobin,  pregnancy  use  can  normal.  where  practical  increase  volume  12 g / d L  Others  l o w PCV,  greater  cell  from  is  Hb a n d  1964).  a  on M a t e r n a l  In  For  to  red  Hb a n d  gm/dL  volume,  to  be to  values  Committee  1970;  to  summary,  increase  of  Jepson,  1970).  In  gm/dL  cell  as  pregnancy  Hb v a l u e s  nant  red  Hb d u r i n g  seems  volume  increase  uncertainty  and  Liley,  a marked  in  altered  apparent  month of There  1972;  text.  Therefore,  degree  (Chesley,  in  pregnancy  1980;  these  11 gm/dL  of  Nutrition,  low  Hb  definitions or  PCV  10  Henderson,  on M a t e r n a l  a cause  as  of  and  are  less  due than  21  33% s h o u l d mandatory  B.  be due and  Mother  Severe  pathological  correction  Detrimental  1.  to  anemia  of  in  mortality  (Llewellyn-Jones,  fetal  hypoxia. In  some  hemoglobin less  and  cases,  (Fleming,  up  to  7 to  infants.  At  made  on  the  rate,  lity  and  0,  The  The  scores  score  of  0-2  are  associated  maternal It about  anemia has  100  1973). increase  (Apgar, and  been  g for  When in  the  evaluation  of  (Garn et  each  a l . ,  1981;  for  is  are  directly Yusufji  in  and  is  of  et  a l . ,  to  is  less  in  the  PCV than  most  or  state  of  observations  reflex  8-10  the  are  irritabias  score  of  Total  with  a  low  fetal  degree  of  1973).  a diminuation  maternal  the  low birthweight,  related  some  three  together.  rate,  in  maternal  of  expressed  added  L i l l i e ,  with  birth,  are  even  results  scores  tone,  of  and  and  assessing  muscle  observation  there  hemoglobin  mortality,  APGAR  after  prevalence  are  2% d e c r e a s e  maternal  effort,  Gatenby  from mothers  system  risk  morbidity  < 10 g / d L )  a high mortality  The  that  (Hb  born  observation  with  1963;  5 minutes  each  deaths  estimated  perinatal  of  1909).  fetal  every  and  a  increased  fetal  one m i n u t e  is  respiratory  results  anemia  infants  with  and  MacGregor,  have  one m i n u t e  2.  abnormalities,  1965;  10 g / d L  or  rate  maternal  20% o f  1,  mortality  adequate  Anemia  associated  APGAR s c o r e  newborn  color.  is  Even moderate  1973).  heart  Deficiency  increased  1958b).  between  Iron  pregnancy  delivery  Tasker,  which  fetus  premature  1960;  for  possible.  Effects  and  causes  in  birthweight  (Harrison 7 g/dL, severe  and  there  of  Ibeziako, is  untreated  a  sharp  anemias,  22  more  than  Jones,  30% o f  1965;  Tasker,  Successful the  fetus.  In  they  were  In  similar  a  weeks, was  4% i n  group 7% o f  Maternal below  7 g/dL,  falls  below  cardiac  maternal iron  maternal  iron  umbilical were  cord  10 n g / m L  (Kelly  et  weight  and  weight.  a l . ,  less  the  than  there  g/dL,  six  infants  weighed  treated  maternal  more  prevent  birthweights less  1968;  Llewellyn-  therapy  below  adverse below  effects  2,000  t h a n 23% ( F l e m i n g ,  2,000  anemia;  pronounced  breathlessness  pregnant  women a r e  be  fatal  delivery  or  following  India  type  are  (Banerji  three  factors  deficiency blood or  PCV  w h i c h may  in  for  g.  at  the  g  on  when  1974).  least  six  Perinatal  38% i n  less.  total  mortality  untreated  and  iron  One months  stores of  exhaust study old  of  congestive  Twenty  percent  of  with  predominantly  anemia,  of  the  1968). iron the  iron  deficiency serum  lower  ferritin  stores  anemia are  is  stores  are  a cause  directly  have  prevalence  born  in  when m a t e r n a l  iron  infants  a  hemoglobin  hemorrhage.  low birthweight  who w e r e  develop  the  1958b),  maternal  reported  to  If  is  Tasker,  infant's  their  rest.  hemoglobin  1965;  First,  the  even at liable  associating  Secondly,  infants and  et_ a J . ,  significantly  Thus,  when t h e  (Llewellyn-Jones,  associated  anemia.  were  1978).  growth  1980).  the  had  can  women u n d e r g o i n g  is  Thirdly,  postnatal et  a l . ,  anemic  and  deficiency  1974;  mothers.  during  are  of  becomes  4.0  (Fleming,  anemia  infants  morbidity  deaths  There  maternal  from mothers,with  in  failure,  especially  of  50% o f  their  treated  from hypoxia  1958).  Nigeria,  reduced  the  died  treatment  delivered  only  also  infants  at of  from anemic  a more  infants levels  values  presumably  low  of  rapid  anemia mothers  in  ferritin  low  related  an e a r l y  with  rate  stage among  to  birthbirthof  (Dallman infants  (Mahasen  et  a l . ,  23  1974). have  However,  normal  active et  transport  a l . ,  1981).  2.  Work  tissues  release  in  patients  red  breathless.  and  et  important The rural  work  the  adequate  level  a l . ,  Viteri  from  anemic  suggested  mothers  that  supplies  that  seriously  Edgerton  of  et  on  is  in  to  there the  to is  an  fetus  by  (Ali  level  a l . ,  Heavy  falls  tropics 1973).  even  lactate  manual  commonly  1982). is  and  (Baker or  deprived  report  falls  very  1980).  anemia  7 gm/dL.  and  accumulates  both male  work  anemia,  anemia  self-employed is  becomes  hemoglobin  deficiency  of  in  concentration  and Hueberg,  family  below  compensarest  by m i l d  When t h e  even moderate  his  3-diphospho-  rapidly  patient  (Domisse,  a  2,  the  (Finch  If  oxygen  These  hemoglobin  iron  and  delivery  at  capacity  1979).  reduced.  1973).  inadequate,  of  of  oxygen  oxygenation  1974).  rest  earning  reduced  the  with  complications  the  while output  decreased  is  performance  is  Elwood, tissue  Torun,  even at  cardiac  exertion,  oxygen  e_t a l ^ . ,  work  farmers  Vaughan  and  obstetric  cultivated  maintain but  anemia,  concentration  1974;  and management  and  in  correlation  breathless  subnormal  1977;  was  by  raised  performance  a direct  performed are  a  to  anemia,  work  prevent  reduced  increase  through  diagnosis  1979;  area  It  born  from maternal  (Bellingham,  1977;  is  is  by an  p e r f o r m when h e m o g l o b i n  this et  has  iron  blood  compensation  the  workers  farmer  to  a^.,  to  DeMaeyer,  and  shows  mother  Therefore,  are  Maximal  7 gm/dL,  the  cells  moderate  uptake  (Gardner below  by  maintained  with  infants  capacity  carriage is  for  concentrations.  mechanism of  mechanisms  oxygen  possible  from hemoglobin  glycerate tory  is  hemoglobin  Oxygen to  it  of  becomes It for  is  female and  subsistence his  output  impossible  usually  treatment  at (Ezem  24  C.  Nutritional  There The  first  are  nutrients to  does  not  withstand  any  nutrient  iron  is  to  pregnant  is  WHO,  to  be  therapeutic the  stores  to  The  demand  for  second  stage  without  anemia.  produce  anemia,  The the  DeMaeyer,  deficiency,  individual's  increased  iron  about  basal  is and  blood  which  about  If  there  an  are  the  each  no  iron  any  of  and  less  involves  overt  1979).  nor  intake  third  absorption  be met  by  assumed  stage  able  biochemi-  is  when  deficiency  is  to  women, be  required  allowance  the  requirements  placenta.  are  the  symptom  to  is  the  for  the  the  increase  of  the  total  fetus  requirements  concentrated  during  the  the  start  second-half  can  there  only  are  on  be  iron  these  of  of  achieved  stores  second-  pregnancy,  pregnancy  stores  in is  (Masawe,  at  non-  whole  period  the  drawing  iron  pregnancy  stores  which  for  The  but  similar  The  whole  in  If  pregnant  iron  iron  day  supplementation. can  the  requirements  absorbed  6 mg,  mg f o r  in  are  500 mg,  2 5 mg f o r  1,000  These  would  with  available,  (Baker  some  and  1979).  developing and  losses  meet  mass  iron  over  of  losses.  1970).  of  loss  to  requirements  DeMaeyer, In  the  2 2 0 mg o f  pregnancy.  amount  have  but  of  and  pregnancy  basal  290 mg;  therefore,  of  the  (Baker  evidence  Approximately  cell  approximately  the  the  period red  in  no m e n s t r u a l  state.  maternal  half  deficiency  deprivation.  enough  balance  meet  pregnancy  1981;  meet  abnormalities  severe  Iron  There  are,  to  Anemia  deficiency.  1.  needed  iron  disturbance,  able  clinical  of  Deficiency  show c l i n i c a l  not  and  Iron  stages  biochemical  deficiency  of  of  is  cal  of  three  stage  detectable  Aspects  routine  countries,  most  administration  mothers of  iron  have  low or  supplements  negligible to  a l l  iron  pregnant  women  25  has  been  practiced.  women h a v e  low  Pritchard,  1967  2.  a  ing  and  radioactive  the  nonheme  The  (Layrisse, that  1975;  iron  muscle.  addition  of  which  depends  technique  of  incorporat-  et  1979).  fiber,  present  in  content  Widdowson,  1960).  (1959),  intake  Based of  15  in  the  diet  1973),  Inhibition  presence 1970;  oxalates  and  Watt  3 0 mg p e r  of  of  iron  of  iron  food  increased also 1974;  the  be Bjornacid, from  (Bjorn-Rasmussen, coconut  foods  and M e r r i l l , of  The  soyabean  absorption  (Fleming,  Numerous  being  1971).  tricarboxylic  1968),  tannates  surveys day  acid,  phytates  Elwood,  foodstuffs. 1983;  citric  et  absorp-  some  6% f o r  a l . ,  on d i e t a r y to  meat  rice,  (Sayers  1982).  (Tee,  1% f o r  acid  a l . ,  many  of  and  individuals,  and M a r t i n e z - T o r r e s , was  the  inhibit  ascorbic  a l . ,  1975),  500  on  or  could  et  a l . ,  Layrisse  than  sources  enhance  absorption  the  Than et  an  iron  Iron  in  (Callendar  iron  this  1975).  occurs  eggs  their  et  by more  presence  (Layrisse,  1974b),  for  ligands  absorption  The  (Fleming,  foodstuffs  to  foodstuffs  sugars  is  those  of  availability  the  and  and a n i m a l  iron  amines  Iron  of  vegetable  determine  into  Sayers  a l . ,  from  bioavailability  1974a;  other  iron  food  iron  of  1966).  iron  of  number  iron  Rasmussen, and  Scott  a  veal  by  1982;  used  indicated  increased  a l . ,  (Hallberg,  considerable  One s t u d y  deficient  of  stores  a  1982).  iron  absorption  countries,  (Fleming,  from a v a r i e t y  22% f o r  iron  concentrations  tion  and  of  diet,  absorption  findings  developed  de Leeuw e t  common p o o l .  properties iron  and  a mixed  in  negligible  Absorption  In enters  or  Even  intake  iron  is  1982;  have  1963;  milk  (TheinRossander  been  McCance  analyzed and  conducted  sufficient  b y WHO for  a  26  pregnant  woman.  this  recommended  iron  present  because or  of  the  because  al.,  in  of  1959;  iron  iron  of  is  not  forms  of  iron  substances and  the  status  the  level  Hussain  composition diet,  in  food  Therefore, the  However,  of  of  the  of  a l . ,  where  may n o t  sufficient  infection,  for  et^ a l . ,  that  anemia  is  if  1974;  Chodos  iron  prevalent,  the  absorption;  inhibit  ferrous  either  et^ a l _ . ,  absorption  1957)  (Foy  et^  1959). absorped  individual  1978);  be  available  diet  iron  pregnant  et  countries,  (Hallberg  Patwardhan,  the  presence  intake  readily  in  amount  (Monson  tropical  the  in  a  given meal  (Heinrich,  amount  and v a r i o u s  of  1970);  iron  other  is  dependent  the  available  factors  on  dietary in  the  discussed  above.  3.  Evaluation  Dietary  analysis  standard  food  evaluate  the  position  of  compiled  food  local as  food  food)  unusual This  could  nutritional  table diet  the  many  appetite,  should  also  to  is The  iron  be  presence of  study  done  by Tee  for of  the  area a  pica  excess  (a  patient.  and v o m i t i n g  The  for  social  This Inquiry  which  be u s e d  to  nutrient of  a  fats  be  are  com-  locally  nutrients  unnatural  class  about  reduce  of  and  should  of  use  estimation  carbohydrates  anemia.  A  compilation  craving  of  content.  should  (1983).  accurate  women r e g a r d l e s s  deficiency  nausea,  the  nutrient  in  articles not  (McFee,  1973).  corrected  for  other  factors  nutritional  such  as  intake  made.  24-hour  characterize  important  of  determine  In Malaysia,  was  consumption  well-being  a poor  The  foods  to  within  encountered.  pregnant  cause  necessary  compiled  table  items.  diet  is  Malaysian  and in  of  dietary diet  recall  has  been  (Rush and K r i s t a l ,  the  most  1982).  frequently  This  is  in  used  technique  comparison  to  27  the  diet  history  developed  (Abrahamson  and K o s o v s k y ,  recall  a  with  dietary  change  Rush and calories, protein  a  that  and  fat.  the  days  24-hour  in  recall cases  food  the  consumption  frequency of  Recommended countries.  suggested  values  food  daily  the  the  it  is  pregnant and  Cultural  on her  like  in  order  by  Tee  on  factors  and  daily assess  of  checklist  24-hour  the  dietary  problem of  recalls  recalls of  were  to a  for  have-to  a  considered  the  would  as  the to  estimating  estimating  be  on  examine  trend  and  for  three  two m e t h o d s ,  checklist,  give  (1983)  influences  are  the  tables  to  the  recalls  factors  protein  intake  of  24-hour  three  for  also  suggested  mother  two  possible  committees  taboos  and  other  not  frequency  pregnancy.  frequency  will  sociocultural  A Malaysian depending  food  food  overcome  a combination  a  the  would  subjects  dietary  technical  beliefs  (a)  of  groups  compiled  Sociocultural  Among  dietary  of  calcium, various  and  integration  recommended  checklist  been developed  a number  4.  where  An  during  Thus,  and  In Malaysia  women h a v e  of  However,  recommended.  The  take  (1982) and  (1947)  checklist  occur  availability  diet  meaningful  by  might  Kristal  Burke  1963).  frequency  carbohydrates  including cutive  food  by  for  be  conse-  example,  more  patient  the  again.  pattern  in  carbohydrate.  have  been developed  dietary their  intakes nutrient  adapted  from  the World Health  for  for  most  pregnant  status.  studies  These reported  Organization.  nutrition  influencing  cultural  the  practices,  socioeconomic  nutrient dietary  or  food  in-  patterns,  status  (Lourdenadin,  1964).  racial  and  beliefs  practices  mother  could  cultural  have  different  background.  There  are  three  religious major  races  28 belonging to three d i f f e r e n t r e l i g i o n s i n Malaysia.  The Malays a r e  M u s l i m s , t h e Chinese a r e m o s t l y B u d d h i s t s , whereas t h e I n d i a n s a r e H i n d u s . The c u l t u r e s o f t h e Chinese and I n d i a n s a r e those passed on t o them by t h e i r o r i g i n a l a n c e s t o r s , from t h e i r mother c o u n t r i e s , I n d i a and C h i n a , r e s p e c t i v e l y (Chen, 1973a).  The Malay c u l t u r e , e s p e c i a l l y t h e r u r a l one,  i s made up o f s e v e r a l i n f l u e n c i n g f o r c e s , o r i g i n a l l y from a n i m i s t i c and customs.  beliefs  The f i r s t was Hinduism ( s i n c e t h e t h i r d c e n t u r y ) , t h e second  and most i m p o r t a n t i s I s l a m ( s i n c e t h e 15th c e n t u r y ) and t h e t h i r d i s w e s t e r n m a t e r i a l i s m ( s i n c e t h e 16th c e n t u r y ) .  The Malay women's t r a d i -  t i o n a l m e d i c a l systems and common customs a r e s t i l l a n i m i s t i c ; ceremony i s p a r t l y Hindu and p a r t l y A r a b i c , and h e r r e l i g i o n I s l a m , d e r i v e d from A r a b i a (Chen,  1973a).  I r o n d e f i c i e n c y anemia i s q u i t e common where h i g h c a r b o h y d r a t e i n t a k e i s observed.  Carbohydrate foods seem t o be f i l l i n g and p r o v i d e c a l o r i e s a t  the expense o f meats and o t h e r foods c o n t a i n i n g i r o n .  Carbohydrates a r e  cheap t o purchase as compared t o meats, eggs and f i s h .  Because o f t h i s ,  the f l e s h foods a r e n o t consumed by t h e l o w socioeconomic groups. Hindus, due t o t h e i r r e l i g i o u s b e l i e f , do n o t consume f l e s h f o o d s .  The There-  f o r e , t h e l o w socioeconomic group and t h e Hindus a r e r e s t r i c t e d t o b u l k y , s t a r c h y , f i b r o u s and v e g e t a r i a n d i e t s . The i r o n i n t a k e o f these women a r e much lower than t h e l e v e l r e q u i r e d . T h i s has a l s o been observed i n o t h e r l a r g e p o p u l a t i o n s where t h e s t a p l e food i s r i c e , namely i n o t h e r Southeast A s i a n c o u n t r i e s and s o u t h I n d i a ( H a l l b e r g e t a l ^ . , 1974; Aung-Than Batu e t a l . , 1976).  I t has been shown i n  o t h e r s t u d i e s conducted i n M a l a y s i a t h a t l o w income mothers tend t o be more anemic (Ong, 1973; L o u r d e n a d i n , 1969).  29  (b)  Dietary  The is  staple  rice.  your it  often  contains has  taste,  consumed are  rice  with  origins.  the  right  The  Chinese  other  use  the  rapid body  becomes  'cool'  'overheat'  are or  have  Chinese  it  is  methods  of  food  when  to  body  not  amounts  meats  or a  and  eat  unusual  or  are  use  foods to  in get  vegetables. stir-fry  frequently  a Malaysian a  There  sweet  time  always  for  by  ethnic  other  the  more  for  preparation  and  rice  long  overcook  also  of  milk,  for  dishes  unless  experience,  different  fish  simmer  a meal  taken  and v e g e t a b l e s .  the  cook  to  as  you  conventionally,  coconut  in  pregnancy  is  baby  improve  overindulgence  of  the  single  their than  mother  to  meal.  taboos  process',  the  large  Malaysia  "Have  author's  with  side  than  From  the  in  Thus,  food  tendency  more  rice.  rather  between  to  origins  describe  usually  However,  and N i c h t e r ,  said  fish  The  and  eating  cereals,  pieces  dishes  the  periods.  beliefs  not  ingredients  to  a woman's  (Nichter  foods  having  tend  like  ethnic  rice?"  other  Indians  thus,  as  Usually,  cook  the  'ripening  and  the  do  over  side  usually  separate  the  the  three  1970).  item.  allow  short  Dietary  in  in  races.  three  change  delivers 'hot'  for  eaten  many  dishes  while  usually  two  (c)  As  and  food  the  denoted  you  because  side  sauce,  flavor,  vegetables  "Have  preferred  Malays,  recipes  the  been  some  The  often  of  (Chandrasekharan,  variations  chilly  curry  is  people  is  is  an e s s e n t i a l  slight  sour  a meal  This  always  as  among  asked  meals?".  rice  food  Having  question  patterns  has  considered is  fully  1983; the  'hot'  'hot'  foods  that  1979).  and keep is  considered  during  'ripened',  Manderson, blood,  been  the  believed  this is,  During body to  be  a  time  time. when  of Her  she  pregnancy,  warm  but  dangerous.  30  Therefore,  the  restricted  during  not  excessively  become  (Nichter foods  to  of  pregnancy.  development  and  certain  in  'hot'  that  There  is  the  association  any also  fetus.  fishes  are  believed  often  order  that  'heaty'  The  the  have  as  sometimes  of  abnormalities  classified  which  1983).  a belief  the  foods  pregnancy  and N i c h t e r ,  leads  during  eating  been  form  of  pregnant may of  folklore  that  For  example,  foods  said  in  is  bad  certain like  to  resemble  the  is  believed  that  body  with for  foods  in  not does  baby  will  affect  cuttlefish  the  features  'heaty'  the  crabs,  abnormalities  if  abortion  medication  medication  cause  decreased  woman's  result  a  to  are  fetus.  of  the  These seafoods  taken. Among lead  to  the  the  Chinese  child  fairer-looking instance, culty  in  quence,  amounts  and  of  taboos  44 d a y s  foods  are  after  avoided.  'hot'foods  are  'cooling'  foods  content.  Some o f  fruits, foods  papayas,  such  It  as  is  also  taking  lead  been  to  after  in  childbirth The woman's advocated  include these  include green  catfish,  with  also  is  this  1973;  taboo  foods that  'cool' are  cockles  a  the  after  avoided.  have  Difficonse-  right  rural  for  and  fetus. Malay  1972).  The  when a v a r i e t y  high  watermelons,  and  As  Bolton,  period  In  fruits,  belief.  among many  them  baby.  of  vegetables.  cuttlefish  large  development  considered  pineapples,  'twin'  the  (Chen,  and vegetables  a  would  give  from eating  exist  'cooling'  leafy  or  mutton  will  eating  birth  healthy  known as  body  while  fruits  and most  for  Malaysia  are  that  themselves  childbirth  tribes  twin  implicated  necessary  eating  soyabean m i l k  believed  women p r e v e n t  food  prawns,  it and  might  often  indigenous  first  and  has  pregnant  Dietary  fits,  bananas  delivery  adequate  mothers  having  babies.  'twin'  some  mothers,  delivery The  moisture  cucumbers,  addition, are  of  citrus  'poisonous'  avoided.  Foods  31  that  caused  potatoes,  flatulance  pumpkins  and  recommended  include  (Manderson,  1979;  food  items  (Wilson, diets  has  income  house,  agricultural Malaysian  chillies,  of  these  taboos  factors levels  lands,  which  and  shops,  population,  it  It  therefore,  more m e a n i n g f u l  evaluating of  money  the  reflect  most  recent  together  with  the  and  cash  available  the  Other  variables  and  occupation.  formal since  on f o o d  frequency in  schooling. some h i g h l y  of  of  to  Sri  folate, occur  and of  generally  are  coffee these  carotene,  property  boats  or  difficult  use  to  and  in  iron  deficient  Lankan mothers,  month.  of  of The  purchased  food  food  also  for  to  a l .  used  of  indicate  the  such  a  the  a  information. evaluate  (1983)  of  family. in  amount This  a week  amount  the  in  money a v a i l a b l e the  In  household  estimates  purchased  amount  example  assess  et  nutritional  resources).  estimates  Waxier  purchase  other to  with  (for  disclose  other  frequency  per  food  quite  of  household.  the  food  level  mother's  on  spent  that  consumption  been a s s o c i a t e d  reluctance  level  money the  the  the  income  spent  information,  of  of  have  fishing  is  because  status  fish  sweet  1973a).  ownership  accurately  economic  of  foods  salted  The  tips,  factors  income is,  1973).  nutrients  (Chen,  tapioca  'Heaty'  smoked o r  serum l e v e l s  low  example  avoided.  in  Socioeconomic  include  are  for  Wilson,  these  socioeconomic  wind',  1973a;  Low l e v e l s  status  rural  peppers,  Chen,  even without  The  'carry  jackfruits  resulted  1973).  (d)  or  of  would for pooled  household. associated Education  Income paid  is  jobs  not  with  socioeconomic  level always  do n o t  is  usually  determined  require  high  status assessed by  levels  are by  educational the  educational of  years levels  education.  of  32  For  example,  not  necessarily The  towards  above iron  pregnancy. income  a  teacher  e a r n more  Factors  usually  income  occupation  of  D.  Intervention  evident  have  from  the  of  and  -  her  Iron  many  problem  in  Malaysia.  It  Health  of  Malaysia,  and  countries,  One o r are:  more i)  to  and a d e f i c i e n c y  develop  intervention  therapeutic  reducing  nutrient  and  nutrition  i i i )  ways  of  advice  has also  a  have with  pregnant  (Working  Group,  India,  1982),  1976),  and  1974). (1972)  Food as  fortification  a method  to  with  improve  1973;  does  factors  condition  include  in  low  low education Lourdenadin,  iron  that  and  1969).  iron  nutrients  concern  of  dealing  to  WHO i n  with  other  this  implemented.  situation.  Some o f  fortified Thailand  been  balance  salt,  sugar  (Garby  proposed in  Malaysia  like  by  a  develop-  nutrient(s),  However, foods  is the  hookworm and m a l a r i a l  in  in  has  earlier  hemopoietic  iron  sauce  iron  the  anemic  resources,  a major  women.  in  fish  fisherman  inhibitory  anemia  concern  of  programme  a l . ,  the  (Ong,  been  fortification  et  the  hemopoietic  of  any i r o n  (Layrisse  with  or  been  launched India  aggravate  other  eradication  to  with  reviewed  and means  techniques  by  the  a  Supplementation  supplementation  losses  fisherman.  family  reports  nationwide  ing  than  property  anemia  of  than  together  earlier  deficiency  Ministry  educated  been a s s o c i a t e d  mother  Techniques  month  factors,  ownership  the  more  per  mentioned  that  minima  poor  is  is  socio-cultural  absorption  levels,  It  who  and Finch  women a n d  i i ) parasites,  has  as  in  these  not  was  done  Venezuela Arekul, and  Monson  children.  33  1.  Definition  Iron given  in  terally  medicinal by  as  of  iron  in  supplementation  2.  Types  (a)  Oral  The  use  correcting  many  sulfate, certain  iron  of  to  is  of  food  about  provide  tablet  times  preparations molybdenum or  of  anemic  long  tablet  in  or  pregnant  iron  is  period  cases  called  paren-  large  short  In  are  or  employed when  women. it  of  a mixture,  a relatively  term b a s i s ,  tablet  of  it  anemia  and the  iron  the  amount  of  where  the  prophylactic.  from  or  which  vitamin  iron  to  C with  slow  dependent  on  are  ferrous has  a  needs.  sources  deficient  occurs  in  are  a  reduced.  3 0 0 mg f e r r o u s dosage  elemental  combined w i t h a  There  these  is  higher  states.  An  from  oral  the  small  symptom d i s a p p e a r s  consumed  an a p p r o p r i a t e  is  most  1973).  of  been observed  iron  The  of  to  include  inorganic  iron  of  1970).  giving  amount  is  these  oral  1966).  (McFee,  Each  absorbed  method  routinely  fumarate.  has  by  given  forms  absorption  amount  cheapest  Standard  in  treated  daily  be  especially  a l . ,  the  from occurring  ferrous  irritation  and  be  should  absorption  intake,  et  to  preparations.  an e q u i v a l e n t in  seems  (Goodman and G i l m a n ,  effectively  which  be c o r r e c t e d  on a  and  25% o f  (Hallberg  three  to  addition,  iron  daily  iron)  usually  gluconate,  supplements  anemia  is  prevent  degree  of  Supplementation  cases  In  the  centration  a  supplement  amount  patients  as  iron  Gastrointestinal of  orally  amounts  supplements  oral  ferrous  of  t e r m u s e d when e x t r a  iron  iron  from  average  of  a  either  given  anemia.  Generally, than  is  supplementation  is  have  acute  mothers  oral  forms  injection.  seen  pregnant  iron  supplementation  deficiencies time,  of  release  of  iron.  other of  when  Iron  sulfate  other  There  for  ( 6 0 mg  are  better  the  con-  deficiency  ferrous  substances,  iron  percentage  for  of  salts many  other  example,  absorption.  34  For  public  health  purposes,  prophylaxis  during  prescribed.  McFee  latter  half  (b)  of  take  is  l i t t l e  The  iron  bound free  sorbitex stable  oral  that  intima.  The mL.  Jectofer longer  cy  for  two  and A s t r a f e r  from o c c u r r i n g .  (Chanarin Holly,  and  1955).  England  the is  provide.  forms  of  For  iron  daily  should  be  even during  the  anemia.  of  to  India in  The  in  not  iron  have  the  Iyengar  a l l  shown  majority  and A p t e ,  improvement  in  prevent in  very  ironand  is  ionic  the  carbohydrate  the  vascular  Astrafer  of  1970;  hemoglobin  Imferon (McFee, most  United  that  iron  has  Leeuw  levels  20  a  1973). deficien-  States  pregnant  has  whereas  of  supplemental  de  less  forms.  intravenously,  and A s t r a f e r will  where  that  is  mL;  intravenously.  studies  vast  per  or  so  iron  irritate  of  (Imferon)  free an  first  patient  molecule  the  is  types  second  (Astrafer),  pregnancy of  three  colloid,  smaller  5 0 0 mg o f  only  the  iron-dextran  are  does  anemia  when  are  weight  a  Jectofer  A series and  is  iron  and  or  There  intramuscularly  than  during  Malaysia,  pregnancy  one  bound  be u s e d  use  deficiency  preparation.  contain  given  1971;  of  molecular  reaction  normalcy  Rothman, In  to  deficiency  iron  dextriferrin  should  anemia  hematologic  is  be  supplementation  provided  in  forms  Iron  Canada,  iron  first  amounts  in  clinical  America,  standard  reasons.  large  iron  iron  I m f e r o n may  and w i d e r  expensive  6 0 mg c o n s u m e d  u s e d when  The a  where  neutral  first  that  medical  significant  is  be the  few weeks  present  parenteral  complex  last  dextran, is  of  prevent  often  available.  iron  that  third  mg p e r  the  (Jectofer)  so  is  iron  to  one  stated can  may  iron  iron  during  parenteral iron  (1973)  Parenteral  discovered cannot  pregnancy,  pregnancy  Parenteral  these  iron  women et  were  a l . ,  1966;  observed  35  among p r e g n a n t  women g i v e n  These  together  findings  conclusively tion  of  with  demonstrated  anemia,  total  provided  dose  infusion  numerous  others  the  value  of  iron  that  these  anemic  of  imferon  throughout  (Kuah,  the  world  supplementation women  take  1972).  in  their  have  the  preven-  supplements  as  prescribed.  3.  Compliance  It ments  has  have  centers  prevalent studies  Malaysia  have  with  of  women i n of  was  this  iron  (1973)  the a  in  the  compliance  by  these  Ross  et  prophylaxis on i r o n area.  al^. did  population  the out  to  mothers  to  anemia  since  the  not  a  that  anemia  these  al.  (1973)  hemoglobin of  a l l  supplehealth  is  s t i l l  factors,  but  no  mothers  are  not  45% o v e r  iron  could  the  have  level  the  in  therapy.  been  fact  black  common p r o b l e m was  by  only  percentage  their  of  to  possible could  stating  10%.  It  McFee 6  weeks. non-  have  existed.  that  population the  in in  iron his  study  the  pregnant was  status  that  values  among  supple-  iron  However, 4  signi-  pregnant  The  after  hemoglobin  pregnant  prevalence  of  the  12 w e e k s  improve  supplementation above  confirmed  intervention.  supplementation  iron  the  attending  various  women t o  of  increase  among  was  these  it  with  an  the  78% t o  iron  disputed  lead  et  12 w e e k s  study,  of  iron  program.  duration to  routine  However,  fact  Basu  from  that  mothers  result the  and  45% o f  short  deficiency there,  be  4  chapter  mid-sixties.  increasing  of  (1981) not  pregnant  reduced  former  deficiency Iron  in  response  Therefore,  a l l  (1982)  failure  suggested  to  rule  after  was  to  first  supplementation  Africa  attributed  the  the  to  therapy  The  supplements  in  could  Latham  mothers  mentation.  since  This  and  West  anemic  free  been done  Jackson ficance  given  today.  complying  iron  been mentioned been  in  with  Durban  black  therefore,  36  observed that hemoglobin l e v e l f a i l e d to increase.  The author f e l t that  these anemic pregnant women, knowing that their anemic condition was not considered a major problem did not comply s t r i c t l y with the iron supplement prescriptions.  As a r e s u l t , no s i g n i f i c a n t increase i n their hemoglobin  l e v e l s was observed.  A similar finding regarding f a i l u r e of hematinics to  improve the hemoglobin status due to suspected noncompliance was reported i n 77 urban Zambian pregnant mothers (Jenkinson, 1975). In most cases, regardless of how the hematinics are given, the anemic mothers would respond to the supplements within 4-6 weeks.  A reticulocyte  increase i s seen within one week and over the next few weeks the hemoglobin levels r i s e to normal (McFee, 1973).  The degree of response to supplemen-  tation both i n r e t i c u l o c y t o s i s and r i s e i n hemoglobin i s more marked i n severe anemic conditions.  If the anemic mother does not respond to the  supplements, she should be evaluated with regards to causation.  Anemia  as a result of causes other than iron deficiency i s l i k e l y to exist (Reed, 1969; Wintrobe, 1967). (a)  Measures of compliance and demographic c h a r a c t e r i s t i c s  The v a l i d i t y of the measure of compliance i s important especially when one wishes to prove that the anemia i s due to noncompliance. objective and subjective measures have been used.  Both  Marston (1970) explained  that the objective measures of compliance was a more r e l i a b l e method i n evaluating compliance; for example, the excretion test and p i l l counts compared to subjective reports.  Regardless of whichever method i s chosen  one should remember that each method has i t s own merits and p i t f a l l s .  Even  the  p i l l counts and the excretion tests could give inaccurate results i f  not  properly done.  For example, i n s u f f i c i e n t r e p l i c a t i o n might not give  37  a  valid  measure  compliance strongly  specific  and  There  economic  are  or  questions with  simpler  between  some  namely  young  inconsistencies  that  and  forgetfulness. their  could  be  in  the  asked This  to  behavior level  errors  geriatric Regarding  medication  of  in  in  and the  the sex,  patients,  twice  as  due  to  as  (Gillum  gastrointestinal considered 1973). make  Barsky,  1974).  problems  related  to  to  take  factor  well  Educational  has  been  less  educated,  that  good  iron  intolerance  immediate  patients  (c)  and  frequent  Thus,  the  It  a  patient-physician  compliance  was  of  due  iron to  have  been  nausea  and  of  the  that  poor  have  language  associated  oral  is  pregnancy  problem must  (McFee,  be  taken  to  supplements.  patient  compliance  with  to  vomiting,  of  the  (McFee,  supplements  anemia  take  to  related  unresponsive  to  tend  characteris-  in  the  and  studies  forgetfulness  overcome  age,  group.  simple  to  iron  other  age  environmental,  interaction  either  30 y e a r s  or  enough  or  in  of  swallowing  oral  background  poorer,  reported  Blackwell  to  measures  reported  in  socio-  extremes  same  ingestion  tablets  at  the  the  and  occur  men i n  tics  failure  more  associa-  status,  of  psychological,  including  been  regarding  age  factors  The  be a much  the  Other  Health  of  characteristics  instance,  problems  women u n d e r often  For  often  1973).  (b)  to  marital  patients.  compliance  gender,  age,  have  noncompliance  measure  the  prove  literature  and n o n m o t i v a t i o n  regimen  define  could  Forgetfulness  of  subjective  task.  educational  reported  Whereas,  compliance.  compliance  (1973)  neglect  compliance.  associated  rewarding  tions  of  occurs  problems. the  middle  more  Marston class,  in  those  (1970) well  who  are  reported  educated  38  and  Caucasian  patients  most  (d)  likely  patient's  explanation The a u t h o r  of  not  people.  to  clinics.  want  to  is  lose  instructions  to  the  physician  can have  Malaysia,  true  patients.  feel  that  the medication  has  superior  private and,  clinics,  therefore,  the  government  the  patients  the  not  overlooked  the they  patients value  clinics  tend  to  or  place  basic  are  by  quality,  cost  paying  for  typify  the  and  the  the  compliance.  practice when  the  than  the do  patients  or  medication,  the  patients  as  compared  the  govern-  of  are the  the  the  same.  Another In  prescriptions  and  tend  hospitals,  the  medication  is  pay  to  medicine.  compliance  on and  on  physicians  convincing  and  value  received  private  them more  less  she  especially  preparations is  way  in  enterprise,  preparations  though be  better  Sometimes,  best  should  in  competitive  the  which  to  consequences  is  prescribed  factor  powerful  the  This  are  even  and  is  they  supply,  said  given.  compliance  that  ment's  were  that  a very  their  the  attributes  relationship  treatment  observed  practice  These  follow  relation  the  has  government  private  of  Patient-physician  The  in  group  less  to  be  often  the pills  better.  given  attention  to  At  free  and  the  supplements. Davies  (1968)  in  doctor's  advice  made  assumptions  the  ailment of  the  or  regimen with Such  reported  condition  regimen,  friends  with  study that  on v a r i a t i o n s  37% o f  the  patients  have  that  requires  them t o  or  with  discussed other  the  doctors'  the  patients' did  something see  doctor's  influential  doctor-patient  orders.  in  patients  that  patients  interactions  compliance  his  a  in  not  comply.  common,  doctor. advice  persons,  compliance  on  relatives  relationship  namely  After the  He  and  produced  first  an  being  value  with  told  of  the  associates. patterns  of  39  Davies or  making  (1968)  a  compliance  to  behavior,  (1972) He  review  measure  between  doctor used  stated  living  study three  doctor's  culture  medical  use  of  he  for  being  medication,  from which  is  patient's  compliance  result  was n e c e s s a r y  of  compliance  records.  The  as  of  namely,  perception  'defaulter*  the  an index  factors,  scores.  patients  word in  used  patient's  compliance  the  a  of  of  and  that  in  his  composite  independent used  in  indicated positive  receiving  perception  Weighted  patient  integrating  behavior  averages  that  to  is  were  communication  information  Stimson  doctor's  the  of  and  compliance.  a noncomplier the  by  orders.  decision about  maker  health  and  disease.  (e)  It  Presence  has  existence  the  'hot'  (Manderson,  1979;  dered  and  nant  'hot'  as  the Malay a  to  juices  or  tions,  the  pregnant  concept  mother  could  A  or  It  other  these  the  foods  during  'hot'  to  the  medications  1971).  has  been w e l l  been  established  woman i s  consi-  also  Other Puerto like  Rican  been  or  pregof  observed have  also  patients  when  or  substances from  in  association  cultures  aspirin  'hot'  consider-  observed The  has  Therefore,  compliance.  the  too much i s  1983).  'cool'  being  culture,  pregnant  fetus  that  with  has  eaten,  pregnancy.  supplements  the  the  finding  reported  (Harwood,  affect  of  and N i c h t e r ,  medications  iron  food  can be  similar  was  the Malaysian  of  body  and h a r m f u l  practices  magnesia of  The  (Nichter  belief.  neutralize of  1979).  in  theory  'hot'  'heaty'  vitamins  milk  1973a).  India  cultural  similar  administered tend  being  that  'cold'  though  I n d i a n women i n  reported  oil  even  beliefs  earlier  and  Chen,  (Manderson,  medication in  cultural  been mentioned  of  ed h a r m f u l  of  cod-liver like  these  'heaty'  fruit  observato  the  40 (f)  In of  time  can  Duration  addition or  for  found  that  the  It  iron  of  became  (g)  these iron  medication  its  probable  penicillin  in  understand  the  These and  is  lack  of  race  are  It  to  At  anemia.  of  the  It  the  treatment  important  for  the  the  were of  the  most  that  suggest  a  patient  (Mohler  et  aJ.,  supported  to  lack  the  factors of  should  leading  medical not  of  to  a  treatment prescrip-  iron  reported  the  (Bonnar,  compliance  to  was for  that  patient  before  1969).  medication.  understand appears  felt  given  for  and  and not  failure  and  of- c o m m u n i c a t i o n  illness  logical  well,  carelessness  the  prescribing  taking  to  insufficient between  the  1955). of  noncompliance,  understanding  by  the  care,  i t  tablets  aspect  to  length  two m o n t h s ,  advanced  reasons  patient  failure  (1979)  the  treatment  treatment,  reasons  to  frequent  the  the  also  reduces  patient  the  under  the  therapy  the  that  take  was  that  women w i t h  end o f  pregnancy  of  so  the  not  therapy  of  observed  Antenatal  women d i d  as  was  be m a i n t a i n e d  1969).  comprehension  purpose  important  compliance.  duration  study  continuity  has  i t  studied.  cooperative  one  Other  education.  were  pregnant  example,  related  factors,  (Bonnar,  For  Unterhaulter  diseases.  patient  consequences  acceptable.  was  a  explanation  the  found  above  deficiency  longer  Patient's  physician  the  that  less  that  A clear  money.  a l l  therapy  supplements  32% o f  appears  the  compliance  treatment  subjects  to  duration  influence  tions  of  this  patient  which  about  he  the  non-compliance  include  crowded  and  provide  adequate  health  language  and  failure  be  overlooked  that  variables  w h i c h must  be  to  barriers  taken  into  like  account  when  clinics,  studying  41  The the  review  compliance  has  factors  care,  environmental  considered  E.  Health  1.  contributing  as  workers  and  to  provide  of  the  every  has in  center,  four the  health  center  upgrading people.  of  staff.  of  rural  countries  that  can  However,  accessibility  control,  influence  to  health  and m u l t i p a r i t y  have  to  In  The  village  areas,  was  to  1981).  primary  unit  these  services  There  are care  better  are  many  the  being  to  serve  4,000  of  care  in  sub-  system  supervision  fully  are  center,  to  these  for  health  of  situations  facilities  unit  quality  health  care  areas  1973b).  two-tier  desa)  drive  rural  one main  (Chen,  the  improve  excellent health  to  health  health  main health  (Klinik  and  the  one of  stations  to  village  in  for  made up  converted  care  began a major  children  namely,  designed  health  is  health  centers,  called  clinics  provide  these  and  plan  population  supplying  Whether  was  primary  government  20 m i d w i f e  stations,  the  health  the  system,  s y s t e m was  and f r e e  mothers  and  aim of  the  1957,  health  three-tier  of  best  primary  for  rural  to  Anemia  care  rural  care  clinics  (Mackay,  where  poor  Deficiency  world's  subcenters  the  people.  questionable  factors  with medication.  namely,  disease  population.  coverage  primary in  the  basic  two-tier  medical The  of  rural  midwife  a wider  possible  patient  Iron  health  and m i d w i f e  through  and  in  form of  The  1970's  of  health  health  This  a  anemia  facilities.  primary  During  groups  the  country.  located  Factors  one  other  50,000  the  well.  Accessibility  organizations  to  of  sanitation  Related  Malaysia  some o f  characteristics  other  be  covered  care  facilities,  vulnerable  used  is  s t i l l  developing  excellent  but  by  42  grossly people that the  underused. just  the  do n o t  felt  people  need  as  turn  need  examinations. education  In Malaysia,  for  cure The  to  for  routine  medical  for  their  probable  well.  strengthened  up  It  is  some m e d i c a l  are  ailments  rather  solution  the  medical  services  is  imperative  complement  officers  to  that  health  that  examinations.  just  than  health  routine the  services  in  implies  Perhaps,  medical  mothers  extension  the  This  hypothetical.  provide  care  admit  with  health  services  existence  be  in  the  country. In on  the  any  case,  rural  population, dropped  has  produced  76  to  the  same p e r i o d ,  1.1  per  1,000  40  the  life  be  the  environment  is  parasites  and  agents  vectors removal  and water  lowers  infestation  in  thus  the  reduce a  of  health  73% o f  changes.  births  and  the  Infant to  mortality  rate  was  favors  disease  water  should  be  free  from  pathogenic  or  contaminated  be  not  polluted and  agents  pregnant of  1972. from  transmission.  air  and  Malaysian has During 3.2  to  control  foods,  disease  centers  mortality  1957  water,  be  care  total  between  disease  should  improve  these  1977).  houseflies  incidence  of  about  maternal  (Chen,  infection  to  in  sanitation  food  like  live  sanitation  should  the  chance  1,000  healthy,  purposes,  The  significant  through  household  or  some  births  transferred  air  comprises  decrease  environmental  can  on c o n t r i b u t i o n  which  per  Environmental  Poor  mothers  impact  population,  from  2.  the  safe  and v e c t o r s  mothers, anemia  for  To  drinking  ensure and  bacteria with  that  other and  disease  mosquitoes.  infestation.  their  and v e c t o r s .  Disease  would  from  The help  the  reduction break  and m a l n u t r i t i o n .  health  and  environment,  the  of  nutritional  infection  anemia  This  food  will  status.  cycle give Some  and and the  43  important mothers  diseases  include  that  malaria,  deficiency  diseases.  sanitation  is  mothers result  in  disease  the  Sewage  with  human w a s t e  food  are  hygiene  not and  population  to  The  role  community  and  infested  hemolysis  and  status  infections  of  the  conditions  such as  caused  which  close in  for  good  with  or  of  these  disease loss  health  and  vulnerable  agents.  of  these  nutritional  environmental  including  chronic  This  blood  will  caused  by  the  1942  rate  well  link  and  Philippines  case  Bank,  1972).  sanitary  cut  incidence  Malaysia,  1973)  dependent  upon w e l l s  supply  and  for  (van  50% ( S c h l i e s s m a n ,  70%  of  supply  (Philippines  census  54.4% o f  water  water  of the  supplies,  1970  Cholera  that  in  the  demon-  1966). the  In  a  1971).  Statistics,  rural  10.4% w e r e  have  facilities  Committee, of  not  reduce  1959).  toilet  (Department  dwellings and  and  of  improvement  Zijl,  helped  the  level  been  enteritis  by  Rica  of  has  health  facilities  easily.  do  health  reported  Costa  more  the  and  personal  s t i l l  in  about  that  sewage  with  Malaysia  and  for  soils water  proportion  construction  housing  showed  and  also  the  or If  spread  rises  in  conditions  studies  improvement  by  the  These  privy  study,  In Malaysia,  (World  water  diarrhea  water  areas  water  diseases.  will  facilities,  piped  food,  insufficient  diseases  rural  studies.  1957,  is  Many  between  better  with  of  transmitted  and water  sanitation  served  facilities  contamination  waterborne  development.  from  cholera  and  supply  fecally  consumption  disposal,  is  several from  various  supplies  these  resulting  death  the  and water  sewage  socio-economic  Between  of  hematological  bacterial  disposal  safe  both water  strated  infected  absence  Unsanitary  access  Therefore,  the  agents.  (a)  For  affect  hookworm,  protecting  from being in  would  areas  dependent  were on  44  untreated the  water  from  responsibility  ments, share  but the  (Chen,  from  rivers,  for  1975  water  not  a l l  facilities  result  that  the  infection  rate  (Stewart  possibly  be  example,  drinking  always  federal  found  because  in  the  on  Up  the  to  of  end  respective  government  cost  the  has  rural  of  1974,  state  govern-  undertaken  water  to  supply  projects  Among t h e  blood  2,250  1965),  increased 1958c).  Therefore,  an  loss  treatment helminthic  the of  The  stored s t i l l  in  water  in  of  practices  convenience,  factors loss  anemic  9 0 mL w i t h  often  families  always  pregnant  them were  supply  health.  water  does  systems  Some not  to  of  population  the  cooling  continue better  to  this  studies  paradox  which  drink  well  social  have the  may  studied.  jars,  taste,  and  influence  answer  in  of  was  a heavy  treatment  anemia.  anemia,  are or  For  nearly river  patterns  or  its  in  hookworm  infestation  thought  to  be  mothers  studied  in  Malaysia  the 2.0  study  of  anemia  light  than  should  be done  anemic  by  Ong  in  It the  aboriginal  also  found  stool, 1975;  Tasker,  (20 worms)  worms)  together  (1974)  problem.  was  (Oomen,  1,500  resulting  (Llewellyn-  infestation  (greater  done  a major  hookworm.  hookworm ova  mL w i t h  hookworm  69% o f  by  with  severity  infestation for  malaria  been  infested  A similar  infestations  hookworm and  indicated  increase blood  -  causing  has  infestation,  with The  or  purity  1955).  cultural is  better  improvements  a l . ,  infestations  65% o f  hookworm  in  that  qualities.  t h e many  excessive  the  greater  Parasite  Among  et  water  special  (b)  Jones,  of  show  bacteriological  contaminated,  supposed  about  canals.  rested  meeting  studies  concluded  that  to  the  or  1977).  sanitation  in  supply  onwards,  responsibility  However,  water  streams,  per  with  day. the  reported  pregnant  mothers  in  to  45  Malaysia.  There  helminthic  infestations.  jungle  areas  Similar  were  there  are  situations  exist  in  other  helminthic  worm i n f e s t a t i o n infestation In  cases  detected, of  had the  anemia  71 M a l a y s i a n  infection,  as  no  been  found  evident  by  was  to  aboriginal  be  be  the  the  are  iron  areas  of  causes  by m a l a r i a .  present  hook-  Hook-  the  (Tasker,  higher  1958c).  parasites  were  was  that  their  found  had  the  disposal.  where  anemia,  It  in  anemia.  (1974)  and  live  excreta  of  levels  b y Ong  tetrad  Malaysia  and m a l a r i a l  studied  parasites  and  deficiency  hemoglobin  caused  and  population  waste  major  observed  patients  of  rural  to  triple  aboriginal  means  remote  correlated will  double,  these  proper  some  hemolysis  was  of  infestations  lower  where  cases  However,  where  worm and  the  reported  21%  malarial  jaundiced  appearance.  3.  Multiparity  The  fact  documented  that  pregnancy  throughout  the  and  iron  world.  related  to  studies  done  Malaysia  and  and Ko,  1968).  In  studies,  pregnancies  were  enough  for  next  time  short any  pregnancy.  replacement  took  since  was  there  intake  of  embark  The  and  Singapore  not  body  iron  animal  it  multiparous pregnancy.  was  shown i n  1973;  or  state  food  to  foods  women a r e  were  feed was  that  means to  the  et  that  there  a n d no  the  family  a l . ,  duration  correct  made  to  be  several 1968;  Kwa  between was  itself  not  before  the  adequate  problem  even  adequately.  worse The  lowered.  frequently  Secondly,  Chong  depleted  status  well  trend  reported  anemic  been  been known  This  stores  protein  was  has  has  This (Ong,  coexist  parity  planned.  Low e c o n o m i c  insufficient  on a n o t h e r  pregnancy.  pre-anemic  place.  costly  Therefore,  these  in  Increasing  closely  in  anemia  deficiency  the  stage  iron of  deficient being  when  pregnant  they itself  46  often This  results was  in  iron  shown by  hemoglobin, pregnant  PCV  women,  a  deficiency  response  and  other  most  of  to  blood  anemia iron  of  high  supplementation  indices  whom w e r e  because  iron  as  compared  deficient  iron  and to  requirements.  increase  the  (Holly,  in  unsupplemented  1965;  Lawrence,  1962). Thus, because diet  successive  iron  alone.  pregnancy  for  formation  of  iron  requirements Additional  1971;  fetal  1965).  pregnancy Council  of  of  hemoglobin various  which  on Foods  have and  can  develop  pregnancy  iron,  replenishment  requirements,  normal  pregnancies  over  are  the  workers  red  placenta. have  1968;  iron-deficient and  often  available,  blood In  derived  been discussed Nutrition,  high  normal  maternal and  an  cannot is  mass,  considering the  earlier de  cell  iron  et  be met  needed and  for  these  a l . ,  and  by  during the  necessary  requirements  (Hellman  Leeuw  state  of  a  Pritchard,  1966;  Holly,  47  CHAPTER  A.  Description  The the  13  study  states  was of  Appendix  B.  Malaysia  facing  of  district  of  about  in  the  mining  of  is  is  (that  54  the  of  west  (Figures in  this  one. of  Selangor  kilometres,  are  in  located  6 0 km n o r t h  estates  There  description  Malacca  Selangor  Kuala  square and  is  located  Malaysia coast  5 and  is  of  6).  State.  Lumpur  nine  the  The  is,  agricultural (villages),  has  city  nine in  this  an  area  6). It  this  holdings 57  in  capital  lived  (Figure  in  of  given  Selangor  population  one  Peninsular  subdistricts.  and  kampongs  Selangor,  T h e women s t u d i e d  Kuala  has  in  has  district such  estates  as  and  live rubber  five  areas. the  clinics  with  presented  district  centers,  healers  together  The  facilities  health  private  in  in  Table  of  However,  This  to  for  three  district  subhealth There  The  State  status  Selangor maternal  Peninsular  could  this  7).  area. the  in  health of  are  a  district  centers,  four  are  traditional  also  indicators  Selangor  and  estate  of  hospital,  hospitals Malay  and  and  this  district  Peninsular  Malaysia  are  7.  health  Kuala  found  (Figure  this  those  overall  compared  1974).  about  of  PROCEDURES  a district  A brief  Straits  Kuala  is  in  Selangor  which  palm).  Chinese  as  of  Lumpur,  1,191  two m a i n  whole.  out  State  district  Among  eight  carried  the  villages  oil  Area  Kuala  which  The  and  of  METHODS AND  Study  Malaysia.  The  Malaysia,  districts  of  3.  be  due  based  (Table  7)  mortality Malaysia to  on  the  is  much b e t t e r  rate  three  for  the  (Department  several  reasons,  of  health than  year  indicators the  1981  poor  country  was much  Statistics,  namely,  for as  the a  higher  Malaysia  health  services,  •0-  5.  Map  showing  the  location  of  Malaysia  and  adjacent  territories.  0 0  49  Figure 6.  Map  of Peninsular Malaysia showing location of the study  site,  50  Figure  7.  Map by  of  the  numbers  study 1,  area  2 and  3.  showing  the  health  centers  as  indicated  51  TABLE  7.  H e a l t h i n d i c a t o r s f o r the d i s t r i c t of Kuala Selangor, S e l a n g o r S t a t e and P e n i n s u l a r M a l a y s i a (Senan, 1981, 1980).  Mortality  D i s t r i c t of Kuala Selangor  rates  1980  1981  1.2  1.2  16.0  14.5  *Toddler mortality rate (1-4 yrs) TMR/1000 *Infant mortality (IMR)/1000  defined  in  increase  in  maternal  health  Three  0.66  of  care of  for  after  the  Ijok  and  Batang  Berjuntai  they  are  in  rural  the  people  depend m a i n l y  palm.  Some a r e  also  has  occupations From majority  the  lifestyle.  setting.  as  The  are  in  3.1  25.37  35.4  in  Table in  8  and  a decline  the  district  of  are  mainly  subdistricts  1.05  in  tin  livelihood,  and  it  1981; c a n be  involved the  paddy,  of  the  emphasis  in  Kuala  Tanjung were  the  cocoa,  coal.  occupational  8,  of  subdistricts  coconuts,  (Senan,  Table  people are  0.4  These  their  paddy,  mining  in  the  7).  an important  the  Malays  mothers  For  on growing  shown  of  They (Figure  information  (83.3%)  2.04  1.6  subdistricts  study.  involved  fishing are  .  on  1980.  nine  chosen  it  1974  A.  childbearing  were  the  1980  rate  Appendix  number  out  Peninsular Malaysia  rate  *Maternal mortality (MMR)/1000  *Terms  State of Selangor  Selangor Karang,  chosen  majority  rubber  Being  activity.  of  and  the  oil  a coastal The  since  area,  types  of  1980). generalized agriculture  coconut  and  that and  cocoa  the  have  a  rural  growers,  52  whereas  the  the  miners,  tin  Indians  descriptions  of  TABLE  8.  are  the  agricultural  fishermen  and  the  subdistricts  three  estate  businessmen  in  are  this  given  D i s t r i b u t i o n of occupation (Senan, 1981, 1980).  in  Occupation  Estate  workers area. in  Kuala  of  24.0 23.7  Small  rubber-holders  20.0  Small  coconut-holders  15.5  coal  miners  6.6  Fishermen  5.3  Government  Choice  The ing  the  incidence  1979).  This  clinics  in  total  due  mothers clinic same  means  a year  of to  day  the a  was  of  4.8  was  that  out  there  clinic study  were  revisited  Subjects  deficiency reported of  was of  for the  to  a  among  pregnant  be  about  a  total  of  2225 m o t h e r s  be  about  400  to  500  given  in  Appendix  is  sample  time All  anemia  to  attendance  upon.  sampled  of  would  constraint  decided  patient  iron  centers  antenatal  objective but,  workers  and D e s c r i p t i o n  health  1980  population  growers  and  are  C.  Selangor,  laborers  Chinese  Additional  Paddy  Tin  the  Appendix  Percent  workers,  and  and  a l l  clinic.  of It  is  25  to  these  mothers.  D.  The  a  sample  health  four for  months every  The  initial mothers  of  centers or  attend-  (Arshad,  and nonanemic  the  required  percent  attending  anemic  support  attending three  to  anemic  financial  mothers period  the  20  mothers  300 on  until  pregnant  each the  53  mother  in  obtain  a  the pass  Indirectly, three the  to  this  study and  (MCHC),  for  packed  ova  and  and  frequency  A  flow  shown i n  patient, medical  the  Figure  history  some  In  forms  of  their  almost that  brief  of  parametric  measurements.  of  volume volume  blood  cell  to  also  The  (PCV), (MCV),  a l l  a l l  at  choice  least  of  pregnant  once  to  delivery.  pregnant  by  a  in  the  mothers  mothers  in  the  attend  Study  instruments objective  blood  categorized  measures  morphology,  thick  blood  smear  measures.  interview,  and  The  cell  concentra-  serum  for  as  include  mean  hemoglobin  serum f e r r i t i n  objective  30 m i n u t e s  Used  mean c e l l  (TRBC),  parasites  are  20  of 8.  of  were  interviewers.  activities  on a  Registration such  asked  record  dietary After  for  advice. the  typical  was  questions  as  The  where  the  turnup  interviewed  after  the  blood  of was  the  folate  malaria  and  subjective  a 24-hour  sampling  first  address,  dietary  nurses  step  recall  sample was  taken  ensure  to  high, a  For  clinic a  new and  then weighed  and  was  of  the  husband  directed  patients  at  done.  She was  then  a blood  day  occupation  purposes.  interview,  cases  patients.  on  center  tabulation.  diagram  a series  mother.  health  and Measurements  cell  cysts  include  food  red  detection  measures  be  assumption  mean c e l l  total  The  two  subjective  (MCH),  to  the  used  stool  staff  sampling  This  levels.  health  the  the  Instruments  hemoglobin  the  with  at  centers.  (Hb),  given  the  ensured  hemoglobin  is  register  Parametric  objective  tion  to  inform  subdistricts,  health  C.  district  the  mothers  drawn from  some m o t h e r s smooth  flow  of  to each had  54  PREGNANT  MOTHER  NURSES STATION Registration Weighing General Advice  Interview  TECHNICIAN STATION Blood Taken Vaccination  Interview ir MEDICAL  EXAMINATION  Doctor/Midwife  Random Observations  DISPENSER Supplements Medication  X STOOL -  Figure  8.  Flow  COLLECTION  Instructions  diagram  of  a  sampling  day.  55 After  the  prescribed the  or  were  medication  Objective  (a)  Collection  of  blood  samples  The  collection  of  blood  samples  had on  About plastic pylene  to  be  the  transported  day  7 mL o f  (PP)  added.  of  venous  centrifuge  tube,  an a n t i c o a g u l a n t ,  who h a d  not  breakfast.  taken  after  indication  (i)  blood of  to  received  was  done  a  set  be  were  Hematological  (MCH)  and  performed (Clay health  was  the  mL o f  while  the  omitted  as  for  and  since  total  of  their  instructions  morning in  since  Kuala  for  these  Lumpur  from was  remaining  each put  and  4 mL w a s  a plain put  acid  collection,  complained  of  (EDTA)  headaches  and  had  blood  done  milk  our  study.  analyses  was  cell  the  was a  and as  in  bottle  for  supplement  cooperation  a  except  a nutritional their  a  polypro-  into  flavored  Logic  were  into  using  strawberry  packed  Ultra  the  given  biochemical  red  in  subject  a  electronically  centers  this  they  was  EDTA b o t t l e  (Hb),  Adams  the  laboratory  collected  Three  Each mother  Hemoglobin  main  encountered  collection  from  the  in  ethylenediaminetetraacetic  appreciation  blood  to  blood  syringe.  few cases  The  and  took  collection.  No d i f f i c u l t i e s  (b)  the mothers  measures  disposable  which  done,  collection.  1.  analyzed  drink  examinations  supplements  stool  samples  to  medical  analyzed volume  cell  for:  (PCV),  (TRBC).  on an automated 800). using  mean c e l l  These  the  analyses  hematology  The h e m o g l o b i n  hemoglobin  analyser  analysis  cyanmethemoglobin  were  in  the  method  (WHO,  56  1972,  1968;  ICCND,  microcapillary (ii)  Thick  blood  parasites (iii)  Thin  detecting (Dacie The separated The  by  in  deep  following  in  low  separated  frozen tory  blood  Lewis,  the  plain  the  were  (c)  of  were lin  then to  return All  by  the  method  mothers usual  reduce  odor.  This  of  stool  the  samples  were  (1974). morphology  and hypochromic  allowed ensure  plain,  to  coagulate  that  capped  transporting Medical  and  cells  and  the  serum  no h e m o l y s i s  occur.  PP  kept  tubes  them t o  Research,  the  and main  Kuala  labora-  Lumpur.  The  serum: by  a Radio  Immune A s s a y  Inc.,  (RIA)  620 M e m o r i a l  kit  Drive,  02139). by  the m i c r o b i o l o g i c a l  (Lactobacillus  (1961).  a  bags,  rubber  problem  collecting  of  the  bottles  seemed  work  was  stored  the  malarial  1963).  universal  samples  the  samples  was  in  examining  Herbert  plastic  There  to  of  and Lewis  Laboratories,  of  stool  given  the  stool  given  to  determined  determined  of  were  was  of  the  Trarenol  assay  collection.  experienced  on  for  by  (1974).  detection  microcytic  tubes  before  the  Dacie  ICCND,  Massachusetts  Collection  The mothers  1974;  done  Serum f o l a t e , casei)  of  determined  and Lewis  for  of  made  Institute  Serum f e r r i t i n ,  (ii)  made  transferred  freezer  Cambridge,  were  PP  freezer  analyses  Dacie  centrifugation  s e r u m was  at  The PCV was  method  presence  and  speed  of  were  the  smears the  (Division  stool  smears  a portable  (i)  the  method  using  blood  1963).  in  to low  since  bands  smell sample  in  the  at  the  swabs  for  difficulties  plastic.  with  However,  some m o t h e r s  a refrigerator  cotton  and a l s o  half-filled  better.  and  diluted  the  They forma-  percentage  lived  very  far  local  clinic  away. before  57  analysis. tive  of  The  ova and  Subjective  The  interview  final  from  how t h e s e  (a)  interview the  was  questions  in  used. were  the  before  iron  iron the  the  knowledge the  detection  and Lewis  tablets  explaining  study If  of  were  was  she  the  did,  E.  of  posi-  (1974).  were  and  the  If  An example  could  these  anemia.  set  the  iron  of  procedures  supplements  supplements  mother  the she  requested  she of  of  of  whether  of  review  tested.  She was  purpose  she was  are  with  the  for.  the  No s t a n d a r d  use  to  on  aspects  following  on the  conducted  tablets.  reasons.  The  shown  based  and o t h e r  on compliance  supplements  of  tablets.  give  Dacie  formulated  understanding  asked  for  developed  Appendix  of  Degree  by way  to  given  (i)  of  by  on c o m p l i a n c e  questions  understood  asked  carefully  of  she  her  proposed  Formulation  what  words  is  literature  understood  the  were  literature  she  of  the method  questions  interview  Samples  also  examined m i c r o s c o p i c a l l y  measures  cited  coded  were  using  2.  questions of  cysts  previously  The  stools  to  not  to  then  ensure asked  tablets. was  aware  explain explain  questions  is  that  whether She  of in  the her  this, shown  was  1.  How m a n y since 1. 2. 3. 4.  times  you were  have  you v i s i t e d  the  First visit Second v i s i t More than 2 Others  12 ( ( ( (  ) ) ) )  was  below:  clinic  pregnant?  own  she  Column IRON  uses  No.  58  Column IRON 2.  IRON 3.  Have  you been given  some  iron  1.  Yes  2. 3. 4.  No Cannot Others  tablets  Do y o u h a v e  any  of  tablets  13  (  )  ( ( (  )—> ) )  8 9.  Skip No r e s p o n s e  ( (  ) )  Do y o u k n o w w h a t 1. 2. 8. 9.  1  14 ) )  5.  BELIEF  left? ( (  IRON  7.  these  (Show  clinic?  Yes Finished  Why?  IRON  the  1. 2.  4.  6.  tablets?  by  remember  IRON  IRON  these  given  15  these  tables  are  Yes No Skip No r e s p o n s e  Can you  please  for? ( ( ( (  explain  to  me w h a t  16 ) )—> ) )  they  are  1.  Healthy  baby  (  )  2. 3. 4.  Healthy Improve Improve  mother appetite blood  ( ( (  ) ) )  5. 8. 9.  Others Skip No r e s p o n s e  ( (  ) )  Where  did  you get  IRON  for:  ( •  this  8  17  )  information? ( ( (  18  1. 2. 3.  Doctor Nurse Friend  ) ) )  4. 8.  Others Skip  (  )  9.  No r e s p o n s e  (  )  COMPL (  )  1  No.  59  Column IRON 8 .  What  was  the  understand 1. 2. 3.  (ii)  The the  4.  Cannot  5. 8. 9.  Others Skip No r e s p o n s e  times  was  that  usually  whether  she  did.  she  This of  source  of  should  be  3.  took  took  question  as  "It  is  would  bad  information.  black  or  of  tablet  required  have  Some e x a m p l e s  it  was  to  for?  19  explain.( brief...( (  questions  ) ) )  ....(  ) ) ) )  if  response.  First  tablets.  the at  the  times  the  recent  week was  baby"  She was  of  mentioned.  and  tablets  also  were was  coloration questions  so  a positive  answer  the  asked  if  final  that  asked.  taken  daily.  she  for  her  she  took  t h e n was stool the  possible  question  she  also  claimed The  If  the  asked  color  the  since  iron  are:  R e g a r d i n g t h e t i m e t h e s e t a b l e t s a r e t a k e n , some m o t h e r s t a k e them a f t e r b r e a k f a s t , l u n c h o r d i n n e r o r a t o t h e r t i m e s ; when do you u s u a l l y take yours?  that  she  compliance.  given,  if  formulated  told  The  time  of  not  asked  was  she was  check  per  give  she  a quick  the  a dark  to  Then  the most  day  for  carefully  forced  give  per  were  or  their  any  taken  what  threatened  a negative  the  not too  you not  are  compliance  feel  during  were  such  supplements.  COMPL  not  tablets  such  of  caused  tablets  ( ( (  compliance  people  hers  Explanations response  of  did  some  was  i t  set  actually  took  frequency  remember  Measurements  next  that  these  Doctor or nurse did The e x p l a n a t i o n was Did not understand  respondent  when i t  problem  what  No.  22  60  Column  COMPL  COMPL  COMPL  4.  5.  6.  1. 2.  Breakfast Lunch  ( (  ) )  3. 4. 5.  Dinner Bedtime Others,  ( (  ) )  8. 9.  Skip No r e s p o n s e  ( (  ) )  specify  (  T h i s morning a f t e r b r e a k f a s t , d i d you take tablet? (Substitute w i t h other meal times d e p e n d i n g o n r e s p o n s e i n (COMPL 3 ) . 1. 2. 3.  Yes No Cannot  8. 9.  Skip No r e s p o n s e  How m a n y week d i d  remember  times in you take  1.  Everyday  2. 3. 4.  Six times Five times Four times  5. 6. 7. 8. 9. 10.  a week, f o r the your tablets?  whole  your 23  ( ( (  ) ) )  ( (  ) )  of  last 24  (  )  ( .( (  ) ) )  Three times Two t i m e s None a t a l l  ( ( (  ) ) )  Skip No r e s p o n s e Others  ( (  ) )  Why i s  i t  that  (  you are  not  taking  )  them  everyday?  )  25  No.  61  Column COMPL  7.  S o m e t i m e s y o u may o r may n o t s t o o l s change c o l o r to b l a c k n o t i c e any c o l o r change t h a t bowel movement?  (iii)  This  1. 2. 3.  Yes No Cannot  8.  Skip  9.  No  response  Health  problems  set  of  asked whether was h e r  action  questions spite  PROB  of  1.  was the  if to  2.  26  ,  associated  is  incurred  quite  any  with  had  some  find  out  whether  iron  tablets  straightforward.  problems  she  problem.  when on  complications. she  Some e x a m p l e s  continued of  these  the The  The  respondent  iron  tablets,  objective  taking  the  questions  of  What 1. 2. 3. 4. 8. 9.  Yes, always .., Yes, sometimes No Skip No r e s p o n s e ...  kind  of  problems  Stomach pains Constipation . Diarrhoea Others Skip No r e s p o n s e  ,  you  have?  what  these  supplements  are  as  in-  follows:  27  > BELIEF  do  was  and  Some p r e g n a n t w o m e n , w h o t a k e i r o n t a b l e t s seem t o h a v e p r o b l e m s b u t some do n o t . What about you? Do y o u h a v e a p r o b l e m w h e n t a k i n g these tablets? 1. 2. 3. 8. 9.  PROB  notice that your or brown. Did you l a s t time you had  remember  questions  she  No.  1  28  62  Column PROB  3.  What  do  taking  Stop  C o n t i n u e t a k i n g them Sometimes t a k e them Talk to nurse/doctor  5. 6. 8.  Forget Others Skip  the  about  29  tablets ... ...  them  , ,  of  demographic  Socioeconomic  The measurement  of  of  These  family.  and  The  2.  The number  3.  The  questions  status  was  based  on f o u r  characteris-  are:  family's  levels  of  property land  health  status  socioeconomic  1.  have  happens?  response  Formulation  the  this  1.  (i)  tics  do when  2. 3. 4.  No  (b)  you  No,  of  working owned  and  members.  by  crops,  education.  the  family,  and whether  for the  example, house  is  whether theirs  they  or  rented. 4.  The amount tion  was  of  available  obtained  purchased  for  by  the  cash  asking  family  An everyday  spending  pooled  cash  and  were  to  no  on  the the  and  has.  frequency  the  staples  available  family  amount would  in  spent  This a week per  mean t h a t  refrigeration  informafood  was  purchase.  there  equipment  was in  no  the  house•  had  (ii)  Parity  These  questions  a n d how many  and was  survived.  cross-checked  with  determine This  the  was  on  medical  the the  number  of  children  basis  of  recall  records.  In view  of  the  by the  the  mother mother  time  63  constraint her  of  The  Medical  purpose  contracted  recall  the  mation  were  time  (iv)  It  she was  not  required  to  list  a l l  the  names  of  history  of  these or  she  them.  had  from  Sanitation,  to  hands  questions  be  eat,  would  various  purposes.  always,  sometimes  possession  of  or  the  past  medical  the  mother,  response  of  to  the  the  and  respondent  for  treatments  her or  to infor-  especially when a s k e d ,  water  whether  and why.  and usage  problems  bathroom?"  drinking  asked  boiled,  type,  the  parasite  going  further  rarely  of  in  whether  records.  positive  source  determine  and  that  after  the  toilets,  rest  supply  a  She was or  The  to  diseases  the medical  give  on  was  other  obvious  meals  asked  any  water  quite  before was  questions  malaria  obtained  would  fingers your  interview,  children. (iii)  ever  the  of  if  she  "Did  the  were  these  toilets  by  'kit'  containing  a  set  the  of  for  water asked  her  wash  used  drinking  Questions  you  Instead,  and water  uses  was on  family  members.  (not  (c)  Assessment  (i)  The  Each  interviewer  a  24-hour  standard  tablespoon,  8-oz  1.  nutritional  dietary was  measuring  the  doing  this  It  would  be more  viewer  of  doing  with  cup  a  since  teaspoon  respondent  of  quantities  a  intake  recall  equipped  a dessertspoon,  common m e a s u r e s , purposes  of  was  nobody  and  asked  a to  probably  ruler.  With  estimate  her  a  6-oz  has  seen  the food  use  teacup one), of  a  these  intake.  The  were: accurate  food the  items  for she  estimate.  the  mother  actually  ate  to  estimate  rather  than  the the  exact inter-  64  2.  The  respondent rather  than  then  dividing  it  felt  that  latter  The  the  not  noted  could  that  teaspoon done  by  the by  everybody  quantities  measures  a  of  for food  items  of  kati  the  example, she  bought  about 100  the  easily  six  gm,  up e a t i n g fruits  50  and  estimate  for  the  edible  of  or  meant the  i t  the  the  family  family  have of  is of  by  was  fish  is  ate  common  using  it  was as  items  to  were  605  g.  weighed  used  1983).  asked  in  For  common  which  50%.  these  was  a  a  were  Malaya,  came  fish, to  approximately  Thus,  conversions  accurate  day.  weights  mackeral,  fish  Similar  per  them u s i n g  quantity  one  accurate  these  of  equivalent  and was  same w e i g h t  their  the  portion  she  food  her  It  However,  the  and  each  was more  less  and w e i g h i n g  Is  ate  members.  common f o o d  'horse'  edible  food  for  (University  that  fish.  from  grams.  beef,  of  she  ate  recall  items  grams  number  However,  not  One k a t i  particular  portion  food  size  mackeral,  this  vegetables.  ate.  This  to  cooking  of  she  when e s t i m a t e d  estimations  into  the  of  same a m o u n t  does  chicken  usual  kati.  horse  gm o f  knew  cooked  dietary  the  oil  A list  The  per  of  preparing,  fish,  she  converted  of  quantity  number  consumed  Prior  respondent  kati.  fishes  and  like  that  consumed  conversion  respondent  per  method  teaspoon  standard  actual  total  be  actually  For  the  food  sugar.  the  amount  of  common m e a s u r e s .  terms  asked  plate  since 3.  was  she  were  for  the  the  standard  ended  used  for  respondent  to  measures  provided.  (ii)  The ing  the  Food  set prior  respondent  of  frequency  questions  information,  happened  to  eat  tabulations  asked the  on  food  24-hour  mutton  the  frequency dietary  previous  was  aimed a t  recall.  For  day,  would  she  supplement-  example, be  if  asked  the how  65 often  m u t t o n was  eaten  only  daily  protein  once  ( i i i )  The of  food  pregnancy.  that  most  delivery  of  with For  of  this  the  iron  women,  or  Manderson,  either  during  pregnancy  food  (d)  of  clarity  specific  Students  University testing.  the of  clarity  and  questions  was  the  health  British  of  race,  1979).  was  asked  whether  period.  not  do h a v e  have  to  be  that  represent  correlate  mutton her  was  actual  any  a  food  puerperium were  the  presence  characteristics  regarding food  This  The m o t h e r s  weak  coding  of  interview  designed  food  beliefs  is  to  of  the  beliefs  were  check  and  practised  the  fact  "taboo"  period  after  belief  during  pregnancy  who a v o i d e d  classified  care  not  of  certain  as  those  foods  who h a d  food  measure  Columbia were points  in  interview  characteristics  questions  was  to  were  chosen  the of and  cut  these not  at  the  formulation  variables  was  completed.  of  clerical  format  questions down on UBC  once  random and  interview  some  tested  desired  p r o g r a m and members  applicable  recommended.  interview  questions  to  and m o d i f i c a t i o n  format  were  demographic trial  of  Several  Reconstruction  does  could  noncompliance  were  asked  may n o t  or  and  questions  in  It  beliefs.  Pretesting  The  also  confinement  they  1973a;  or  it  questions  questions  regardless  though  of  supplement  were  (Chen,  taboo  a month.  beliefs  set  example,  puerperium  even  or  therefore,  food  The mothers  the  a week  source.  objective taboo  in  a month and,  Presence  respondents.  during  eaten  the  students  similar  to  the  employed  were  were  done  time. and  staff  the  for  the  detected. to  improve  Some o f  staff  actual  at  since  sample.  on  the their A  field  66  Once and  the  again  questions  tested  Columbia.  The  Appendix  F.  informal  Malay  again of  Community  complete edited  were  mothers  the  ones  few mothers again The data  at  be u s e d  questions  more  the for  and  of  translated  University the  choice  of  In Malaysia, and  completely  the  of  center  since  were  Selangor. chosen  random from each  a  final  test  coded,  typed  and  of  the  final  was  out.  were  Six  tape-  clinics  The  the  form other  interviews.  interviews  f o r m was ready  to  finally  Three  clinic.  were  taken  interview  test  copies  the  the  to  interview  were  Department  time  carried  finally  study  the  in  an  Some o f  was  and  Kuala  the  interview  reconstructed at  and  The  interviews  Malay  given  questions in  the  field  is  Malaysia.  deleted  into  British  words  attendants  20 m i n u t e s . health  of  interview  random and  the  at  the  University  than  at  they were  right  used.  an urban  were  the  assistants  some  picked  picked  were  and  at  in  that  being  at  version  National  was  selected  tape-recorded  Malay  ensure  the  trial were  were  students  laboratory  Some p h r a s e s to  or  was  reworded  real  ready  than  to  interview  and a  recorded. was  the  Health  the  pregnant  was  language  on  reconstructed,  some M a l a y  translated  This  tested  questions  on  were  A  were  completed.  for  the  actual  collection.  (e)  Training  A group the  340  the  final  of  of  eight  interviews  interviews interview bad p o i n t s  the were  was of  interviewers  performed.  interview  even during  interviewers  forms  early  stage  made among  recorded the  were of  including  About  five  printed. testing  interviewers  and d i s c u s s i o n s  questions.  In  fact,  the  group This  and  group  check  were  held  the  was  sessions  editing.  to  by  author  was  responsible  were  held  actively  Tape  concerning  time  the  before  involved  recordings  on weaknesses. the  for  A  sample  good  interviewers  of  and were  at  67  the  clinics,  views  were  they  done  some p r e v i o u s As week  an ongoing  throughout  interviewer the  each  made  the of  in  the  medical living  were  age,  or  center  other was  the  of  The  subsequent  explain  the  medical as  a  Other  husband, hemoglobin  of  are  was  records.  anemia  on  incurred  some  held  were  once  and  a  each  remedied.  intra-  interviews  to  asked  validate  similar  and  checked  the were  from  advice  and  made  these  women.  interviews  purposely  information  the  and  of  number  records  made  obtained given  and g e s t a t i o n  which might  in  diseases,  the mother  treatments  found  the  medical  information  body w e i g h t s information  were  history  visits  Demographic  the  on p a r i t y  deaths, of  during  questions  obtained  The number  among  had  discussions,  inter-  question  and n e o n a t a l  important  inter-  process.  A few  the  values,  were  random o b s e r v a t i o n s  not  measure  medical  the  records  that  available.  and  interviewers  these  interviews  interviewing  information  ailments.  also  reduce  Actual  is  the  on problems  recorded  finished  An example  visit  causes  author  check  of  problems  to  from medical  miscarriages  occupation  respondents. each  the  children.  operations  the  were  information  interview  of  in  questions  During  and  interviewer.  data  records.  number  health  from  The  during  important  obtained  asked  each  Available  Other was  by  interviewer  3.  evaluated  variabilities. made  period.  meetings  the  techniques.  discussions  study  was  with  The m a j o r i t y  interview  group  entire  these  responses  responses on  of  in  check,  the  familiar  efficiently.  progress  objectives  with  very  already  experience  interviewer's The  were  to  to was  these  period  be u s e d  the  to  on  68  were  4.  Coding  The  data  coded.  given  in  Problems  the  code  sheet,  were  coded  example  is  the  were  the  with to  not  was  coding the  to  The  ensure  stage.  the  other  and  data  into on  has  In  the  no  these  code  was  categorization  finding  that  the  the  the the  analyses  remedies  Fortran  coded  separately.  number  were by  was  done in  questions  response  was An  respondent's as  lost  were  80-space  open-ended  the  are  interview  the  of  number  stool  where  responses  information  or  but  occupation  in  The  cases  categories  why  into  and and  questions  information.  a different  reason  blood  collection  directly  responses.  asked  that  records,  close-ended  entered  Grouping  variables  during  was  the  Each occupation  medical  the  pooled  question  H).  the  incurred  information  (Appendix  lating  from  Since  according  they  earlier  G.  together  varied,  husband.  data  obtained  Appendix  precoded,  book  of  shown i n not  code  categorized  grouping after  each  the  them  during  crosstabu-  cell  was  less  all  the  than  five. The used, time  code  a  statistical  dependent  this  is  very and  important  description  analysis  Statistical  Since  are  is  column numbers  5.  ever  book  a  was  study  to  hemoglobin  minimum v a l u e  is  chosen  anemia.  These  has  the  variables.  and  confirm  is  factors,  of  it  the  list  It  results  of  was  referred  codes  every-  interpreted.  analyses  variable  the  done  since  previously  variables  to  level  in  possible  less  indicate  stated  include  the  the  than  anemia.  causes  10 g / d L The  hypotheses  socioeconomic  of or  anemia, 11 g / d L ,  independent as  status,  which-  variables  contributing demographic  the  to  69  characteristics, tions,  parity,  nutritional  compliance  status,  with  iron  parasite  infestation,  supplements  and  the  sanitary  presence  condi-  of  food  beliefs. Standard analysis include tests, this  of  statistical  variance  t-tests a  likely  be  ratios  were  done  and Duncan's  stepwise  collection  were  tests  of  included  logistic  calculated  a  association  together  multiple  selection  independent in  of  with  range  regression according  to  tests  model.  In  addition 1981)  variables relative  Schlesselman  and  and  differences  (Laszlo,  those The  Chl-square  of  tests.  procedure  variables,  namely  Stolley  to  these  selects  which  risks  which  or  should odds  (1982).  from most  70  CHAPTER  A.  in  General  Demographic  Some  the  Table  of 9.  rural  demographic  equal  population  greater  number  of  years  (Table  Test  showed  than  the  age  mostly  other  in  The 32 weeks weight, from  the  Malays  and  the  body w e i g h t  being  third  difference  (Figure  the  stage  trimester in  of  gestation  the  This  the  at  Duncan's  from  in  (P  mothers  groups  was  27 Range  <^ 0 . 0 5 ) in  were  thirties.  the the  the  measured,  was  difference  period  highest  and no  detected  but  could  mothers  of  body  Indians,  body weight  80% o f  the  Multiple  younger  the  had  and  typical  hence  a mean g e s t a t i o n  <0.05)  were  A  conducted  early  mothers  shown  smaller  9a).  significant  their  is  study.  was  the  no  because  three  this  study  difference  weights  in  a  Malays,  general,  mothers  gestation  among  was  in  (P  (Table  of  and  studied  with  significantly  The M a l a y  when t h e  Malays;  the  In  some  different  9). of  were  Chinese.  9d).  significantly  Chinese to  (Table  when  There  with  mothers  and I n d i a n s  variance  groups.  average  57 k g  of  Indian mothers  racial  are  represented  mothers  analysis  the  composed m a i n l y  being  mid-twenties,  was  the  their  the  a l l  the  DISCUSSION  for  (72.5%)  Chinese is  group  The  two  of  their  attributed  and  that  between  of  9b).  them  Malaysia  this  The mean age  information  of  number  in  R E S U L T S AND  Characteristics  The m a j o r i t y  approximately  4.  not  not  were  be  in  significant (Tables  9c  9d). The  overall  ly  (Table  (P  < 0.05)  9d). for  No s i g n i f i c a n t  means  for  gravida  The a n a l y s i s both  these  difference  of  and  variance  parameters was  parity  found  were  showed a  between between  the the  3.5  and  2.2,  significant  respectivedifference  Malay  and  Indian  mothers.  Malays  and  Chinese.  This  71 TABLE  9.  Some d e m o g r a p h i c c h a r a c t e r i s t i c s o f s t u d y p o p u l a t i o n at the D i s t r i c t of Kuala Selangor, Malaysia. a.  Racial composition Race  Number of mothers  Percent of t o t a l  274 54 50  72.5 14.3 13.2  378  100.0  Malay Chinese Indian Total  Age  Mean  Race Malay Chinese Indian Total  c.  Age (yra) S.D.  Range  27.4a 27.5a 25.0b  6.5 6.6 6.0  32.0 26.0 24.0  27.1  6.5  32.0  Gestation stage Gestation stage Trimesters  Weeks  Percent of t o t a l  First Second Third  <16 16-27 >28  1.0 19.0 80.0 100.0  d.  Mean body weight, gestation, gravida, and parity  Race  Number of mothers  Body weight (kg)  Gestation (weeks)  Gravida  Parity  224  57.6a (+10.0)  31.7  3.7a  2.3a  Chinese  49  56.3a (+7.9)  32.1  3.2a  2.0a  Indian  41  53.4b (+7.3)  30.0  2.8b  1.7b  314  56.8 (+9.5)  31.5  3.5  2.2  Malay  Total  Numbers designated by the same l e t t e r are not s i g n i f i c a n t l y different at P < 0.05. Numbers In parenthesis are standard deviations.  72  30  Figure  9.  40  50 body  60 weight  70 (kg)  80  90  C u m u l a t i v e f r e q u e n c y d i s t r i b u t i o n of body w e i g h t s of 314 m o t h e r s f r o m t h e t h r e e r a c i a l g r o u p s a t t e n d i n g the antenatal c l i n i c s at the d i s t r i c t of Kuala Selangor, Malaysia.  73  information Kuala  Selangor  difference with  suggests  the  is  that  tend  to  have  attributed  number  of  the  Malays  more  to  age  children  in  and  the  children  than  variations this  Chinese the  since  population  in  the  District  Indians.  age  is  This  strongly  (discussed  of  in  associated  Section  4(d)). The (1984)  above  findings  do n o t  in  their  study  of  Malaysia.  They  found  that  three  racial  groups  characteristics these  B.  age  were less  and y e a r  Diagnosis  two m a i n g r o u p s and  There  section  confirm were  discusses  the  of  iron  eight  Hematological (a)  no than  of  slightly  reported urban  significant four.  by Tee £ t  pregnant  marriage  mothers  difference  Variations could  have  a l .  in  among  in the  demographic  contributed  to  between  illustrates population.  anemic  that  deficiency  have  anemia and  Anemia been used  are  two  in  this  hematological  biochemical  study  and  to  biochemi-  indicators.  This  obtained.  (Hb)  value the  of  were  the  cut-off  and nonanemic  frequency  There  Deficiency  indices  results  10 g / d L ,  the  Iron  Indices  Hemoglobin  above  of  hematological  The mean h e m o g l o b i n  tiate  those  socioeconomic  there  when p a r i t y  namely  Differential  diagnose  1.  low  with  differences.  The  cal.  the  agree  level  used  conditions  distribution  90 m o t h e r s  mothers  of  studied  10.9  b y WHO ( 1 9 7 2 ) in  pregnancy.  hemoglobin  (29%) w i t h  is  levels  hemoglobin  g/dL to  levels  is  differen-  Figure of  which  the  10 study  between  10  74  100 r  80 >» o ®  60  cr 9>  40  20  CD V  0> (0* 1 <0  0) 1^ 1  0) 0Q 1 00  0> 1  cn  o> O i  o  O)  3 -  Hemoglobin  Figure  10.  i  0)  cvi  7  w  (J)  O)  (J)  (J)  ro  «^  !£>  <fi  7  io  i ^  i m  i w  (g/dL)  Frequency d i s t r i b u t i o n of hemoglobin l e v e l s of 332 mothers a t t e n d i n g the h e a l t h c e n t e r s a t the d i s t r i c t of K u a l a Selangor, M a l a y s i a .  75  and  10.9  g/dL.  g/dL.  An  g/dL.  This  values  ranging  Sixty  equal  mothers  number  indicates from  of  mothers  that  9 to  (18%)  had hemoglobin  had hemoglobin  a majority  11.9  g/dL,  of  the  which  is  levels  levels  mothers near  between  between  (65%)  the  had  9 and  11 a n d  9.9 11.9  hemoglobin  threshold  value  for  anemia. Tee  e_t a l .  among u r b a n anemia  (1984)  pregnant  among a l l having  (1984)  the  for  mothers This  in  mothers  in  and  43  three  the  racial  of  less  anemic  group a  among  than  10 g / d L , to  of  below  cut-off  globin  for  with  level.  three  races  that  point  that  in  the  of  11 g / d L  (P  the  Chinese  41.9% o f  mothers  is  cumulative illustrated  the  a l .  5 5 . 1 % among used  severe  was  was  the  (Table  10).  among  mothers  frequency Figure  (Table 28.0  the  the  be  among  10). and  distribution  the  Its 19.6%, level  considered  highest  hemoglobin  11.  Chinese  cut-off  could  showed  having  46  detected  41.9,  Using  Indians  in  Malays,  anemia  trend.  The  the  (243,  of  and Chinese this  et  g/dL of  (28.6% of Tee  is  more  <^ 0 . 0 5 )  the Malays.  The  is  by is  11.1  areas.  prevalence  Malays  19.6% o f  anemia  of  prevalence  higher  of  investigated  difference  of  is  level  the  reported  anemia  urban  that  study  incidence  illustrates  only  appears  than  332 m o t h e r s  Indians,  It  cut-off  those  mean h e m o g l o b i n  present  assumption  28% o f  anemia,  the  The  the  terms  11  the  10 g / d L )  than of  in  the  incidence the  in  significant  Figure  compared  the  areas  groups  respectively.  than  when  supports  Indians),  prevalence  less  study  rural  Within  mothers  a higher women.  urban mothers.  this  finding  Malaysian  the  population  reported  values of  hemo-  76  6  9  12  hemoglobin concentration  Figure  11.  15  18  (g/dL)  Frequency d i s t r i b u t i o n of hemoglobin concentration o f 332 m o t h e r s f r o m t h e t h r e e r a c i a l groups a t t e n d i n g the a n t e n a t a l c l i n i c s i n the d i s t r i c t of Kuala Selangor, Malaysia.  77  (b)  Packed  cell  Based  on  the  prevalence  of  anemia  (Table  11).  as  the  cut-off  in  Malaysia  study  Tee  shows  regardless  lower  et  of  frequency  above PCV  33%.  among  existed anemia  the  among between  (30% a n d  33%)  as  and  the  groups.  13. is  The  similar  (c)  Iron values WHO  of  of  anemia  The  32% o f  33%,  the  among  the  53.0%, limit  cut-off  races of  was  among  reported  volume  general  respectively  for  normal  PCV  urban pregnant  mothers  PCV  level,  present  the  rural  the  mothers,  both  curves  of  Tee  et  origins  al^. ( 1 9 8 4 )  mean c e l l  is  to  normal  (MCHC)  characterised values  and  3.3  by  x  10 /L 9  PCV  for  the  <^ 0 . 0 5 ) incidence  was  in  blood  by  of  values among  the  between Figure  this  urban  (MCH),  red  in  shown i n  obtained  these  with  threshold  l o w MCV,  for  the  PCV a r e  recommended  recommended  (MCHC)  total  gives  intermediate  hemoglobin  and  (P  incidence  frequency  12  differences  in  PCV  being  by  for  differences  highest  ethnic  Figure  the mothers  pattern  using The  test  Malays  anemia  32 g / d L  found  three  values  to  the  deficiency  standard  used  31-32.9%.  47% o f  similar  anemia.  (MCV),  the  A  Chinese;  the  were  Significant  11).  cumulative  those  (MCH),  lower  between  was  groups.  the  is  variance  concentration  pg  the  (53%)  There  hemoglobin  The  30% a n d  21.6% and  similar  PCV.  (Table  among  Mean c e l l  on a  T h e mode  of  three  when compared  26  Based  racial  pattern  with  (1972).  (MCV),  about  indicators  lowest  PCV  that  32.4%.  races  the  Indians two  found  analysis  the  is  of  origin.  is  three  study  PCV  33% a s  distribution  The  this  incidence  racial  normal  used  and  a higher  in  for  (1984)  anemic.  The mean PCV the  a l .  (PCV)  limits  found  value  were  volume  study  mothers.  mean  cell  count  (TRBC)  M C H , MCHC a n d  TRBC  George  and  indices  (TRBC).  The  (1983) are  75  mean  fL  78  TABLE  10.  Race  Hemoglobin (Hb) i n the d i s t r i c t  Number  of  l e v e l s of mothers a t t e n d i n g the of Kuala Selangor, M a l a y s i a .  Mean  (+ S . D . )  health  % < 10 g / d L  centers  % < 11  g/dL  mothers  Malay  243  11.0a  (+1.8)  28.0  54.3  Chinese  46  11.4b  (+1.9)  19.6  39.1  Indians  43_  10.0a  (+1.7)  41.9  79.1  10.9  (+1.8)  28.6  55.1  Total  332  Numbers d e s i g n a t e d P < 0.05. Numbers  TABLE  in  11.  Race  parenthesis  the  are  same  letter  standard  Percent  packed  cell  centers  in  district  the  Number o f mothers  Malay  are  significantly  different  at  deviations.  volume  Mean  not  of  (PCV)  of  Kuala  Selangor,  mothers  (+ S . D . )  attending  the  health  Malaysia.  % < 30 g / d L  % < 33  g/dL  243  32.4a  (+4.0)  20.7  52.7  Chinese  46  33.3b  (+4.0)  15.2  45.7  Indians  43_  30.9a  (+3.5)  37.2  62.8  32.4  (+4.0)  21.6  53.0  Total  Numbers P  by  332  designated  by  the  same  letter  are  not  significantly  < 0.05.  Numbers  in  parenthesis  are  standard  deviations.  different  at  79  80i  60  •" • * • * • *• •  >» u c a> 4 0 3  V  a> •••-•  • • •  20  • ft  •. • r •  . •. •  IO CM V  ID co o cvi M M IO IO I I I I IO r— — c j c s j c v J i ^  o  ^ IO I ro r o  6 cvi to IO I? i I I I 0> tf> Lt r o r O t o ^ 0 0  Packed cell volume (%) Figure  12.  F r e q u e n c y d i s t r i b u t i o n o f p a c k e d c e l l v o l u m e (%) o f 332 m o t h e r s a t t e n d i n g t h e h e a l t h c e n t e r s in the d i s t r i c t of Kuala Selangor, Malaysia.  80  Figure  13.  The c u m u l a t i v e f r e q u e n c y d i s t r i b u t i o n o f p a c k e d c e l l v o l u m e (%) o f 3 3 2 m o t h e r s f r o m t h e t h r e e r a c i a l groups attending the antenatal clinics i n the d i s t r i c t of Kuala Selangor, M a l a y s i a .  81  values were  for  above  possible  three  these  and  Indians  indicating  the  Malays  (P  = 0.05). This  iron  for  George  anemia. cating  the  TRBC at  P  47.5% had h i g h e r seen  condition  of  indices required  to  discussed  than  in  Iron  which  are  60% o f  them had  indicating  that  Table  values  may  12 be  Range  Test  higher  presence  anemia.  of  The  and  13).  were  below  This  mothers,  condition  about  seen  standard  in  level  deficiency  anemia.  deficiency  and  reliable  deficiency  for  is  infers  indicators  anemia  and  of  these  recommended deficiency  The  indi-  remaining  macrocytosis, that  a  a  mixed  biochemical  iron  (biochemical  PCV,  signi-  l o w MCV v a l u e s  MCV i m p l y i n g  possible,  of  iron  deficiency.  This  than and  of  showed  values  of  52.5% had  iron  the  erythrocytes  mothers  indicative  TRBC  microcytosis  pale  standard  the  MCV a n d MCH  The mean v a l u e s  the  is  that  t h e mean v a l u e s  (Table  mothers  for  indicate  of  MCHC a n d  showed  values  small  t-tests  in  among  status  indices  were  are  B2). also  anemia  indicates  (Table  13).  l o w MCHC l e v e l s . they  high  not  < 0.0002  iron  section  deficiency  Multiple  but  and nonanemic  specific  A l o w MCHC v a l u e iron  the  folate  shown i n  differences  anemic  the  and  that  between  folate  confirm  in  a  < 0.0002),  significantly  95 a n e m i c  microcytosis,  condition  (P  a n d WHO ( 1 9 7 2 ) .  the  races  significant  L o w MCV a n d MCH v a l u e s  implies  anemic  (1983) Among  had  three  indicates  indicated  Duncan's  deficiency  difference  indices  This  the  mothers.  variance  The  M C H , MCHC a n d  ficant  by  of  among  levels.  nonanemic  12).  hypochromia.  MCV,  the  indices  i n MCV a n d MCH l e v e l s  (Table  Chinese  blood  standard  analysis  races  values  these  among  The  the  a l l  had  microcytosis, Among 95  The  spherocytosis  anemic  remaining but  not  implying  the  mothers,  40% s h o w e d  (Hb  high  macrocytosis.  presence < 10 MCHC,  The  TRBC  of  g/dL),  82  TABLE  12.  MCV, MCH, antenatal Malaysia.  No. Race  MCHC a n d T R B C v a l u e s o f m o t h e r s a t t e n d i n g t h e c l i n i c s i n the s u b d i s t r i c t s of Kuala Selangor,  of  mothers  MCH  MCHC  TRBC  fL Mean  Pg Mean  g/dL Mean  lxl0 /L Mean  (+  202  Malay  MCV  SD)  79.8  (+  28.0  a  41  82.1  a  28.8  (+8.4) 40  Indian  283  Total  Numbers P  <  73.5  designated  by  in  parentheses  29.4  b  SD)  33.8  a  34.0  b  32.4 (+3.8)  79.2  27.6  33.6  (+8.1)  (+5.5)  (+3.9)  not  standard  significantly  deviations.  a  SD)  4.02  a  (+6.4) a  (+4.7)  (+4.8)  l e t t e r are  (+  (+3.8)  (+7.5)  t h e same  are  a  (+5.9)  0.0002.  Numbers  (+  (+5.3)  (+7.6) Chinese  SD)  9  4.01  a  (+0.59) a  4.16  a  (+0.52) 4.04 (+0.59)  different  at  TABLE  13.  Anemic  and nonanemic  recommended  by  mothers  George  (1983)  with  PCV,  a n d WHO  MCV,  M C H , MCHC a n d  TRBC b e l o w  the  standard  values  (1972).  Hematological  Indices  9 PCV Hemoglobin  levels  Mean  g/dL  Anemic  (%)  MCV  % <30  Mean  mothers  = 95  28.9a  75.3  (+3.5)  Nonanemic mothers Hb > 10 g / d L  = 237  Numbers  in  each  column  Numbers  in  parentheses  33.7b (+3.3)  designated are  73.8a  15.4  81.4b (+6.7)  deviations.  MCH ( p g ) Mean  % <26  (+SD)  52.5  (+8.8)  by d i f f e r e n t  standard  % <75  (+SD)  (+SD)  Hb < 1 0 g / d L  (fL)  23.39  letters  are  29.3b (+5.1)  Mean  (g/dL)  TRBC  % <32  Mean  77.5  30.96a  60.0  3.86a  (+3.37)  22.1  34.69b (+3.62)  significantly  different  (1x10  12.5  (+0.54)  25.3  at  P  4.116 (+0.60)  <  1x10  /L  % <3.3  (+SD)  (+SD)  (+3.8)  14.8  MCHC  3.9  84  values  was  useful  deficiency  (d)  in  the  derivation  Blood  anemic  various  mothers.  sizes  hemoglobin  and  with  tion  between that  cytosis.  The  these  was also  of  a l l  also the  the  was  of  present  in  10.4% o f  of  anemia might  stage  summary,  indicated  by  the  and  on what  indicator  mothers  42% o f  et  a l .  of  iron  difference  is  probably  characteristics  of  the  significance  such  there  a  early  a  was  a  condition anemic  anemic  mothers  there  stage  to  associa-  have  where  mothers.  Table  anisopoikilo-  the  small  implying  associa-  = 0.0004).  mothers.  or  are  The  significant (P  among  of  significant  reported  the  where  hemoglobinopathy.  showed  were  the  of  anemia cell were  and Chong  due  of  in  observed  erythrocytes In  addition  erythrocytes Microcytosis  that  first  was  or  present.  packed  (1984)  condition  microcytosis  nonanemic be  were  anisopoikilocytosis  parameters  Tee  of  example,  79% a m o n g  prevalence  by hemoglobin  30-55% d e p e n d i n g reported  the  mothers  findings,  approximately  a  observed  hypochromia,  about  two m o r p h o l o g i c a l  is  indicative  and  anemic  in  In  This  For  status  prevalence pale,  be  anemic  observed  second  a good  and m i c r o c y t o s i s  erythrocytes  morphology.  70% o f  abnormally  of  could  hemoglobin  shows  to  It  blood  hypochromia  Anisopoikilocytosis  shapes  status  tion  are  not  morphology  erythropoieses.  14  MCH b u t  anemia.  Anisopoikilocytosis, the  of  to  populations  in  the  volume  variations studied.  characteristics  in  was  used. (1968)  any  population found  This for in  This  is  urban  studied  to  be  higher  suggests  nutritional  about than  Malaysian  demographic  and  the  study.  as  those mothers.  geographic  practical  TABLE  14.  Morphological  findings  of  the  thin  blood  smears  of  Hemoglobin Blood  morphology  Anemic mothers  Anisopoikilocytosis  Hypochromia  Microcytosis  Total  (%)  Nonanemic (%)  mothers  (%)  324 m o t h e r s  studied.  status Total  (%)  Statistics  Negative  28  (30.1)  121  (52.4)  141  (46.0)  Positive  65  (69.9)  110  (47.6)  175  (54.0)  Negative  20  (21.5)  150  (64.9)  170  (52.5)  X  Positive  73  (78.5)  81  (35.1)  154  (47.5)  P  <  Negative  54  (58.1)  207  (89.6)  261  (80.6)  X  i  Positive  39  (41.9)  24  (10.4)  63  (19.4)  P  <  93  (28.7)  231  (71.3)  324  (100)  X l  2  =  12.36  P  =  0.0004  i  = 48.2 l x l 0  =  -  4  40.1  lxl0"4  86  The d i f f e r e n t i a l morphology also are  conclusive  present  in  some  required  to  confirm  following  2.  Biochemical Iron  The  iron  shown i n  Range  Test  Indian  higher that could  showed  than  there  diagnosis.  Folate  analyses  for  This  subject  determined  the  mean s e r u m f e r r i t i n  significantly  of  different  less  than  the  cut-off  mothers  from  the  other  was  a  few h i g h  the  of  mothers  (68%)  had  mothers  characterized that  their  ferritin mean  serum  significant  is  the  blood  deficiency  folate  and  discussed  was  iron  in  the  was  by  the  their  is  serum f e r r i t i n  the  value  of  (12  Duncan's  was  those  percentage  of  the  Malay  was  races  (P  = 0.05).  values  among  the  Indian  ferritin  for  levels,  the  and  Indian mothers ng/mL)  levels  Multiple  highest  two  found This  values  Hb v a l u e s ferritin  hemoglobin  finding  were  used.  serum f e r r i t i n with  and  from  value  the  whose  significantly This  implies  mothers  and might  which  have  findings.  differences  15 ng/mL  the  by  variance  But,  level  This  mothers  = 0.05).  cut-off  implies  the  that  affected to  of  analysis  (P  were  have  status.  biochemical  M C H , MCHC a n d  anemia.  The  No s i g n i f i c a n t  This  this  deficiency  15.  and  the  contributed  as  The  MCV,  Indices  Table  value  nonanemic  cases.  status  mothers  ferritin  iron  the  status  mothers  Chinese  of  using  section.  (a)  is  was  diagnosis  values  consistent  of  with  is  the  because  below  of  not  less  the  races  than  Out  of  12 n g / m L  by  of  the the  223  iron  indicative  reported  when  majority  66% w e r e  totally  that  three  15 n g / m L .  >^ 1 0 g / d L ,  values are  among  deficient (Table  of  George  16).  iron et  a l . ,  87  TABLE  15.  Iron  Race  status  of  mothers  determined  by  Serum f e r r i t i n  Number Mean (+ SD)  Median  serum f e r r i t i n  levels  levels.  (ng/mL)  Range  % < 12  % < 15  234  18.3 a (+30.2)  9.0  218.6  62.8  67.9  Chinese  47  24.7 a (+35.5)  12.5  188.4  46.8  61.7  Indian  42  32.1 b (+80.9)  4.7  498.6  66.7  73.8  21.0 (+41.2)  9.0  498.6  61.0  67.8  Malay  323  Total  Numbers d e s i g n a t e d P = 0.05. Numbers  in  TABLE  by  parenthesis  16.  the  same  are  letter  standard  Iron s t a t u s of anemic ferritin values.  are  not  Number of mothers  and nonanemic  -  levels  Number of  mothers  measured  by  (g/dL)  (% > 1 0 g/dL)  T o t a l number of mothers  (%)  mothers  12  66  (72)  148  (66)  214  (68)  >  12  26  (28)  75  (34)  101  (32)  92  (29)  223  (71)  315  (100)  number  (%)  2  at  <  Total  X i  (% < 1 0 ) g/dL)  different  deviations.  Hemoglobin Ferritin (ng/mL)  significantly  0.63;  P  =  0.04.  88  (1980) where they found t h a t one 12 g/dL  was  iron deficienct  t h i r d of women w i t h hemoglobin above  ( f e r r i t i n < 10 ng/mL).  The f e r r i t i n v a l u e which i s i n d i c a t i v e of i r o n s t o r a g e and i s v e r y s p e c i f i c f o r i r o n s t a t u s , c o n f i r m e d t h a t the m a j o r i t y o f the mothers  (68%)  were i r o n d e f i c i e n t ; among which 30% t o 50% were anemic as determined the Hb and PCV  levels.  by  The i n f e r e n c e i s t h a t most mothers were i r o n  d e f i c i e n t even b e f o r e they were pregnant and the chances f o r them to be anemic became h i g h e r ; and f o r those who were a l r e a d y anemic, the of the anemia i n c r e a s e d as pregnancy (b)  severity  progressed.  Folate status  Serum f o l a t e l e v e l i s dependent on the r e c e n t i n t a k e of food or supplements c o n t a i n i n g h i g h amounts of f o l a t e .  Thus, those mothers  who  took the v i t a m i n B complex t a b l e t s g i v e n to them a t the h e a l t h c e n t r e s or those who  consumed l a r g e amounts of green l e a f y v e g e t a b l e s p r i o r to serum  f o l a t e e x a m i n a t i o n had h i g h f o l a t e v a l u e s .  Table 17 shows the mean f o l a t e  v a l u e s of the mothers f o r the t h r e e r a c i a l groups and the p e r c e n t of mothers below the s t a n d a r d l e v e l s recommended by K h a l i d (1983) and  WHO  (1972). The mean serum f o l a t e o f the Chinese mothers as shown by the a n a l y s i s of v a r i a n c e was  s i g n i f i c a n t l y h i g h e r than t h a t of the Malays and  I n d i a n s (P = 0.002).  The Duncan's M u l t i p l e  the  Range Test a t P = 0.05  showed  no s i g n i f i c a n t d i f f e r e n c e i n serum f o l a t e v a l u e s between the Malay and I n d i a n mothers.  This r e l a t i o n s h i p  frequency c u r v e s i n F i g u r e 14. the percentage  i s i l l u s t r a t e d by the  A s i m i l a r p a t t e r n was  the  cumulative  found when comparing  of M a l a y , Chinese and I n d i a n mothers w i t h f o l a t e v a l u e s  less  TABLE  17.  Folate  status  the mothers  Serum f o l a t e  Number  Race  of  Mean (+ SD)  Median  by  racial  levels  Range  groups.  (ng/mL) % < 3  % < 5  216  9.05 (+9.8)  a  5.9  83.2  24.1  44.0  Chinese  42  16.9 (+26.0)  b  7.0  159.1  23.8  35.7  Indian  35  8.1 (+10.2)  a  3.8  29.2  48.6  60.0  293  10.1 (+13.7)  5.4  159.2  27.0  44.7  Malay  Total  Numbers d e s i g n a t e d P = 0.002. Numbers  in  by  parentheses  the  are  same  letter  standard  are  not  significantly  deviations.  different  at  90  Figure 14.  Frequency d i s t r i b u t i o n of serum folate i n 293 mothers from the three r a c i a l groups attending the antenatal c l i n i c s i n the d i s t r i c t of Kuala Selangor, Malaysia.  91  t h a n 3 ng/mL with  folate  number  was  (Table values  found  below  3 ng/mL.  their  diet,  vegetables however  was  The in and of  folate  below  g/dL),  49  ng/mL.  In  to  the  high the  The Malays  in  these  was  two  in  had h i g h  Indians,  and  anemic  food  the  of  folate  Malay  association  Relative  the  the  about 95  (26.2%) folate  mothers  majority  of  the  the  anemic  had iron  green  in  leafy  deficiency,  are  between  hemoglobin  folate  mothers  folate  A  had (Hb  folate < 10  smaller  level  deficient  shown  level  mothers  deficient.  also  folate  mothers  standard  44.4% o f  levels  mothers.  and nonanemic  to  folate  namely  significant  of  this  folate  the  green  leafy  level  compared  their  the  to  the  less  than  5  anemic  mothers  levels  less  diet  Chinese values  consisted  vegetables.  There  mothers  folate  prevalence as  (folate  mean s e r u m f o l a t e  that  and Malay  similar  deficiency  Indians  had h i g h e r  Chinese a  of  indicating  example,  using  rich  prevalence  considered  among  mothers  indicating  races  mothers  same  folate.  higher  for  Chinese  women,  prevalence  Chinese and  some  folate  (48.6%)  The  with  The  Among  the  and C h i n e s e .  mothers  of  nonanemic  that  the  percentage  3 ng/mL  pregnant  the  implies  folate,  same  than  of  summary,  Malays.  < 1x10"^).  Indian mothers  Chinese  the  a highly  more  than Malays  Chinese  of  them were  deficient  3 ng/mL)  the  levels  was  (P  of  that  however,  and  supplements.  standard.  (37%)  This  also  than  this  Malay  consumption  normal  (65%)  percentage  were  for  the  between  There  were,  3 ng/mL  implies  by  similar  levels  5 ng/mL  level  This  folate  18.  than  between  serum f o l a t e  Table  There  less  either or  17).  of  cut-off  with folate point  of  was,  foods  however  levels  folate  the  compared  deficiency for  and  less between  deficiency.  TABLE  18.  Serum  folate  levels  of  anemic  and  Hemoglobin Serum f o l a t e levels  < 10 g / d L  (ng/mL)  Number  i  levels  > 10  g/dL  (%)  Number  (%)  Total  (%)  49  (65.3)  78  (37.0)  127  (44.4)  > 5  26  (34.7)  133  (63.0)  159  (55.6)  75  (26.2)  211  (73.8)  286  (100)  number  (%)  2  mothers.  < 5  Total  X  nonanemic  = 16.9;  P  <  lxlO  -  4  .  93  3.  Hemoglobinopathies  Sixteen based  on  indices  the  iron  dietary cal  to  the  findings  summary  among  and  and  20  three  prevalence These  of  Their  anemia was  Causal There  These  was  It  is  beyond  many low  probable  in  George  to  among  to  20  and  was  the  Malay  anemic  hemolysis  to  of  this  by  blood  in  analyses  Table  and  1  19.  A  percent  the  Indian prevalence  with  was  4.7%.  14.7%  serum of  about  8.8  to  discuss  this  deficiency  nutritional  20).  ferritin  to  iron  The  (Table  failure  leading poor  morphologi-  or  Anemia  status,  while  hypochromia,  mothers  Deficiency to  (1972).  21.  a m e a n Hb  thesis  The  given  mothers  indicated  high  The values  a n d WHO  complete  The  due  factors  socioeconomic  the  blood.  h i g h MCHC  low.  2 Chinese  with  Iron  or  are  anemic  scope  or  (1983)  The  mothers  13 M a l a y ,  status  be  their  values  normal  cells.  Tables  among  were  of  hemoglobinopathy  anisopoikilocytosis,  these  were  iron  the  Leading  by  of  normal  hemoglobinopathies.  they  considered  Factors are  but  of  of  highest  high  form  analyses  either  target  given  there  having  had  ng/mL,  include  that  a  serum f e r r i t i n  were  of  hemoglobinopathy  of  hemoglobin.  by  indicators  of  mothers  104  recommended  conditions  is  having  MCV a n d M C H b u t  intake  indices  of  biochemical  PCV,  presence  races  value  C.  iron  shows  and  indicated  the  suspected  the  suspected  values  indicated  these  Table mothers  as  demographic of  Hb,  normal  protein  some  low  status  microcytosis and  were  hematological  used were  compared Their  mothers  status,  g/dL.  synthesise aspect.  anemia. non-  TABLE 19.  Sixteen cases of suspected hemoglobinopathy based on hematological and biochemical indices and some associated demographic factors.  Demography  Hematology  No.  Race  Age (yrs)  Gest. (mo.)  Gravida  Parity  Mlscarr.  01  M  22  7  1  0  0  Hb g/dL  9.6  PCV Z  MCV fL  32.0  Blood biochemistry  MCH P8  MCHC g/dL  Folate ng/ml  Ferritin ng/ml  _  30.0  9.0  580  Nutritional Intake  Blood morphology  Protein (8)  Iron (mg)  Aniso.  118.4  26.8  *  Micro.  Hypo.  Targ  *  *  *  *  *  02  M  29  7  5  4  0  8.2  27.9  64  18.8  29.4  38.0  100  35.2  4.9  03  I  27  5  1  0  0  8.0  25.5  69  21.7  31.4  8.0  33  144.4  23.1  *  *  *  *  50.1  *  *  *  * *  04  M  22  7  2  1  0  5.8  15.1  62  23.9  38.4  2.2  82  05  M  37  10  12  10  1  9.0  29.3  68  21.1  30.7  8.0  60  148.1 ;  46.7  19.3  *  *  *  *  *  *  *  *  *  *  *  *  *  * *  06  M  35  10  4  2  1  8.0  23.8  61  20.5  33.6  4.5  350  65.0  10.1  07  M  26  11  2  1  0  9.3  28.0  -  -  33.2  92.0  270  83.6  17.6  08  M  21  8  1  0  0  8.6  24.8  57  19.8  34.6  2.6  60  58.4  7.9  09  C  20  6  1  0  0  9.3  27.4  54  18.4  33.9  10.0  600  39.4  6.0  10  c  19  7  1  0  0  9.6  31.0  84  26.1  31.0  30.0  190  77.3  25.7  11  M  25  7  1  0  0  8.9  28.6  74  22.9  31.1  1.2  190  58.8  9.6  * *  *  * *  *  12  M  32  9  7  6  0  9.7  29.9  84  27.3  32.4  12.0  27  37.3  12.2  *  *  13  M  -  -  -  -  -  8.7  28.0  74  23.1  31.1  -  -  75.3  13.0  *  *  *  *  *  *  *  *  14  M  26  9  3  2  0  11.0  32.8  73  24.4  33.5  112.0  60  55.8  11.8  15  M  27  9  3  1  1  9.5  30.1  67  21.4  31.5  3.4  76  74.0  10.6  *  *  *  16  M  31  8  2  1  0  7.2  22.5  60  19.4  32.0  10.0  21  -  -  *  *  *  M C I *  "  Malay Chinese Indian Indicates positive  •is  95  TABLE  Race  20.  Prevalence of hemoglobinapathy total population studied.  Sample  .  number  Malay  Total  = n  .  number  % Prevalence  „  = N  £ x  N  100  among  the  anemic  Total Hb  <10 g / d L  and  % Prevalence of anemic v A  x  100  13  274  4.7  77  16.9  Chinese  2  54  3.7  11  18.2  Indian  1  50  2.0  21  4.8  16  378  4.2  109  14.7  Total  A = anemic  mothers  with  hemoglobin  less  than  10  g/dL.  TABLE  21.  Hematological  and b i o c h e m i c a l  Hematological Race  Malay  Number  Hb  PCV  g/dL  indices  indices  of  16 m o t h e r s  (mean)  MCV  MCH  MCHC  %  fL  pg  g/dL  suspected  of  hemoglobinopathy.  Biochemical i n d e x (mean) TRB^ 1x10  Ferritin /L  Dietary intake mean Protein  Iron  ng/mL  (g)  (mg)  13  8.7  27.1  68  22.4  32.4  3.92  156.3  71.4  16.2  Chinese  2  9.5  29.2  69  22.3  34.3  4.37  125.0  58.4  15.9  Indian  1  8.0  25.5  69  21.7  31.1  3.69  33.0  144.4  23.1  97  compliance discussed anemic  1.  with in  this  condition  has  several  tion,  of  the  ways  of  the  of  amount  reflect family  of  of  (Table  educational  is  with  made  of  These  factors  each v a r i a b l e  socioeconomic  socioeconomic  was  status  level  of  them t h a t  of  the  evaluated  the  discussed  status.  by  ownership  is  had  are  with  type  in  the  study  the  levels  property  and  cash  of  of  In  variables.  assessing  Another  related  water  section  There  mothers.  of was  no  and  could  to  due  educational  years  these  both mothers  of  among  factor  supply  4c(i)  of  the  There  populaof  economy  which  or  could  available  this  formal  level.  the as  three  to  the  chapter.  shown i n  here  education  difference  and anemia  homogeneity  of  In  the  that  of  found  ( P _< 0 . 0 5 )  the  to  betwen  population  whole  the  formal  as  of  the  Malay  were  Chinese  Chinese the  the  The  There  and  Malay  35%  and  26%  Indian  mothers.  education. education  shown i n studied  population  formal  between  22.  10% o f  compared  years  years  (P = 0 . 0 0 3 ) .  Table  to  is  1-6  association  races  compared  similar  general,  a maximum o f  significant  inference  significant  the  had  education  women h a d  husbands  a  schooling  The of  (70%)  was  mothers  secondary  less  spouses  of  mothers There  years  had  Indian  the  22).  had more  be  is  factors.  Education  education  mothers  been a s s o c i a t e d  cash available.  supply  A majority  mothers  related  population.  occupation,  socioeconomic  (a)  study  status  pooled  (water  health  and a s s o c i a t i o n  measuring  socioeconomic types  and  status  always  education,  The  section  Socioeconomic  Anemia are  supplements  levels  Table  23.  in  terms  of  studied  could  be  of This  98  TABLE  22.  Education  levels  of  the  mothers  in  the  three  racial  categories,  Race Education  level  Malay N u m b e r (%)  2 2  Indian N u m b e r (%)  Total N u m b e r (%)  < Grade  6  162  (65)  43  (90)  31  (74)  236  (70)  > Grade  6  87  (35)  5  (10)  11  (26)  103  (30)  (100%)  44  (100%)  339  (100%)  249  Total  X  Chinese N u m b e r (%)  = 11.8;  P =  TABLE  (100%)  48  0.003.  23.  Education l e v e l s of respondents r e l a t i o n s h i p to anemia.  Education Hemoglobin level of mothers (g/dL)  level  and  spouses  (years)  Husbands 0-6  >6  in  Mothers  T o t a l number of husbands  0-6  >6  Total of  number  mothers  <  10  50  37  87  63  25  88  >  10  123  75  198  141  65  206  173  112  285  204  90  294  Total  99  classified mothers  as  having  having  (b)  low  middle  to  of  the  farm workers,  teachers  mately  the  13% o f  above).  Ten out  were  not.  were  reasonably  The  of  43  well  of  the  the  fact  that  1-6  homogenous The  years  of  were bulks  laborers  were  small  (91%)  and  labo rers.  Table  24  them  were  formal  (23%)  here  percentage  is  in  that  terms  was  there of  found  of  was made up  education  the  were  approxi-  and  remaining  nonworking  of  33  mothers  who  schooling.  mothers.  As  status  (both  mentioned  91% h o u s e w i v e s ,  classified  that  (Form 4  occupational  of  remaining  shows  while  were  years in  the  education  working  and nonanemic  population of  housewives  secondary  anemic  of  the  husbands  were  jobs  and  level  income.  involved  of  and  seafoods  quite  similar The  15.7% o f  to  the  them as  officers  categorized  the  farmers  wives  earlier,  with  majority  belonging  worked  them i n  as  six  food  were the  they  are  to  a  groups  shown  The  workers.  items.  involved  were  city.  Table  and  other  The in  involved  in  based  included  capital  businessmen  farmers.  factory  and  they  since  into  businessmen  goods  since  occupations  22.9% as and  The  trading  distributing  husbands by  or  businessmen  remaining  followed  junior  of  selling as  laborers,  teachers,  in  categorized  activities.  Approximately  were  a  levels.  had h i g h e r  difference  the  their  catching  contract  with  population.  who w e r e  fishermen  of  were  contract  educated  occupations  on nature  and  implication  and husbands)  farming  education  mothers  mothers  No s i g n i f i c a n t  those  high  status  Occupation  A majority  having  educational  The in  25.  33.7%  job  categories  100  TABLE  24.  The e d u c a t i o n and mothers s t u d i e d .  occupation  Education  Occupation  levels  level  of  the  339  (years)  of mothers  1-6  Housewives  219  (92.8)  56  (93.3)  33  (76.7)  308  (90.9)  17  (7.2)  4  (6.7)  10  (23.3)  31  (9.1)  236  (69.6)  60  (17.7)  43  (13.0)  339  Others  Total  TABLE  Job  categories  25.  (%)  7-9  Occupational  Number  (%)  10 and a b o v e  categories  (%)  of  Types  (%)  Total  of  occupation  (15.7)  Businessmen, shopkeepers  Laborers  103  (33.7)  Contract  Teachers  22  (7.2)  Farmers  70  (22.9)  Farmers, gardeners, pensioners  officers  34  (11.1)  Firemen, policemen, army, sailors, government f a r m i n g b o d i e s , bus conductors, postmen  workers  29  (9.5)  Junior  Factory Total  306  (100)  fishermen,  self-employed,  laborers  Religious school school teachers  Factory  (100)  spouses.  48  Businessmen  (%)  workers,  teachers,  elementary  vegetable  mechanics  farmers,  101  Table definite their in  26  shows  relationship  husband's  decreasing  factory  the  order  was:  and  less  disposable  tion  here  is  (1968) that  and  that  Ong  sented  by  amounts  requirements  property. their  In own  parent's,  variable this  parent  rented Among  to 0.2  grow and  those  food  and  to  clinic.  seems  groups that  lacked  eggs  that  of  to  of  provide  for  the  and  trend  teachers implica-  in  the  of  Lourdenadin reported  associated  mothers  purchasing  power  with  as  repre-  to  buy  protein  and  property  27).  houses  approximately  About or  socioeconomic  16% r e s i d e d  siblings.  which were  The  status  53% o f in  the  the  ownership  mothers  relatives'  remaining  partially  is  had  houses,  mothers  subsidized.  a  houses  namely,  lived  Only  of  in  small  (16.5%).  who  while  owned h o u s e s , About  34% o f  16% h a d  a majority the  between  mothers 2 and  (72%)  had  who owned  3 acres,  and  agricultural land the  a  officers,  They  always  income  The  The  those  mothers. were  the  wives  was  women  junior  factors  with  low  the  farmers.  important  on anemic  is  the  There  pregnancy.  reflecting  crops.  1 acre,  spouses  fish  in-law's  houses  here  among  agreement  income  anemia.  anemia  those  are  with  businessmen,  It to  in  studies  population,  (Table  government-owned group  during  of  is  low  their  meats,  Ownership  Another  of  of  the  visit  26).  education  their  of  laborers,  compared  inference  of  occupation  first  (Table  finding  to  the  occupation  (c)  on  belonging  Therefore,  adequate iron  This  (1973)  their  anemia and  of  prevalence  farmers,  income  anemia.  mothers  anemia.  to  the  on  teachers  were  of  between  occupation  workers  etiology  association  had  land  between  remaining  50%  102  TABLE  26.  The r e l a t i o n s h i p between p r e v a l e n c e of respondents' spouses.  Hemoglobin Occupation  of  Anemic mothers < 1 0 (%)  spouse  levels  of  on  anemia  first  and  visit  occupations  (g/dL)  Nonanemic mothers > 1 0 (%)  Total (%)  Businessmen  23  (18.5%)  25  (13.7%)  48  (15.7%)  Laborers  26  (21.0%)  77  (42.3%)  103  (33.7%)  6  (27.3%)  16  (8.8%)  22  (7.2%)  46  (37.1%)  24  (13.2%)  70  (22.9%)  officers  15  (12.1%)  19  (10.4%)  34  (11.1%)  workers  8  (6.5%)  21  (11.5%)  29  (9.5%)  124  (40.5%)  182  (59.5%)  306  (contract) Teachers Farmers Junior Factory Total  2 x  5  = 33.3;  (%)  P  <  lxlO  -  4  .  (100%)  TABLE  27.  Ownership  of  house  and  land  of  Number Land ownership  Own house  (%)  Relative's house  (%)  the  of  Government house  340 m o t h e r s  studied.  mothers (%)  Rented house  (%)  Total  (%)  Yes  104  (57.8)  19  (32.8)  10  (21.7)  12  (21.4)  145  (42.6)  No  76  (42.2)  39  (67.2)  36  (78.3)  44  (78.6)  194  (57.4)  180  (52.9)  58  (16.1)  46  (13.5)  56  (16.5)  340  (100)  Total  (%)  104  owned more  than  while  31% w e r e  trees  and  is  of  that  study  test  the  houses  term  income  dried  purchased when  products  from 28  daily.  This  This  a  tor  is  a  daily  by  g r o w n was  palm,  and  food  and  the  coconut  rest  (36%),  were  fruit  vegetables mangoes,  crops.  tapioca,  of  and  grew  was  observed  were  fruit  in  food  trees  abundance  rambutans,  other  property.  land  hemoglobin  The  that  in  grown were  probable  crops,  who  house  area.  bananas  this  those  the  this  reason  since  even  around  pineapples,  The v e g e t a b l e s and  between  Some  a n d many  spinach,  of other  cabbage,  greens.  economy cash for  a  economy purchase put  twice  with  the  sale  of  the  of  items.  food  some p o o l e d  a week. cash  the  amount  cash  Whereas  brought  food  It  back  items  like  in  of  pooled  appeared for poor  cash available that  an average  purchase  of  homes,  food  from a day's coconuts  or  in  work  or  groceries is  or  often  at  livestock  and  times and  other  farm.  shows  that  was m a i n l y  item  could  denotes  aside  or  the  luxury  the  ownership  owned h o u s e s ,  be  the  majority  fresh  common f e a t u r e  possibility  their  and  once  is  Table  is  crop  association  garden  daily  there  and  significant  vegetable  family  goods  no  have  Cash  household  high  o i l  It  greens,  (d)  the  rubber,  based.  include  locally-grown  The  The m a i n  agriculturally  Fruits  fruits  mustard  showed  majority is  compound. these  land.  coffee,  the mothers  area  rented  paddy,  of  vegetables.  The X levels  3 acres  in  fish,  the  rural  fishermen  preference  from  their  the mothers  vegetables  and u n a f f o r d a b l e the  of  areas to  of  many  for  fresh  daily  haul.  and  (73%)  other  Malaysia families. fish  purchased  fresh where  food  products. a  refrigera-  Another  w h i c h was  brought  in  105  Approximately for  their  same  pattern  spent  more  shopped the  of  The  cash  analysis the  of  ficant  mothers  mostly  r e a s o n why mothers  variable. the  have  foods  bought,  of  iron  foods could  respect  significant  gardens.  items  food  value  In  groups  food  status  based s t i l l  summary, to  the  In  on  items  the  education  and  most  among  and  was  and  of  the  be  Indian  as  shown by  two-  tailed  rather  anemic of  than of  is  mothers.  mothers  M$213.03. the  these a more  amount  was This  of  a  implies  probable Chinese  diagnostic choice  nutritional  spent was  of  while  that  spent,  important  of  Malay  this  Apparently,  knowledge  The signi-  M$208.96,  money  proper  ).  t-test  to  The  races  Chinese  mothers.  Therefore,  4  and  difference  respect  -  on  29.  The  the  the  spent  No  detected.  that  by  between  Indians.  fact  with  mothers  <^ l x l O  could  who  three  the  mothers  The  Table  the  (P  this  of  daily.  cash  of  bought  mothers  house  food  the  spite  nonanemic  good  Indians  of  on  mothers  shown i n  month  Malays  whereas  some n u t r i t i o n a l  ensure  per  food  those  amount  is  a month  association  difference  the  their  status  the  the  head  and  an average  dietary  of  per  than  on f o o d ,  spent  significant  racial  food  for  a majority  three  around  and  observed  and  on  significant  no  M$200.00  them bought  a week  the Malays  less  of  general,  was  on food  mothers  influenced  indicate  more  anemic  In  was  about  in  The mean e x p e n d i t u r e  of  tional  sive  have  the  nonanemic  choice  spent  between  spent  no  between  a  grow gardens  not  on f o o d ,  found  spent  they  did  the  showed  money  difference  mothers  more  variance  habit  There  purchased  of  spent  A majority  a month.  food.  food  of  mothers  purchasing  economy  amount  Chinese  28).  for  of  month.  (Table  $200.00  everyday  per  the  food  than  frequency  food  in  families  42% o f  the  could nutri-  tool  to  inexpen-  value  of  nutrition. studied  occupation  came  f r o m a homogenous  levels.  They were  population  mainly  of  low  with  106  TABLE  28.  The f r e q u e n c y spent on f o o d  o f f o o d p u r c h a s e p e r week p e r week p e r h o u s e h o l d .  Amount Frequency  (M$)  number  Daily  number  of  amount  per  number  M$  household  >$400  of  in  Total n u m b e r (%)  of  mothers  mothers  87  125  34  246  (73%)  mothers  2-4  times/week  13  8  1  22  (7%)  < 4  times/week  42  27  2  71  (21%)  339  (100%)  142  Total  TABLE  29.  Race  160  (42%)  (47%)  37  (11%)  The mean amount o f c a s h s p e n t p e r m o n t h p e r h o u s e h o l d among t h e t h r e e r a c i a l g r o u p s .  Number  of  Amount  of  money  mothers  spent Mean  on food (+  person  per  $195.30  a  (+  Chinese  45  $296.50  b  (+153.0)  Indian  36  $218.20  a  (+  295  $218.50  Total  Numbers  in  Numbers  designated  <  lxl0 4 _  parenthesis by  are the  standard same  letter  in  person  a  (M$)  S.D.)  214  Malay  P  the  on food/month  $200-400  <$200  of  spent  and  6.50)  86.00)  (+110.00)  deviations. are  not  significantly  different  at  107  socioeconomic  status  status.  These  property  and  schooling  occupation of  the  mothers  of  were  not  the  they  were  was  highly of  Malay  there  was  the  mothers.  they  spent  nutritional less  occupation with  Thus,  As  on food  the  years  of  the  anemic  among  of  between  levels,  the  even  money  needs.  money  had more  relationship  lowest  less  ownership  mothers no  associated  a n e m i a was  socioeconomic  occupation,  the  for  middle  conditions  Chinese  though  the  Malay  food,  and  probably  on for  the  Indian  and were  the  mothers,  most  anemic  races.  Status  plays  an  important  These  include choice  knowledge  of  food  values  the  of  As  spent  beliefs,  high  or  anemia.  Indian  Good n u t r i t i o n a l  practices.  but  their  educated,  Nutrition  habits  and  of  on e d u c a t i o n ,  races  educated,  meet  Nutritional  anemia.  two  and  percentage  In general,  prevalence  Malay  three  based  husbands The  to  less  the  other  better  able  smaller  economy.  the  the  a  were  background  to  were  2.  cash  mothers.  compared  among  levels  than  educational  with  basic foods  physiological  status  role  in  the  could  be  obtained  nutrition of  awareness,  inexpensive  preparation  eaten.  In  requirements  etiology  in  cases  but  from  absence  to  food  of  pregnancy,  of  the  retain  iron  sound of  nutritious  order  where  of  deficiency nutritional  negative  foods,  and  maximal  consumption  food  nutritional  cannot  supplementation  is  meet  the  considered  necessary.  (a)  Daily  The The  daily  daily  beliefs  dietary  dietary  dietary  and  by  pattern  pattern  pattern  customs.  is  of  the  three  three  influenced  by  races  races  is  religion,  discussed and  separately.  nutritional  108  (i)  In have  a  diet  typical  rural  much v a r i e t y  Animal at  Malay  protein  an average  consumed amount economy rarely  foods of  daily  of  the like  three  purchasing  consumed  or  only  non-breastfed  infants.  popular or  is  of  in  a  the  of  ordinary  side are  (Table  fishing  be  This  the  and mutton  a month  taken  breast  taken  not  family.  once  a month  It  depends  Milk in  is  constitutes  only  a  an average  of  babies.  four  or  the  milk  their  though  Kuala  powdered  feed  Even  times  does  is  only  fish  Selangor) on  the  not  minimal.  frequently;  like  substantial.  diet  consumed  eaten  30).  area  the  dishes  Malay  may the  cash  dairy  products  are  form of  powdered  or  usually small  confined  number,  if  to  the  any,  Sweetened  condensed  per  usually  week,  be  since  milk  with  is coffee  tea. A popular  usually be  Malaysia,  Otherwise,  mothers  and  times  power  milk.  Malay  beef  e a t e n may n o t  reconstituted  most  in  quantity  (especially  fish  or  and  home  appetizer,  served.  eaten  as  a dip  leaves.  This  However,  it  is  5 g or  about  Three of  some  or  tapioca  times nasi  to  the  teaspoon. are  served and  as  Bread the  every is  rice  is  of  and  taken  intake  large  amounts.  a  boiled  in  day.  about  breakfast the  cucumber  protein  in  in  paste  chillies,  like  fritters,  taken  of  fish  fresh  vegetables  banana  main day  with  consumed  usually like  made  calcium  a  dishes  It  fresh  usually  tubers.  lemak.  prepared  not  meals  a day,  is  with  adds  is  sweet  sometimes  It  usually  item.  week. coconut  or of  belacan,  and  Rice  is  the  usually sweet  a week. eaten  with  is  juice  to  tapioca  mothers.  An a v e r a g e  favorite  served  lime  blanched  plantains,  times  Another milk  salt  A breakfast  fried  three  called  serving  consist potatoes  Fried almost  breakfast fish  rice  is  three item  cooked  in  is  TABLE  30.  Food  frequency  pattern  Mean Food Protein  Race  Carbohydrate  Milk  group  6  5  10  6  4  8  7  7  1  9  6  4  10  5  5  9  7  6  2  3  7  6  5  10  7  3  7  6  6  3  3  9  6  4  10  6  4  8  7  7  1  9  Chinese  48  5  Indian  42 340  Seafoods  Eggs  are:-  1  = Once/month  6 = Three  2  = Twice/month  7 = 4  times/week  3  = 3  8 = 5  times/week  4  = Once/week  times/month  5 = Twice/week SCM = S w e e t e n e d  Pattern  Noodles  3  used  races.  Bread  250  Codes  Frequency  three  Rice  Meats  Total  the  Beans  n  Malaya  group  of  condensed  milk  times/week  9 = 6  times/week  10 = 7  times/week  Vegetables  Fruits  SCM  Fresh/Powdered  110  hot  and  sweet  sauce.  ingredients. taken  three  usually  amount  of  average  is  and  a  few  chocolate  tains,  coconut Dishes  sionally, dishes  size.  It  is  of  serve  peanuts for  and  are  optional  breakfast.  sweetened  are  are  fried  salted  fish  Beans,  five  times  of  and  Eggs  coffee  are  is  at  for  1,000  with  fish  and  five  times  plate  about  or  g of  a  substantial  cooked  vegetable  per  of  4 to  week  rice  is  an  dishes.  among  lunch w i l l  5 p.m.  'Ovaltine' The  sweet or  eaten  average  an to  the  be  Malay  filled  a week.  long  Only  tea  or or  include  made five  served  together  example  of  Tea and  with  sometimes  even coffee  porridge  those  served  or  dishes  fritters  similar is  to  is  vegetables.  fruits.  supper  The m a i n d i s h  typical  tea  banana  Fruits  lunch.  a  'Milo'  local  potatoes,  about  served  fish  drinks or  p.m.  an average  for  from  vegetable  at  homes  milk.  eggs  black  Two h u n d r e d  Therefore,  dishes  sweet  1:30  rice.  flavored  sweet  around  pieces  Malay  roasted  half-cooked  Homeground,  boiled  eaten  and  breakfast.  served  studied.  Most  and  is  slices  have  a week.  with  serving  mothers  with  times  plain  Vegetable  rice  Some m o t h e r s  served  Lunch  Cucumber  the  green  times  fried  plan-  per  Occa-  leftover  are  are  rice  week.  lunch.  beans,  coffee  served  from glutinous  during  with  are  hot  side eaten  served  as  a  after  supper.  (ii) The  Chinese ordinary  including or six  mustard times  diet Chinese  vegetables greens, per  week  diet  and meat.  cabbage (Table  and 30).  contains Green other The  rice  leafy  with  several  vegetables  vegetables vegetables  are are  for  side  dishes  example  choy  sam  served  an average  of  usually  stir-fried  for  I l l  short  periods  since  most  include  are  is  home  than  or  stir  in  the  morning.  or  range  from  eaten  during  Like  ten  two  or  labile.  Other  products.  The  average  Fish  served  is  races.  It  In  side  Pork  soyabean  frequency  almost  everyday.  usually  general,  dishes  and  frequently  is  nutrients  serving  eaten  more  more  the  in  a  of  Chinese  prepared Chinese  in  eat  soups more  of  fried  eaten noon) of  soups,  or  rice  drinks.  Bread  is  eaten  milk  about since  plain  noodles,  three  times  breakfast  boiled  or  a week.  was  rice  only  Lunch  taken very  steamed  served  is  early  served  in  with  fish.  snacks  are  retains  races.  are  consists  an e a r l y  may o r  supper  may n o t  followed  usually  the  family  gather  to  twenty  people.  this  are  flavored  (before  by  be  a night  associated for A  the  served.  with  meal  social  evening meals.  substantial  Sometimes  amount  of  fried  of  Relatives  group  food  is  noodles  events. The  it  is  could  '  usually  meal.  The  Chinese  consume  the  Malays,  only  sweetened tea.  early  cooking  soyabean  vegetables.  two  Eggs  Meals  of  other  and  heat  a week.  noodles  the  are  of  Chinese.  may c o n s i s t  afternoon by  the  chocolate  Lunch  seafoods. friends  hot  method  and  twice  other  and meats  substituted and  the  fish,  is  pork  a week.  served  Tea  of  with  or  twice  vegetables  or  those  or  and  breakfast  coffee  usually  beef  This  vitamins  among  daily  than  Their  about  or  fried  frequently  with  popular  served  heat.  soluble  chicken  chicken  Rice  high  water  pork,  products pork,  at  condensed  dairy  products  powdered m i l k  milk  is  taken  is  about  an average taken three  by  of  two  times  some m o t h e r s .  times  a week  with  a  month.  Otherwise, coffee  or  112  ( i i i )  The because Some  Indians it  less  their  is  in  made w i t h  considered  some  house  house.  simmer  for  nutrients In extent.  are  more eaten  probably  but  stir-fried  where  less  and  meats and  vegetables.  to  eat  a  most  and  or  sold  of  They  by  three  or  usually  namely  meal.  pork  Their  products. labile to  lentils  instead,  which  dishes  and  is  allowed  to  from  usually served  and  an  allowed labile  to  certain  a  of  more  prepared  simmer  with  and meats The  They  for  in  but  meals  side  retained. races.  fruits  daily,  together  vegetables  usually  diets.  heat  frequent  Their  are  their  are  bulk  bread  group  vendors  vary  eaten  consist  two  in  carbohydrates,  meals  other  of  only  a week,  in  groups  more  are  milk  usually  process.  chicken  vitamins  the  are  have  beans  the  Therefore,  of  Fish  Otherwise,  a kind  pulses  cooked  racial  meats.  times  food  vegetarians.  and  village  other  are  amount  are  are  fresh  four  cooking  of  lentils  the  the  the  cow f o r  chicken.  Indians  during of  a  chappaties,  flavor.  compared  curry  and  the  fish  The  eggs  enhance  Chinese  heat  Indians  form of  Lentils  30).  Most  The  the  substantial  Meats,  soyabean  rice  an average  amounts  The  every  and  in  sacrifice  pulses,  ghee.  lentils.  diets  quantities.  almost  at  lost  minimal  vegetables  legumes  the  diet.  and  (Table  periods  The M a l a y s  varied in  with  a week  summary,  vegetables smaller  curries  long  either  products  eaten  fish,  legumes,  unpasteurized  are  twice  flour  dairy  usually  Vegetables  of  atta  of  never  animal.  consume  eaten with  is  average  vegetarians  or  Hindus,  sacred  curries  wheat  in  a  consist  The m i l k  prepared  mostly  usually  consume  to  diet  who a r e  strict  diets  prepared  that  Indian  in with  fish  dishes are  and  a  are of  usually  Indians  eat  consume  more  curries  with  long  periods  for  to  113  flavor  and  in  vitamins.  They  (b)  the  indicated  food  Nichter  and  mothers  in  there  'hot'  food  be  pregnancy.  to  or  since  it  and  big  is and  fetus.  Some m o t h e r s  anemia  tional  of  some  heat  labile  fresh  milk.  the  which  in  were  also  are is  for  were  not  that in  this  fish,  women's  food  is  foods  body  is  though  lead  fear  since bad  newborn.  or  body  ' b e l i e f  for  m u t t o n was  cockles  her  Even  eaten  could  Indian  'cooling'  condition  the  of  'heaty'  baby.  24% p r a c t i s e d  fits  since  the  while  the  that  among t h e  woman w h e r e  a desirable  cause  child  recommended.  bad  fruits  avoided  the  1979)  practised  with  practice  established  (Arshad,  who  agreement  advocated  believed  avoided  in  been  area  mothers  similar of  had  research  of  a pregnant  about  not  Others  the  is  are  foods  'twin' is  a  birth  foods  studied, as  in  percentage  found  true  childbirth  during of  it  for  twin  could the  lead  baby  Pineapple,  to  abortion  crabs  since  of  they  the were  'poisonous'. was  among  who a v o i d e d  is  and would  vinegar  There  loss  consumes  after  done  overindulgence  delivery.  ginger  who  'cooling'  such  'heaty'  considered  that  observation  'heaty'  mothers  babies  a high  After  and  Foods  difficult  (1983)  eaten,  Among t h e  substantial  taboos study  This  opposite  considered could  were  Lanka.  'cool' The  is  group  dietary  beliefs.  Sri  only  A pilot  Nichter  considered avoided.  of  area.  that  certain  the  there  beliefs  presence  study  births  process  are  Food  The in  the  no  the  between  women s t u d i e d .  these  values.  association  foods  For  The  substituted  example,  the  presence  possible other  a mother  of  reason  foods  that  who a v o i d e d  food is  that  were  fish  beliefs  ate  of  the  and  mothers  equal  chicken  nutrior  other  114  meats.  In  fits  the  in  the  nutritional  case  baby,  ate  status  foods  of  the a  was  lot not  avoid  any  after  delivery  of  after  delivery  affecting  newborn baby, condition maternal  worsen  tissue  with  Nutrient  The  food  were  computed  food  table of  if  iron  of  and  the  South  acid  for  of  fiber, levels  the  iron, among  consumed more  did  observed  the  'taboo'  period  in  a nutritional status  breastfed. again  based  three  on  table  Asian  detected  Indians  took  A and  protein  intake,  the  Chinese  difference  was  close  as  pregnant,  is  not  not  deficiency  well  Therefore,  as  the  the  anemic  replenishment  of  possible.  the  24-hour  compiled  region  racial  by  by  FAO  groups  significant 3-carotene, races  intake  dietary Tee  are  given  recall  (1983)  (1972).  to  (P  of  differences total  The in  other  compared had the  Chinese  the  to  the  highest  level had  lower  of  in  vitamin  <^ 0 . 0 5 ) .  sodium and n i a c i n  significantly  acid  the  three  the  fat,  vitamin  and  sodium,  in  The  ascorbic  showed  the  races.  Malays  mothers  nutrients  food  East  variance  the  the  their  and  the  average  Table  31.  nutrition  were  ever,  Therefore,  caused  the  result  is  mutton  of  nutritional  being  mothers  f or  fat,  could  other  compiled  analysis  they  mother  Malaysian  differences  This  the  fish.  A majority  but  is  or  that  intake  18 n u t r i e n t s  Chinese  it  the  the  ascorbic  if  who b e l i e v e d  chicken  mother's  using  General  of  pork,  This  the  and  mothers,  affected.  child.  intakes  (i)  intake  of  pregnancy,  especially  will  (c)  intakes  during the  Chinese  No  A,  In  compared  the  Malays level  of and  of  significantly  to  iron,  niacin  other  two  8-carotene,  in  Regarding their  ( P _< 0 . 0 7 ) .  higher  and  general,  Chinese.  protein  significance  dietary  significant  nutrients.  levels  the  levels  of  diet.  Howiron  in  TABLE 31. Nutrient intake of 340 mothers attending the health centres i n the d i s t r i c t of Kuala Selangor, Malaysia (1983). Race Nutrient Mean (+ S.D.)  Malay No. - 250  Chinese No. - 48  Indians No. - 42  Total No. - 340  Energy (kcal)  2181 a (±573)  2293 a (+787)  2039 a (+588)  2179 (+748)  Protein (g)  66.8 a (+40.8)  74.8 a (+29.2)  64.0 a (+22.8)  67.5 (+25.3)  Fat (g)  27.6 a (+16.6)  41.2 b (+31.7)  22.6 a (+11.1)  28.9 (+19.6)  Carbohydrate (g)  378.1 a (+148.0)  366.5 a (+141.6)  362.8 a (+113.1)  374.6 (+141.4)  Fiber (g)  3.4 a (+2.8)  2.1 b (+1.9)  3.2 b (+2.7)  3.2 (+2.7)  Ash (g)  8.2 a (+3.8)  8.4 a (+5.9)  7.6 a (+3.6)  8.1 (+4.1)  Calcium (mg)  482 a (+243)  463 a (+219)  433 a (+190)  473 (+233)  Phosphorous (mg)  906 a (+412)  897 a (+348)  855 a (+373)  898 (+398)  Iron (mg)  14.3 a (+7.8)  15.6 a (+7.1)  12.1 b (+4.8)  14.2 (+7.4)  Sodium (mg)  216 a (+360)  492 b (+723)  198 a (+270)  253 (+431)  Potassium (mg)  443 a (+340)  338 a (+314)  369 a (+286)  420 (+332)  Retinol (Mg)  399 a (+783)  285 a (+298)  280 a (+223)  368 (+687)  13701 a (+6472)  14363 a (+1133)  11140 b (+6111)  13478 (+6379)  Total A a c t i v i t y (vg)  2574 a (+1358)  2550 a (+966)  1978 b (+1042)  2497 (+1286)  Thiamine (mg)  1.07 a (+0.56)  1.26 a (+0.64)  1.04 a (+0.40)  1.09 (+0.56)  Riboflavin (mg)  1.06 a (+0.60)  0.94 a (+0.47)  1.10 a (+0.50)  1.05 (+0.58)  Niacin (mg)  10.3 a (+5.8)  13.0 b (+6.8)  10.5 a (+5.7)  10.7 (+6.0)  Ascorbic acid (mg)  81.8 a (+73.6)  75.4 a (+68.7)  59.1 b (+45.4)  18.1 (+70.2)  6-carotene (Pg)  Numbers designated by the same l e t t e r are not significantly different at P < 0.05. Numbers i n brackets are standard deviations.  116  their the  diet  compared  Chinese  protein  mothers, Fiber  quality  (ii)  Dietary  dietary such  intakes  daily  stages  of  The dered either  to  Indian  unlike  the  the  the  Chinese  in  lower who  that  the  Indian's  with  respect  three  content  was  implies  Figure  absorption  diet  the  for  fiber  affect  than  nutrients.  protein  illustrates  races.  their  of  The  diet  iron  since  ate  15  Malay  the  ( P _< 0 . 0 5 ) . 1982).  consumed  more meats  to  Malay  (Fleming,  they  and  and  The  more  the  Malays  who  analysis  of  the  for  intakes  the  dietary  amounts  pregnant for  of  intakes  of  the  population  food  consumed  to  women i n  Malaysia  (Tee,  a moderately  activity  level  of  the  moderate  since  most  helping  their  husband  chores.  community.  In  bicycles.  They  Figure  16  no  The  areas  of  use  not  often  active  the  pregnant  intakes  in  the  the mothers  were  in  or  of  walked  particular  mothers  the  farm  modern  passable  illustrates  whose mean n u t r i e n t was  better  This  studied  suggested 1983).  daily  Table  women a t  was  32  shows  different  pregnancy.  household  There  of  a higher  the  evaluation comparing  were  mothers.  hemopoietic  had  proteins fish.  by  the  of  Indian  diets  shown  more  The  the  distributions  been  vegetable  done  iron,  however,  has  protein  took  mothers'  and  cumulative  to  to  the  by  the  nutrient  business is  vehicles,  the  marketplace  below that  of  their was  population  involved  equipment  percentage  were  study  to  in  not  manual  common i n  buy  at  to  doing  this  walked  rural  or  used  food.  in  suggested  consi-  work,  addition  mothers  mothers  consumed  in  was  each daily  or  racial  group  intakes.  above  the  TABLE  Gestation stage  32.  Suggested  Energy  Protein  (kcal)  (g)  <13 w e e k s 40W + 1 5 0 (1st trimester)  0.74W  >14 w e e k s (2nd, 3rd trimesters)  0.74W + 13.0  W = Body w e i g h t  40W + 3 5 0  (kg).  dietary  intake  Calcium (mg)  for  Iron (mg)  pregnant  women i n  Vit.  Vit.  (pg)  A  Bj^  Malaysia.  Vit.  B  2  (mg/1000  (mg/1000  kcal)  kcal)  Niacin (mg/1000  Vit.  C  (mg)  kcal)  450  9  750  0.4  0.6  6.6  30  1200  18  1200  0.4  0.6  6.6  50  118  <I0 2 0  Figure  40  15.  60 80 100 120 protein intake per day (gm)  140 >I50  The c u m u l a t i v e f r e q u e n c y d i s t r i b u t i o n o f d a i l y protein intake of mothers from the three races attending the a n t e n a t a l c l i n i c s i n the d i s t r i c t of Kuala Selangor, Malaysia.  Malays Chinese Indians  100  i  .0  80  o •o c o  i  % 60  o o 40  :  u CL  ''xt  / •  V.  20  I  Energy (kcal)  Protein  Co (mg)  (g)  Fe  Vlt. A  Vit. B|  Vlt. B2  (mg)  (ug)  (mg)  (mg)  Nutrient  Figure  16.  The  percentage  suggested  daily  of  mothe intake.  in  each  race  Niacin (mg)  Vit. C (mg)  categories  with  nutrient  intake  below  the  Malaysian  120  suggested  level  that  not  were  These were intakes  mothers the  and  were  The  the  is  diet.  of  poieses is  in  the  diets  of  value.  The  quantity races. ascorbic  intake high  these  of  Chinese  acid  iron  these  is  of  particular  majority  the mothers calcium  milk,  a  the  (99.1%)  in  Even  large  the  mothers.  had  nutrition  nutrient  mothers.  of  nutrients  calcium  is  not  development  though  number  the  did  of  Indian  not  meet  (94%)  of  16).  the  This  and  In  nutrition,  iron but  from meats,  thesis  to  the is  is  it  is  forms  more  mainly  discuss  were  indicates  supplementation  also  iron  mothers  of  that  is  not  below iron  necessary  only  iron  available  to  the  taken for  in  the  hemo-  from vegetable  the  the  sources.  availability  of  iron  mothers. nutrient 77% o f  since  more  was  quite  high  in  had  of  respect  mothers higher  they  ate  50% o f is  was  are  the  iron  below of  flesh  important  vegetables  nutrition  the  foods  to  did note  is  suggested  protein, than  riboflavin,  mothers  population.  leafy  to  intakes  more  concern  It  this  green  with  the  than  nutrients.  fish,  drank  two  mothers  this  these  of  the  Nonheme  of  intake  of  (Figure  iron  nutrients  since  the  Although  important  mothers  quality, other  that  iron.  scope  all  the m a j o r i t y  is  that  by  an important  status  for  important  and The  of  that  intake  is  intake.  t h a n nonheme  protein  amounts  iron  Almost  were  calcium.  among  iron,  Another The  for  level  the  it  There  amounts  level.  group  intakes  poor  beyond  iron.  calcium only  iron  Heme  adequate  and  intake  adequate  quantity  in  anemia,  intake  nutrition  the mothers.  standard  the  iron  standard  It  the  with  standard  ensure  taken  below  fetus  a l l  calcium  associated the  by  both the  niacin,  not that  standard in  terms  other  might  be  because  and  beans  by  the  and  adequate  vitamin  This  of  of  two  thiamin  consume the  protein.  A  the  mothers.  121  (d)  The  The Table  (P  nutrient  33  between  shows  to  general,  the  compared  to  and  the  intake  well  today'.  appetite',  or  a month. not  removed  from  however, with  the  from  suspected  excluded  in  the  is  nutrients  daily  analysis The tailed a l l  shown  nutrients  of  the  nutrients  dietary  both in  of  cases  their  except  were  and  lower  t-tests  niacin was of  for  intakes  61  g per  70 g .  the  anemia  compared.  two-tailed  mothers  of  normal  Table  in  in  mothers  Table were  day  In  anemic  removed  34.  from  in  In  a  were  the  set  group  only  consinot  of  women  B3 was  latter  also  group,  a  amounts  Therefore, of  the  removed  section  low.  next  feast  They were  appropriate  were  feeling  consumed  Another  taking  the  to  mothers  therefore  They  34.  the  'not  was  pattern.  earlier  levels  or  were  33.  Table  mentioned  hemoglobin  were  mothers  by  went  chicken  dietary  in  comments  yesterday'  fact  these  analysis  the  about  the mothers  actual  analysis  of  for  statistical  34.  show h i g h l y  between  where  analysis  their  groups  Table  deficiency  an average  were  anything  eat  recalls  where  yet  anemic  not  statistical  and  by  protein  who c o n s u m e d  when i n  statistical  findings  t-test  intake  recalls  also  chicken  possible  reasons,  their  hemoglobinopathies,  situation  these  in  iron  mothers  indicated  dietary  statistical  the  and  mothers.  'did  representative  as  mothers  other  the  were  ate The  on or  There  day  the  status  and nonanemic  differences  mothers  nonanemic  w e r e made  'no  dered  of  nutritional  anemic  nonanemic  nonanemic  the  like  previous  of  The mean p r o t e i n  compared  Notes  intake  of  significant  anemic  <^ 0 . 0 5 ) .  once  relationship  anemic vitamin  significant and  nonanemic  C and  fiber.  difference mothers Although  as  in  indicated  the  the  intakes  energy,  by  two-  of  almost  iron,  122  TABLE  33.  The  Iron  A NA A  (mg)  NA  A  Thiamine  A NA A  (mg)  NA A  (mg)  Vitamin  C  NA A  (mg)  Carbohydrate  Fiber  NA  (mg)  Riboflavin  Niacin  A  (pg)  NA A  (g)  NA A  (g)  NA  ns  = not  significant  *,  ** = s i g n i f i c a n t  A = anemic  (Hb  NA = n o n a n e m i c Numbers  in  < 10 (Hb  at at  0.05 0.05  anemic  Number  NA  (g)  Vitamin  of  A  (kcal)  Protein  intakes  Hemoglobin status  Nutrient  Energy  dietary  and  Mean  0.01,  parenthesis  (+717)  207  2226  (+755)  88  60.7  (+26.4)  207  70.2  (+24.8)  88  13.3  (+7.8)  207  14.8  (+7.5)  88  1094  (+116)  207  1415  (+98)  88  1.03  (+0.50)  207  1.14  (+0.60)  88  0.94  (+0.47)  207  1.13  (+0.64)  88  9.6  (+5.9)  207  11.3  (+6.3)  88  83.2  (+80.7)  207  76.9  (+67.7)  88  362.5  (+128.3)  207  380.3  (+144.7)  88  3.0  (+2.8)  207  3.3  (+2.6)  respectively.  g/dL). are  standard  S.D.)  2079  g/dL). >_ 1 0  (+  88  level. and  nonanemic  deviations.  mothers.  P  values  ns  **  ns  ns  ns  ns  ns  ns  123  TABLE  34.  Nutrient  Nutrient  Energy  (g)  (mg)  Vitamin  A  Thiamine  (yg)  (mg)  Riboflavin  Niacin  (mg)  C  (mg)  Carbohydrate  Fiber  (g)  (g)  ns  = not  *,  ** = s i g n i f i c a n t  A  significant  at at  = 70 a n e m i c m o t h e r s  NA = 189 Numbers  nonanemic in  anemic  (Hb  mothers  parenthesis  are  (+ S . D . )  A  2012  (+681)  NA  2312  (+719)  A  57.6  (+22.6)  NA  73.5  (+22.8)  A  12.45  (+6.3)  NA  15.3  (+7.5)  A  2221  (+1036)  NA  2608  (+1399)  A  0.98  (+0.50)  NA  1.19  (+0.59)  A  0.91  (+0.47)  NA  1.18  (+0.63)  9.0  (+5.4)  NA  11.7  (+6.1)  A  83.4  (+85.7)  NA  77.6  (+66.9)  A  354.4  (+121.6)  NA  394.3  (+140.0)  A  2.9  (+2.8)  NA  3.4  (+2.7)  0.05 0.05  and nonanemic  Mean  A  (mg)  Vitamin  of  Hemoglobin status  (kcal)  Protein  Iron  intakes  level. and  < 10  0.01,  respectively.  g/dL).  ( H b >^ 1 0  g/dL).  standard  deviations.  mothers.  P  values  * ** * * * ** **  ns  *  ns  124  vitamin  A,  nonanemic For or  thiamine, mothers,  example, third  were  As mothers.  have  and  contributed  here  an average C,  the  to  this  the  was  intake.  The  high  the  phytate,  of  oxalate  a  and  undernourished.  ly  poor.  to  meet  of  concern  mothers stage  of  the  The a n e m i c the  was  poor,  pregnancy  is  of  were  iron.  the  only  taking  of  Since way  they  of to  more  vitamin  it  intake,  applies  to  diets  also  In  levels  the  is  of  iron  prophylactic  iron  therapy.  the  to  the anemic  general-  nutrients  the  adequate  good  decreased  two m a i n h e m o p o i e t i c  get  be  contributed  The  could  iron  iron  population  of  would  especially  general,  status  vege-  for  their  probably  subnormal  mothers  could  conditions  study  second  C  enhance  Therefore,  protein  the  the  nonanemic  eating  amounts  1974b).  intakes.  nonanemic  than  were  which  by  day.  anemic  their  consuming  pregnancy.  and  by  their  in  the  per  favorable  content  status  that  1974).  (Bjorn-Rasmussen,  mothers  protein  also  fiber  during  C tends  situation  cereals  nutritional  requirements are  similar and  mothers  summary,  high  had  But,  taken  in  Vitamin  mothers  be  mothers  containing  amounts  suggested  iron  higher  larger  daily  shows  mg o f  anemic  iron.  of  In  was  33  in  the  should  and H a l l b e r g ,  availability were  15.3  consumed  below  iron  difference.  vegetable  iron  s t i l l  the  foods  low and  the  of  that  were  Table  intake  anemic  absorption  protein  high  pregnancy.  other  that  were  2 8 mg o f  (Bjorn-Rasmussen  physiological animal  levels  possibility  fruits  inferred  of  vitamin  The  absorption  carbohydrate  approximately  consuming  for  tables,  the  trimester  only  and  nutrients  anemic  iron  at  a  late  125  3.  Iron  (a)  Availability  It health  was  Supplementation  stated  centres  supplements.  for In  the  of  sulfate  supplements  the  review  routine  this  prescribed ferrous  in  of  iron  that  checks  study,  it  containing  pregnant  throughout  was  supplements  a l l  found  Malaysia  that  (Table  35).  6 0 mg o f  iron  mothers  only  The to  were  51% o f  attending given the  supplements  be  taken  iron  mothers  were  three  the  were  tablets  times  per  day. Table were  35  anemic  shows  compared  difference  in  mothers  <_ 0 . 0 5 ) .  these  (P  mothers  supplements The given the  in  iron  tively  that  in  to  46% o f 34% o f  hemoglobin  were  refusal  the  clinic. between  Table  larger  tablets  (P  A  compared  <^ 0 . 0 0 1 ) .  supplements  because  Only  the  that  mothers  following  set  of  of  were  Compliance  (i)  Measures  with  of  Two c o m p l i a n c e questions  of  49% a n d  for  the  proportion  the  by  not  and  higher  of  was  a  iron  tablets  significant  non-prescribed the  tablets  them and u n a v a i l a b i l i t y  of  the  of  supplements  (73%) w e r e  to  is  prescribed  the  Malays  and C h i n e s e ,  respec-  the  Indian  mothers  given  incidence the  the  prescribing  Indians  41% o f  prescribed  compliance  (b)  compliance  to  There  and p r e s c r i p t i o n s  number  A higher  iron  reasons  race  prescribed  prescribed  supplements  relationship  not  prescribed.  between  the  of  mothers  those  levels  Some o f  36.  the  iron  of  anemia  supplements  were  among were  them. asked  the  questions.  iron  supplements  compliance  indices  were  asked  during  formulated the  based  interview.  on The  the  combination  first  index  was  of based  126  TABLE  2  i  of  Not  prescribed  (%)  iron  supplements.  supplementation  Prescribed  (%)  Total  number  (%)  10  71  (46%)  54  (34%)  125  (40%)  >_ 1 0  82  (54%)  103  (66%)  185  (60%)  153  (49%)  157  (51%)  310  (100%)  among  the  Total  X  Prescriptions  Iron  Hemoglobin l e v e l s on first visit g/dL  <  35.  number  = 4.2;  TABLE  (%)  P =  36.  0.04.  Iron  supplementation  record  three  racial  groups.  Race Iron  tablet  Malay Number  prescription  X 2 2  (%)  Chinese (%)  Indian (%)  Number  Number  Total N u m b e r (%)  None  114  (51%)  29  (59%)  11  (28%)  154  (49%)  Yes  109  (49%)  20  (41%)  29  (73%)  158  (51%)  Total  223  (72%)  49  (16%)  40  (13%)  312  (100%)  = 9.8;  P  =  0.007.  127  on the  frequency  the  tablet  at  The  second  index  day  and  was  supposed A  plete  the  the  to  most was  be of  compiler, were  based  the  Association  There  was  pliance  in  the  have  contributed  mothers plied,  only  largest  which  which  or  tribute  supplement  at  of  the  compliance  was  supposed  intake  most  of  in to  tablets  recent  time  taking be  taken.  within  the  a  tablet  variables  hemoglobin  above the  (55.2%)  iron  of  the  while  levels  categories  of  compliance  number  37  shows  first  levels  mothers level  was  and  mothers  38.1% improved  of  com-  visit.  mothers  and  one  The  could  third  of  the  Among  those  who  while  44.3%  regressed.  the  partial  com-  compilers  48.5% r e g r e s s e d . did  their  iron  effect  last  Approximately  complied.  of  with  the  to  among a l l  hemoglobin total  compliance  from  consistent  hemoglobin  total  com-  deficiency  Table  tablets  their  predicted  between  relationship.  iron  an improved 11.5% of  to  anemia.  not  that  These  from a  studied.  relationship  was  was made r a n g i n g  not  comply,  hemoglobin  of  Twenty-  out  of  status  37).  This levels  of  the  52.4% r e g r e s s e d  (Table  and  and n o n c o m p l i e r .  compliance  52.5% i m p r o v e d  49.5% had  one m o t h e r s  with  of  given  group  the  a week  frequency  population  visits to  who w e r e  in  characteristic  deficiency  change  span between  the  compiler,  definite  iron  time  on  compliance  of  and  time  on compliance  associated  no  taken  taken.  (ii)  supplements  tablets  recent  partial  characteristics  The  iron  information  ranking  compilers  of  of  finding the  any  implies  mothers  who  significant  that  there  complied.  difference  was  an improvement  The  number was  compared  to  those  in  the  hemoglobin  small  and  did  that  did  not  not  con-  comply.  128  TABLE  37.  The e f f e c t hemoglobin  of compliance change.  Types A HGB  Complete  Improve  (%)  of  (52.5)  50  2  (3.3)  2  Regress  27  (44.3)  49  Total  61  (33.3)  101  Same  (%)  A HGB = D i f f e r e n c e  iron  supplements  None  (%)  on  compilers  Partial  32  with  (%)  (49.5)  Total  (%)  8  (38.1)  90  (49.2)  2  (9.5)  6  (3.3)  (48.5)  11  (52.4)  87  (55.2)  21  (11.5)  183  (2)  b e t w e e n Hb o n l a s t  visit  a n d Hb o n f i r s t  visit.  (47.5) (100)  129  As  for  those  observed  but  One were  on  of  period  the  tablets, was  no  (a)  majority  better  compilers  more  complied the  comply.  the  be  the  duration  index  that  u s e d was  assumption  with  was  these  mothers  that  only  the  applicable  mothers  for  complied  compliance  significantly  the mothers  stage,  stool  associated  studied,  frequency color,  relationship  the the  comply. than  the  Chinese A  level  well.  were  of and  between  similar  association  Malays,  than  personnel  with  the  associated  significant  anemic  and h e a l t h  hemoglobin  are  ethnic  visit, the  with  the  com-  origin,  cash  attitude  presence  compliance  towards  of  beliefs.  and age,  education  supplementation.  Comparing  not  in  origin  of  38).  could  supplements,  iron  a  (57%)  as  of  significant of  regression  compliance  with  that  gestation  was  did  The  time  factors  (Table  Chinese  reasons  factors  Ethnic  There  among  of  a  significant.  tablets,  problem with  and knowledge  were  not  characteristics  economy,  There  of  Other  Among  comply,  probable  intake  ( i i i )  iron  was  not  supplements.  that  pliance  it the  the  a week's before  who d i d  percentage Malays  This  the of  Chinese  two  make  them f e e l  finding  The that  by Ross  of  et  of  that  the  that not  (1981)  race.  The  compilers  Indian mothers  Approximately  were  was  and  partial  the  31% o f  were  the  Indian mothers,  reminded  supplements  fact  a]N  were  compilers,  implies  it  compliance  Indians  races,  importance  prescriptions.  and  Chinese.  finding  other  the  or  between  by  and  anemia  is  important stated  the  who  physician  therefore not  a  for  that  problem them  failure  to to  130  TABLE  38.  Association  of  compliance  characteristics  with  ethnic  origin.  Race Type of compilers  Malay N u m b e r (%)  Complete Partial Non Total  X 4 2  (%)  = 17.0;  P  =  Chinese N u m b e r (%)  Indian N u m b e r (%)  Total N u m b e r (%)  56  (30.3)  7  (26.9)  16  (48.5)  79  (32.4)  112  (60.5)  11  (42.3)  16  (48.5)  139  (57.0)  17  (9.2)  8  (30.8)  1  (3.0)  26  (10.7)  185  (75.8)  26  (10.7)  33  (13.5)  244  0.002.  (100)  131  comply w i t h  iron  low prevalence that  of  anemia was  Cash  Cash  economy of  status cash  of  mothers  the  to  black  area.  the  The  population physicians  population  the  amount  of  for  the  family  members  mother. per  with  cash  not  agreement  associated  that  the  is  economy  higher in  problem  the  higher  in  among  was  attributed  there  did  not  to feel  studied.  with the  39  household  lower  economy were  with  Table  cash also  middle  per  that  (P  as  It  household  reflects of  compilers  = 0.03).  compared  However,  that  to  the  with to  29.5%  mothers  the  with  finding  compliance low  for  socioecono-  mothers  Therefore  stated  compared  the  (36.2%)  noncompliers. who  in  month.  member w e r e  (1970)  class  available  shows  economy the  Marston  money  is  was  socioeconomic  patients.  (c)  Problems  Table  40  the  have  problems.  iron  when  tablets  This  the  finding  as  supplements  only  7  complied  were  with  of  unresponsive  Failure  to  take  iron  of  those  compared  to  72  aches,  characteristics the  statement  anemia  towards was  with  of made  the by  mothers  (36.2%)  mothers  Problems  supplements  irritation.  the  stomach  consumed.  compliance agrees  (16.3%)  17.8% o f  constipation,  problem  intestinal  iron  In general,  such  predicts  that  tablets  problems the  with  shows  with  a  economy  food of  anemia  a  (b)  purchase mic  supplements  nausea, iron  to  pains  McFee  in  of  during  did  not  having  and  headaches  therefore,  this  (1973)  problems  that  tablets,  mothers  nausea,  had  mothers  complained  supplements  due  that  population.  with  the  pregnancy.  vomiting  and  gastro-  a  132  TABLE  39.  Association  of  compliance  Cash Type  <$200  M$  (%)  >$200  (%)  Total  (%)  (29.5)  38  (36.2)  79  (32.3)  Partial  88  (63.3)  51  (48.6)  139  (57.0)  Non./  10  (7.2)  16  (15.2)  26  (10.7)  139  (57.0)  105  (43.0)  244  (%)  = 6.7;  P =  0.03.  40.  The  association  ingestion  of  of  iron  compliance  Had p r o b l e m s response  Type of compilers  Complete Partial Non Total  (%)  = 6.5;  P =  0.04.  with  problems  (100)  related  to  supplements.  Problems  2  economy.  41  TABLE  X 2  food/person/month  cash  Complete  Total  2  on  with  of  compilers  X 2  spent  characteristics  with  iron  tablets  Had no p r o b l e m s r e s p o n s e (%)  Total  (%)  7  (16.3)  72  (36.2)  79  (32.6)  31  (72.1)  107  (53.8)  138  (57.0)  5  (11.6)  20  (10.1)  25  (10.3)  43  (17.8)  199  (82.2)  242  (100)  133  (d)  Frequency  The the  number  mother  came the  less iron  30.9%  was  of on  than  than  times  three  reported  women. ments  They by  (e) The  end  attitude she  had  on is  positive  attitude  79 m o t h e r s no  definite  pliers. of  Therefore,  compliance  in  came m o r e  of  their  mothers  did  not  supplements  than  of  three  take  only  times  reflects  those A  with  times,  who  the  were better  came  similar  on a group  indicated  A good  more  finding  of  antenatal  iron  provide  the  studied,  supple-  increase  fetal  size.  was  tablets  observed  attitude mothers.  and  remaining  were  good  iron  source  therefore  mothers  (Table  partial tablets  and is  of  patient-  (71.5%)  A majority,  between  towards  or  and  a majority  would  the  type  information  the  that  the  patient-physician  while  the  mothers  tablets  tablets,  of  the  therapy.  the  or  three  therapy  study  duration  38.3% c o m p l i e d  compilers.  in  the  22% o f  than  less  duration  partial  mothers  opinion  behavior  among w h i c h  were  Among  opinion  that  (60.6%)  tablets.  said  indicates  The m a j o r i t y  to  or  shows  who came  shorter  of  the  centre  41  clinic,  necessary  who c o m p l i e d pattern  Table  the  iron  centre  health  those  iron  the  towards  'heaty'  the  (1969)  32% o f  towards  compliance.  were  a  two months  improves  tablets  that  a l .  towards  health  77.8% t h a t  clinic et  that  relationship  to  mothers. the  of  the  the  the  means  Bonnar  Attitude  information nurse  to  found  the  of  to  Therefore,  these  by  made  times  Out  compilers.  to  supplements.  This  for  was  the  tablets.  compliance  visits  visits  three  complied.  better  of  had said  63 o u t 42);  the of  whereas  noncompredictive  134  TABLE  41.  The a s s o c i a t i o n o f with compliance.  number  Number Type  visits  to  > 3  (%)  < 3  (%)  health  health  center  center  Total  (%)  (38.3)  51  (30.9)  69  (32.6)  Partial  19  (40.4)  100  (60.6)  119  (56.1)  Non  10  (21.3)  14  (8.5)  24  (11.3)  47  (22.2)  165  (77.8)  212  (%)  = 8.6;  P =  (100)  0.01.  42.  The a s s o c i a t i o n o f with compliance.  attitudes  Opinions Type of compilers  Good  (%)  towards  on i r o n Bad  (%)  iron  tablets  tablets Total  (%)  Complete  63  (36.4)  16  (23.2)  79  (32.6)  Partial  97  (56.1)  40  (58.0)  137  (56.6)  Non  13  (7.5)  13  (18.8)  26  (10.7)  173  (71.5)  69  (28.5)  242  Total  2  the  18  TABLE  X 4  to  Complete  Total  2  visits  of  compilers  X 2  of  of  (%)  = 13.8;  P =  0.008.  (100)  135  (f)  Gestation  The m a j o r i t y pregnancy Only  4  stage  the  at  situation  of  in  also  change with  iron  anemia  less  compliance.  is  considered  the  those  their  iron  This to  third  pregnant  be anemic This  a problem and  of  (Table  43).  complied.  may i n d i c a t e  tablets.  compliance  trimester  supplements  28 w e e k s  tend  take  in  the  than  to  affect  44  the of  exchanged  supplements.  that  color.  to  the  stool  among  probable  shows  association  Majority  stool  noticed  ingestion  with  gestation  significant  compared  among  mothers  a  color.  compliance The  of  were  The  that  mothers  and were  advised  is  similar  the  to  the  physician-  characteristics  of  the  patient.  color  their  mothers  they  stage  the  Table  stool  change of  was  = 0.02).  their  who w e r e  and p h y s i c i a n  Stool  the mothers  influences  relationship  There  of  them c o m p l i e d  those  later  where  (g)  (P  a  staff  patient  of  gestation  who w e r e by  (89.1%)  and 34.6% o f  (17.4%) of  stage  who c o m p l i e d  partial  Among  the  compilers  partial  Stool  a  is  stool  color  100% c h a n g e  (83%)  also  smaller  compilers  color  and  claimed  noncompliers  and  change.  compliance  in  noticed  a  percentage  claimed  therefore  that  indicative  compilers.  reason  for  noncompliers iron  the  compilers  color  the  of  those  between  a positive could  supplements.  experiences  with  be  response because  Another their  of  regarding their  reason  peers  prior  could  regarding  stool  be  color  observation because  ingestion  of  these the  136  TABLE  43.  The  association  of  gestation  stage  Gestation Type  < 28  Complete Partial  Total  (%)  Compliance  Types  44.  (%)  > 28  69  (32.7)  13  (56.5)  105  (55.9)  118  (55.9)  6  (26.1)  18  (9.6)  24  (11.4)  23  (10.9)  188  (89.1)  211  stage  were  association  significantly  of  compliance  Stool Change n u m b e r (%)  Complete  24  (100)  Partial  69  (83.1)  Non  21 114  P =  0.02.  (%)  (34.6)  of  Total  Total  65  The  compilers  = 7.4;  (%)  (17.4)  and g e s t a t i o n  TABLE  2  (weeks)  4  Non  2  compliance.  of  compilers  x  stage  with  with  stool  (P  =  0.03).  color.  color  None number  0  associated  (100)  (%)  Total (%)  (0)  24  (17.6)  14  (16.9)  83  (61.0)  (72.4)  8  (27.6)  29  (21.3)  (83.8)  22  (16.2)  136  (100)  (h)  Food  Among  compliers (Table food  belief  the  mothers  compared  45)  There  belief  who  to  compliance  with  summary,  not  mothers anemic.  at  opinion  race,  on  about  last  Compliance  including  these  not  percentage Food  one  and  third  effect  have  them were  any  food  non-  beliefs.  of  those  who d i d  beliefs  could  have  therefore  is  not  have  influenced  indirectly  gestation  of  by  the  pregnancy  were  was  predicts  of  stool  complied  with  observed  on  that  fact  by  were  of  the  already of  frequency the  iron  supplements  a number  and  the  the  majority  they  problems,  color,  the  that  when  predicted  presence  stage,  mothers  probability  justified  status,  the  compliance  The  trimester  economic  of  of  characteristics  tablets,  who d i d  mothers  levels.  enough  the  those  35.2% o f  prescriptions.  only  long  beliefs,  partially.  hemoglobin  taken  food  a higher  No d e f i n i t e  of  came  of  iron  prescriptions.  were  also  complied  behavior  improvement  19.6% o f  was  compliance  In  who h a v e  variables of  presence  visits, of  food  beliefs.  4.  Health  There factors. fore  and  If  possible  providing that  is  cause family  anemia  are  a the to  health  related link null  between  chronic  iron  hypotheses  remove care  factors  iron  services  discussed  The in  mentioned  deficiency to  hemorrhaging,  planning.  deficiency  this  earlier  anemia  antenatal improvement  associations section.  anemia  of  and h e a l t h were  from  mothers,  true,  these  these  health  it  mothers  removal  on s a n i t a t i o n  related  of  is  there-  by parasites  and water  related  factors  supply with  138  TABLE  45.  The  association  iron  of  food  belief  Food Type of compilers  Present n u m b e r (%)  belief  Absent n u m b e r (%)  Total (%)  (13.0)  29  (15.8)  36  (15.1)  Partial  28  (51.9)  119  (64.7)  147  (61.8)  Non  19  (35.2)  36  (19.6)  55  (23.1)  54  (22.7)  184  (77.3)  238  Total  2  with  7  Complete  X 2  and compliance  supplements.  = 5.7;  (%)  P =  0.05.  (100)  139  (a)  Accessibility  Most  mothers  clinic.  A day's  sacrificed  to  within  a  work,  either  in  attend  harvesting,  clinics  was  last  poor.  centre  was  child,  either  at  health  centre  was  or  less  clinic to  mothers  for  check  of  to  The  were  come  limiting  factor later  than  is  of  by  two  these  month.  nurses  the  shown i n  hemoglobin  mothers  the  pregnancy.  gestation  stages  Table  status  of  The  homes  once of  to  of  the  those  of  two  the  times  in  the  pregnancy  their  every  to  three  procedure  in  the  visits  came  trimesters  in  third weeks.  mothers  who  visit  raise  to  checks.  visits  t h e management  tablets  mothers  who w e r e  in  iron  the  the  visit  of  for  clinic  delivery  Those  variable  of  for  the  be  year  at  the  the  appointments.  on f i r s t  to  card  to  the  to  of  two  the  trying  came  first  for  to  of  attendance  purpose  of  from  had  The mean number  antenatal their  chores  months  mothers  home.  of  in  other  seasons,  percent  in  15 k i l o m e t r e s  busy  The m a i n  at  scheduled  stage  rainy  scheduled  the  the  stage  stage  oral  or  every  were  or  registration  routine  once  their  gestation  clinic  between  done  Gestation  relationship the  ups  on  the  about  field  that  who w e r e  of  During  even  Fifty  for  pregnancy  an i m p o r t a n t  rather  four.  for  the  pregnancy.  hospital  was  (b)  this  the  radius  is  request  clinic  Home v i s i t s  at  to  or  trend  of  the  trimester  is  The  centre  clinic.  festive  to  come  failed  the  trimester  health  health  live  example  their  of  on  their of  anemic  hemoglobin  Parenteral ensure to  first  There  the  mothers  was  on the a  to  the  conditions.  levels had  an increment  anemia  46.  iron  visit  in  of  to  iron  mothers'  significant  and g e s t a t i o n  Time  anemic  be  clinic is  mothers  administered status.  first  visit  The to  association  stage  (P  =  0.05).  a  140  TABLE  46.  The a s s o c i a t i o n o f anemia w i t h v i s i t to the health center.  Hemoglobin Gestation stage on f i r s t visit  1st  trimester  (< 16 2nd  3rd  X  trimester weeks)  Total  (%)  2  mothers  on the  on f i r s t  > 10 g / d L m o t h e r s (%)  first  visit Total  (%)  3  (2.6)  10  (5.1)  13  (4.2)  72  (62.6)  141  (72.3)  213  (68.7)  40 (34.8)  44  (22.6)  84  (27.1)  195  (62.9)  310  weeks)  (> 28  2  of  stage  weeks)  trimester  (16-27  < 10 g / d L m o t h e r s (%)  levels  gestation  = 6.1; P = 0.05.  115  (37.1)  (100)  141  Majority to  the  (69%)  clinics  approximately they  trimester mothers  the  in  the  them were  time  short  advice,  implemented  (c)  In was  just  in  There  their  came  they  heaped  or  for  pregnant. first  was of  preganancy  a  late  stage  management  of  like  oral  hemoglobin  in  time  general, checks  percent  their  Conversely,  many m o t h e r s  short  four  and almost  that  a  In  27% c a m e  when  of  the  pregnancy.  63% w e r e  anemic.  while  antenatal  only  trimester  early  trimester  is  at  was  of  came  to  left  of  the  23% o r  were  pregnancy.  period  half  only  stage  second  three  anemic.  the  clinic  Majority  before  for  of  delivery.  the  a n e m i a was  difficult.  Other  or  parenteral  supplementation  than  had  levels.  living  was  no  conditions  proper  while  garbage  others  it.  of  mothers  disposal  buried  Water  the  it,  supply  system.  but  and  in  there  sewage  the  research  The  majority  was  s t i l l  disposal  area  some  were  who  s t i l l  problem.  (i)  Water  The  problem  district  of  supply  of  Tanjung  to  sanitation  the  littered  were  here  her  their  There  third  their  were  28 weeks  trimester  their  in  there  raise  garbage  came  second  approximately  category  Environmental  poor.  burned  mothers,  intervention  general,  than  first  their  time,  to  more  at  implication  and  their  pregnant.  who  when  in  16 w e e k s  latter  anemic  this  dietary be  the  were  mothers  35% w e r e  13 m o t h e r s  first  Within  in  were  the  anemic  while  Therefore, the  than  mothers  they  96% o f  who came  Among  of  the  when  were more  mothers  out  of  water  supply  Karang,  the  was  quite  serious  area  where  the  especially  majority  of  the  in  the  sub-  mothers  a  142  comprising had  the  a water  tanks, used  study  shortage  barrels  rain  bour's  and  water,  wells  a water  large  They  had  it  that  way.  germs  or  infection.  The m a j o r i t y  water  to  washing  pipes  during  Sewage  disposal  About  50% o f  the  housing.  unsuitable  for  the  were  houses  mately  80% o f  the  pour-flush  had  'pit'  canals  or  the  houses  constantly  the  mothers  latrines  (50%)  latrines,  where  rivers  defecate.  age  to  between  the  of  The wet  environment  1-12 and  of  flooded had  they  years  and  used  the  proper since  area in  or  50% o f  the  disposal  neigh-  reason  was  for  on  paddy  preferred  far  fields the  The  their  in  has  dry  which  are  rainy  season  ApproxiThese  were  remaining  drains,  favored  from  Karang  houses.  canal,  of  drinking.  lowlying.  children  to  trucks.  During is  had  Department  Tanjong  the  irrigation  others  who  and  Service  (30%).  used  and  in  mothers  The  water  their  latrines  holes  sewage  the  water  The  road  which were  of  mothers  had no knowledge  toilets. the  store  water  carried  in  latrines  the  water.  Public  tanks  located  About  those  piped  subdistrict  flush  dug  Among  mothers  the  purposes. the  roadside  large  proper  improper  the  to  along  unboiled  used  season  were  construction  of  42% o f  had  domestic  pipes  the  fact,  mothers  drinking  (91.5%)  the  In  cooking.  taste  in  in  a l l  stand  that  dry  Some h o u s e s  the  for  along  community  (ii)  for  the  mothers  these  their  inferred  the  the  of  and  boil  acquired  stand  Sometimes,  supplied  area  the  Most  canals,  not  This  of  interviewed.  containers  10% d i d  drink  homes.  problem.  bathing,  problem,  included  were  irrigation  for  preference.  These  sample  20%  irrigation the  drains worm  area or  rivers.  infestation.  143  ( i i i )  Worm  It  found  was  National between  infestation  in  University the  moderate  age  to  of  mild  of  60% d u e  deworming  small  free  among and  96  cysts  while  the  47  = 0.02).  (P  Malay  mothers  agrarian reduce  There  lifestyle.  of  the  and  of  blood.  nutrient  worms In  status  with  of  children  in  children  lumbricoides  the  that  area  students  worms.  among  the  to  in  and of  was  the  this  area  were  Trichuris Ascaris.  lowered  where  from in  These  The  from  90  'combantrin'  percent  of  the  the  other  food  especially  the  two  to  tablets  intake  the  prevalence  presence  Ascaris  and  difference  of  the and  among  might  mothers nutrient  reduction  cause of  ova  hookworm. the  three  worm i n f e s t a t i o n  This  of  lumbricoides  b e t w e e n worm i n f e s t a t i o n  races.  among  Its  for  worm i n f e s t a t i o n  prevalence  mother.  were  trichuria  hookworm c o u l d  ascariasis,  significant  examined  cases  association  a higher  lowering  of  were  had T r i c h u r i s of  showed no  worm i n f e s t a t i o n .  stools  prevalence  was  t-test  Worm i n f e s t a t i o n  thus  presence  affect  mothers  compared  appetite,  loss  Fifty  significant  race  majority  infestation  whose  was  a  medical  had heavy  mothers  the  There  the  infested  held  shows  races.  the  Ascaris  studied,  mothers  45.5%.  by  children.  and nonanemic  remaining  Table  campaigns  a l l  anemic  was  of  percentage  mothers  anemic  the  to  that  were  worm i n f e s t a t i o n  Among t h e between  years  infestation  prevalence  given  conducted  Malaysia  1-12  A  were  study  of  trichuria.  to  a  and  be due  in  the  to  their  children  could  absorption.  chronic  food  and  The  hemorrhaging  absorbed  will  also  144  TABLE  47.  Worm i n f e s t a t i o n among groups as i n d i c a t e d by i n the s t o o l .  Number  Race  Malay Total  Total  = 14  Total  (%)  2 2  39  (60.0)  20  +ve  with  stool  ova  (%)  and  cysts Total  (%)  (40.0)  65  (64.4)  (90.9)  (9.1)  22  (21.8)  11  (78.6)  (21.4)  14  (13.9)  70  (69.3)  (30.7)  101  26  = 22  Indian  X  (%)  mothers  he t h r e e racial ova and c y s t s  = 65  Chinese Total  -ve  of  101 m o t h e r s i n t the presence of  = 8.0;  P =  31  (100)  0.02.  1 out o f 6 (16.7%) o f the v a l i d c e l l s have e x p e c t e d than 5.0. Minimum e x p e c t e d c e l l f r e q u e n c y = 4 . 3 .  cell  frequency  less  145  (iv)  Malaria  None  of  the  mothers  P l a s m o d i u m was  detected  of  claimed  the  mothers  significantly major  health In  in the  the  in  there  were  area.  500E'  larvae  control.  was  had  the  because  of  good  insecticides  (d)  < l x l 0  -  was 4  )  a  in  mothers  been  between The the  imported  malaria  implies  that  positive  nine  before,  it  percent  was  malaria  in  Plasmodium  control  in  the  area.  drains  and  irrigation  of  parasite  (Ong,  reported.  was  not not  a  in  the  measures  to  This  falciparum was  Spraying  infestation  1973).  Deworming  surveilance  of  were  the  measures.  cases  cases  infestation  had  were one  to  most  Table  (Table  mothers  pregnant  three  relationship  48 w h e r e  31 y e a r s  duration  Malays  significant  since  illustrated  children  done  established  good  This  Although  no  However,  population  due  to  of  canals  for  and  anemia  in  the  problem  studied  campaigns  and  control  these  was  spraying  of minor of  parasites.  Multiparity  There (P  were  four  relationship  control  smears.  since  area.  and v e c t o r  parasite  by m a l a r i a  contacted  No i n d i g e n o u s  been w e l l  worm a n d m a l a r i a l  had  blood  anemia.  only  frequently  summary,  Malaysia  this  infected  thick  they  with  surveilance  'Abate  were  their  that  problem  research  In  in  associated  1980,  constant  studied  or  married  at  once  ages  to  older.  at  between age 20 y e a r s  between  three  16-25  times.  Majority  of  and  of  age.  years  Those mothers  gravida This  about  having (67%)  is  70% o f  more  than  studied  the four  had  pregnancies.  from 49).  the The  last  to  the  analysis  of  present  pregnancy  variance  and  the  was  3.3  Duncan's  years  for  Multiple  146  TABLE  48.  The  association  of  age w i t h  Number Age  2  pregnancies.  pregnancies  > 4 number  T o t a l (%) number  (%)  16-25  144  (68.9)  16  (15.4)  160  (51.1)  26-30  48  (23.0)  34  (32.7)  82  (26.2)  31+  17  (8.1)  54  (51.9)  71  (22.7)  209  (66.8)  104  (33.2)  313  Total  2  of  (yrs) (1-3) n u m b e r (%)  X  of  number  (%)  = 100.1;  TABLE  P  49.  <  l x l 0  -  4  (100)  .  Average d u r a t i o n between pregnancies and d u r a t i o n the l a s t to present pregnancy i n each r a c e .  from  Race Categories (years)  Malay number = 161 mean (+ SD)  Chinese Number = 34 mean (+ SD)  3.3 a (+2.4)  DURP  2.7  ADURP  in  ADURP  duration  = Average  Numbers  designated  Numbers  in  years  a  by  parentheses  from in  the are  the  years  same  Total Number = 223 mean (+ SD)  (+2.1)  2.1 b (+1.4)  3.0 (+2.3)  2.0 b (+1.0)  2.0 b (+1.2)  (+1.4)  2.8  (+1.5)  DURP = D u r a t i o n  Indian Number = 28 mean (+ SD)  last  to  between  letter  standard  are  b  present  2.5  pregnancy.  pregnancies. not  significant  deviations.  at  P =  0.05.  147  Range the  Test  showed  Chinese  and  ( P _< 0 . 0 5 ) . between of  2.7  ence  here  is  and  The  that  the  cies  (P  at  close  In  summary,  previous  and  followed  by  duration  between  (2.1  the  the  factor  the  mothers  any  had  and  (2.5  average  (2.0  their  time  years  those  of  duration  longer  years).  families  duration  The  while  anemia  difference  married was  at  infer-  the  years)  Indians  for  the  Chinese  at  closer  cause  of  deficiency  and  t-tests  showed  duration  between  pregnan-  that  to  the  present  successive  age  The  for  significantly  spacing  anemic  The  previous  1-3.  was  and a l s o  tested  pregnan-  1973).  highest and  further  between  50).  an average  gravida was  from  (Ong,  Child  iron  a n e m i a was  conclusion  significantly year)  with  interval  supports  (70%)  (2.8  parity  shorter  caused  pregnancies  had  planned  significant  pregnancies  2.0  Indians  than  respectively  significantly  significantly  mothers  Chinese  the  (Table  This  mothers  for  had  and  years,  two v a r i a b l e s  shorter  most  pregnancy  in  these  to  Chinese  gravida  for  and  mothers  longer  not.  was  mothers  years).  the  there  present  compared  anemic  of  intervals  of  present  did  <^ 0 . 0 0 5 ) .  Majority  that  true  mothers  = 0.009) (P  was  Malay  anemic  pregnancy  relationship  that  mothers  significantly  and 2.1  The M a l a y  the  was  2.8  to  Indians  duration  which were  compared  whether  nonanemic  years,  same  association  prove  cies  The  years  this  Indians  pregnancies.  Chinese  to  that  the  Malays  (3.3  the  Indians.  It  shorter  duration  shorter  intervals  anemia  between  for  is  among  years.  years).  longer  intervals  20  duration  (2.1  and  of  these  average  Malays was  between  therefore  years)  The  between  a  the  the  2.7  shown last  and  pregnancies significant  mothers.  148  TABLE  50.  Gravida  and  Variables  parity  Hb  status  levels  of  Number  (g/dL)  the  anemic  of  and nonanemic  Mean  mothers  (+ SD)  mothers.  P  levels  t-test, 2-tail  Gravida  NA Children  (years)  (years)  =  Anemic  mothers  NA =  Nonanemic  ns  Not  =  (Hb  mothers  significant  at  in  ADURP = A v e r a g e  duration  in  years  parentheses  < 10  3.4  (+2.6)  81  2.5  (+2.4)  197  2.1  (+(2.4)  61  2.5  (+1.9)  136  3.3  (+2.4)  61  2.1  (+1.0)  136  2.6  (+1.5)  g/dL).  ( H b >^ 1 0  DURP = D u r a t i o n  Numbers  197  A NA  A  (+2.6)  A NA  ADURP  3.9  A NA  DURP  81  A  P  <  from in  are  g/dL).  0.05. last  years  to  present  between  standard  pregnancy.  pregnancies.  deviations.  ns  ns  0.009  0.005  149  5.  The  priority  deficiency  Thirteen  and  of  significant  causal  factors  of  iron  anemia  independent  socioeconomic stage  ranking  status,  variables  race,  compliance  with  regression  analysis.  The  hypotheses  and p r e v i o u s  predicting  anemia.  health  iron  as  factors,  therapy  selection  of  these  in  Table  51  nutritional  were  of  statistical  Some  shown  selected  these  variables  aspects,  for  variables  analysis  representing  the  was  gestation  logistic  based  as  significant  were  expected  on  the  factors  to  be  inter-  correlated. The  stepwise  variables tic  in  a  is  success (0,  1)  dent  is  = Exp  (s/n)  dependent of  the  coded  (U)/(l  independent  as  n is  the  selects  the  variable,  1 or  + Exp  0.  (U))  while  these  s  is  sample  others  for  a  determined  The p r e d i c t e d  (Laszlo,  predictor  coefficients  anemia  where  total  variables  categorised  program generated  example,  categories. considered At  as  each  design  ment  estimates  dependent  variable,  were  and  analysis  the  b y Hb  proportion  sum o f  the  size  and U  is  a  1981).  Some  of  the  were  logis-  continuous  as  < 10  of  binary  linear indepen-  shown  in  51. The  tions  The  variable  variables  Table  For  model.  regression  manner  a binary  function  of  stepwise  regression  g/dL  logistic  were  design  variables  two  design  variables  were  The  design  variables  for  a  in  variables  Chi-square  the  generated each  categorical  for  race  categorical  which  variables. had  variables  three  were  set.  step  based  for  on  the  stepping  was  added  the  asymtotic  tested  the  or  process, removed  a  from  covariance  hypothesis  that  continuous the  model.  estimate  variable The  (ACE);  significantly  or  step the  improved  one  set  selec-  improvethe  150  TABLE  51.  The outcome o f l o g i s t i c r e g r e s s i o n a n a l y s i s o f causal f a c t o r s o f a n e m i a among t h e p r e g n a n t m o t h e r s i n t h e d i s t r i c t of Kuala Selangor, M a l a y s i a .  P-values  Variables selected  Occupation Education  of  spouse  level  0.146  6 categories  0.841  2 categories  0.431  3 categories  0.192  3 categories  stage  Race Compliance  Index  1  0.667  3 categories  Compliance  Index  2  0.216  3 categories  0.519  2 categories  visit  0.481  2 categories  Average d u r a t i o n between pregnancies (ADURP)  0.051  continuous (mean = 2.5 y r s )  belief  Gestation first  stage  0.013  (DURP) on  Dietary  protein  Dietary  iron  food  0.790 0.084  2  0.63  -0.1652  0.72  yrs)  categories  continuous (mean = 6 5 . 6  0.083  -0.4605  continuous (mean = 3 . 0  spent  V  on  Duration from l a s t to present pregnancies  Money  Coefficient  on  interview  Food  &  of  mothers Gestation  Categorical/ continuous  g)  continuous (mean = 1 4 . 2 mg)  151  predictive that  ability  step.  A  Among  the  of  small  t h e model when t h e  P-value  indicates  a  variable  was  significant  removed  or  improvement  entered at  at  the  step.  variables iron. has with  the  entered  be  the  of  newly  next  step  The v a r i a b l e  and  has  since  a  its The  log  presence  did  square data  included from  statistics  which  (Chi-square  expected At tion  tests  frequencies each  with  step,  the  association  step.  The  significant study  associated  level  was  to  with  that  improve  was  model.  the  not  Its  entered  model  with  ADURP  added  at  with  protein  the  model  anemia.  the  change  whether  the  model  at  than  that  a  of  protein  for  goodness  of step  few c e l l s  fit  in  the  Chi-  fits  the  have  5.0).  variable. t h e n be for  higher  investigate  new  prediction  three  set  the  into  the  level  it  correlated  and  than  1 since  prediction  ADURP  step  when more  and  presence  previous  unreliable  protein  dietary  likelihood,  independent  anemia.  51)  the  log  would  was  improve  highly  four  correlated  and v a r i a b l e is  under  the  less  significance  the  step  step  are  the  not  indicated in  dietary at  highly  were  each  indicated  dependent  ficant  the  the  DURP,  calculated  will  which  (Table  there  the model  were  constant  further  at  in  entered  iron,  P-value  not  it  51,  ADURP,  P-values  the  Table  DURP w a s  since  be  dietary  lower  likelihood  to  over  slightly  output  model  calculated  improvement  entered  variables.  variable  an  namely  New P - v a l u e s  twelve  provided 1.  DURP w a s  the  shown i n  P-values  P-value.  into  The  variables  small  instead  remaining  model.  would  had  smallest  and not the  which  ADURP  the  thirteen  a l l  variables  were  The v a r i a b l e entered entry  into was  the  possible  with  the  the model  set  than normal  tested  (P  P  <^ 0 . 1 5  <^ 0 . 0 5 )  factors  for  their  most in to  highly  the  might  signi-  following  enter.  because  that  associa-  the be  This aim  of  152  No o t h e r less  than  have  P-values  variables  0.15  to  stopped.  The  exponent  U  Table  shows  coefficient  The iron  the  that  calculation  0.1  of  the  to  be  logistic  2  of  variables  relative  above-mentioned  variables  calculated  the  the  ADURP  removed  model  is  dietary  the  as  the  odds.  protein  did  therefore  the  variables  Negative  protective  for  model,  P-values not the  follows:  significant  relative  odds  from  dietary  had  protein  two  had  and  four  effects  variables  with  coefficient  against  ADURP  their  and  anemia. dietary  are:  „ , Relative  ., odds  =  Odds o f a n e m i c m o t h e r s Odds o f nonanemic m o t h e r s  F o r m o t h e r s who s p a c e t h e i r c h i l d r e n ( x + 1 ) y e a r s a p a r t , (the r i s k of anemia/1 - the r i s k of anemia) F o r m o t h e r s who s p a c e t h e i r c h i l d r e n x y e a r s a p a r t , (the r i s k of anemia/1 - the r i s k of anemia  -  The  the  mean v a l u e s  and  indicate  the  than  + b^ A D U R P + b  the  (3)  and  than  U in  = constant  51  values  enter  greater  stepping  other  relative  *  =  odds  e  <  x l  for  mothers  who  increase  their  ADURP  by  1  year:  " > x  -0.46052(1)  e  v  -0.46052  This one  =  e  =  0.63  means year,  that had  the  0.63  mothers times  the  who i n c r e a s e d risk  of  being  their  ADURP  anemic.  or  child  spacing  by  153  The protein $  A  by  =  20  0.7189  -  0.7  In the  a  increase  of  relative  odds  summary,  population Figure  cating daily  a  for  mothers  who i n c r e a s e d  their  daily  dietary  grams:  =  in  odds  -0.0165(20)  e  suggested  result  in  relative  17.  the  dietary  of  These  were  two  important  ADURP  and  variables  effect.  protein  protein  intake  in  approximately  two most  studied  protective  20 g o f  The were  and  of  these  mothers  would  0.7. contributing  dietary  relative  calculated 0.63  diet  variables  daily  have  the  odds  relative 0.72,  protein less odds  to  anemia  intake than  of  1.0  ADURP  respectively.  as  in  shown indi-  and  (2)  NUTRITION FACTOR Food intake-jProtein, Iron ^ Absorption of iron (3) (1)  SOCIOECONOMIC FACTOR Age, Race, Religion, Education, Occupation, Cash economy, Property, Cultural practices  -  SUPPLEMENTS Compliance  ANEMIA Iron Folate Hemodilution Hemoglobinapathies Standards  Effects  HEALTH FACTOR A c c e s s i b i l i t y to C l i n i c s Pregnancy Stage Environmental sanitation Parasite - malaria and hookworm j P a r i t y ] ^ ^ ^ ^ —  Note:  The scope of this study i s ( 1 ) , ( 2 ) , ( 3 ) . F i g u r e 17.  The two major c a u s a l f a c t o r s of anemia (shown by darker arrows) as p r e d i c t e d by t h e outcome of the l o g i s t i c r e g r e s s i o n a n a l y s i s .  155  CHAPTER 5 .  RECOMMENDATIONS  TO OVERCOME T H E P R O B L E M OF  IRON DEFICIENCY  Multiparity and  low  anemia the  dietary among  Indians  and  shorter  they  had  most  vulnerable  iron  the  good n u t r i t i o n a l  deficiency  advice  mothers  their  iron  gration  of  family  The  use  a of  suggestions health A group. this  this  of  long  to  The  visiting  small  group  Indian is  was  The  less  in  therefore  causes  greater  Chinese  anemic  mothers  in  pregnancies  significant  Chinese. were  It  between  condition  considered  among  mothers,  probably  general  very  of  because  were  the  important  overcoming  the  clinic  family  that  problem  of  the will  well  be  further  supplements activities in  planning the  as  a  and  the and  short  work  integration  as  on anemic to  card  family  planning  urging  the  The  suggested mothers  space  health of  by  term measure.  health  mothers child  and  reinforced  child  their  for  baby  their was  by  in  Tunisia  children.  one  planning  inte-  of and  the child  1980). would  who d e s i r e group  ups,  could  implement  term a c t i v i t y  Mothers  be  (1981)  a common f a m i l y done  the  anemia.  reinforcement  (Schampheleire,  group.  who a r e  planning  and W a l l a s t  form  to  The  check  these  take  be  antenatal  to  to  would  two most  The anemic  status.  towards  duration  anemia.  mothers  Schampheleire  the  pregnancies  variabilities  existing  given  average  were  compared  between  group  short  studied.  Malays  duration  by  and i r o n  mothers  demographic  The  measured  protein  the  with  these  as  ANEMIA  healthy  should  clinics be  involve  babies  include and  based  the  open  will  the to  formation be  pregnant others  on examples  from  as  of  a women's  interested and  lactating  well.  other  to  The  club  initiate mothers  activities  developing  or  of  countries,  156  highlighting The  program  manageable flexible  on  their  should by  a  be  few  and  geared  (Karunayake,  1983).  involved their  the  family  club  to  aimed  at  protein  if  and  a  iron  1982;  The  opportunity  of  India, used the  1982  in iron  was  compound  mothers.  The  The  and  group  18).  longer.  It  their  should It  mothers to  be  ensure  failures. also  has  nutritional  food  Rohde  the  be  to  be  improvement interested  the  and  success  should et  as be  with  of  iron  salt  The m o t h e r s  could  be  ferrous  fortified  government's  salt  program. as  involvement  be  for  success  Infant  possible  feeding  with  improvement  these  the  his  importance  to  as  iron  was  of  also  dietary  mothers  intake  compound.  as  which  in Is  since  the cheap  distributed  of  the  well  mothers  The w o r k i n g  a vehicle  involved  sulfate could  The  and  1980).  dietary  using  be  reported  long  stressed  in  namely  as  well.  a l . ,  the  items  (1975)  feeding  child  nutrition  them w o u l d  The n u t r i t i o n a l  diet  Brown  incorporating One o f  infant  improving  successful  cooking.  conditions.  (Figure  supplements  fortifying  the  on  mothers.  these  objectives  mothers'  and Ogunda,  by  few  together.  (Fashkin  possible  that  of  regarding  practised the  planning  important  on b r e a s t f e e d i n g  improving  reliable.  and e x p e r i e n c e d  family  babies  mothers  stressed  self  precautions  1976).  have  their  taking  and  development  (Park,  nurse  abstinence,  is  activities  Indonesian  methods  towards It  and  small  interested  could  planning  mothers  kept  early  activities The  with  in  successes  to  group  recruit  activity  new a c c e p t o r s  involves for  the  family  use  is  commonly  process  of  adding  and  stable  houses  is  important  to  of  incentive  payments  planning.  This  in  it  of  disseminate  in  humid  these the  information. Another  is  activity  had  to  those  been  who  157  successful authority will  in and  spend  births, cannot  more be  or  a  from  important  are  be  club  family  that  during  the  health  the  health group  is  will  fund  staff self  include  in  activities  as  will  se  be  run  the  the  government  new h o s p i t a l s ,  more  if  the  population  includes  the  integration  Family  group  planning  meetings  packages could  (Heiby,  fund  to  these  also  be  act  as  liaison  a  They  of  packages  can  1982).  baby  shows,  (Karunayake, 18. and  in  terms  raising.  activities  continue  or  group  supportive  Figure  long  by  mothers  done.  could  between  seek  for  well.  involve  raising  donations  illustrated  personnel  be a p p r o v e d  facilities  per  the  to  the  methods.  club  the  the  there  activity  planning  has  In  and o t h e r  representing  activities  solved.  housing  issue  done.  persons  activity  successful,  be  of  and  of  to  distribution  the  collection  has  This  based  management, these  1976).  considering  The  and modern  community  Since  club  money,  b e made a v a i l a b l e  advice  of  benefit  controlled.  mothers  the  (Park,  employment,  The k e y the  cost  less  traditional shall  Korea  to  1983). It the  is  financial  The m o t h e r s  run  sales  of  will  and m a i n t a i n of  A l l  hoped  problem  produce, these that of  the  an  decide  on  club.  Some  foods,  crafts  activities  the  iron  situation,  of  program w i l l deficiency  and  the be  anemia  FORMULATION OF WOMEN'S CLUB - Pregnant and lactating mothers - Young women (mothers-to-be) - Others  ACTIVITY 1  Weighing of Children Child feeding methods 1. Breastfeeding 2. Other nutritious foods available in the community Mothers dietary intake 1. Balanced diet 2. Preparation of nutritious and low cost foods 3. Importance of iron and supplements In the diet  •  ACTIVITY 2  ACTIVITY 3  Spacing of Children  Fund Raising A c t i v i t i e s  Objective: for present child to be nursed and mothered longer  Incentive payment  Key person Is trained to deliver family planning methods and nutrition •  1. 2. 3.  Baby show Sales of produce, crafts Donation  Government involvement (mass media)  * 1  Family Planning Method  Community Feeding Program for mother and child  Traditional and modern methods of family planning  F i g u r e 3,8 .  O u t l i n e of program on f a m i l y p l a n n i n g and n u t r i t i o n a l c h i l d weighing a c t i v i t y .  improvement based on  159  CHAPTER  A  study  to  among p r e g n a n t district used.  The  stool The  of  mothers  Kuala first  samples  with  iron  taken.  being The In  of  equal  most  thirties. at  of  pregnancy  when  overall  The M a l a y  mean p a r i t y of  of  1.7.  deficiency assess  were  of  Malay  since  study  means  for  their  of  the  the  Chinese  2.3  and  2.0  the  than  heavier  32 w e e k s . mothers  were  blood  infestations.  smaller  other  with  popula-  this  group  27  two  groups.  some  the  other  This  difference their  and  was  than  at  records  rural  of  mothers  compli-  recalls  medical  typical  the  and  parity,  number  the  in  their  two was  third  years.  racial not  due  trimester  done. and  parity  were  mothers  tended  to  compared  difference  A  a  in  were  dietary  the  with  mid-twenties,  were  gravida  and  younger  of  status,  greater of  instruments  from  anemia  conducted  parasite  Indians.  The mean age  period  was  data  the  was  supply,  (72.5%);  and  hence  mothers  80% o f  the  This  Chinese  in  and  and water  deficiency  analyses  socioeconomic  significantly were  anemia  Malays  Malays,  iron  population  Additional  Study.  a mean g e s t a t i o n stage  parity  the  were  The  gestation  The  of  mothers  to  ly.  number  in  Indian mothers  groups  mothers  composed m a i n l y  general,  iron  of  and h e m a t o l o g i c a l  tabulations.  the  represented  early  biochemical  causes  Two p a r a m e t r i c  sanitation  also  is  Malaysia.  supplements,  was  and rural  to  frequency  tion  a  a interviews  food  approximately  CONCLUSIONS  presence  representing  confirm  and  Majority  the  Selangor, was  to  s e c o n d was  ance  determine  6.  to  could  the be  3.5  and  2.2,  have more  Indian mothers  contributed  by  respective-  children with  age  a  with  mean  variations.  160  The mothers values  hematological were  less  hemoglobin 65.3% was  anemic than  also  present  were  suspected  level, money  less  together of  had more  of  of  status  low  between  a definite  on f o o d ,  compared  lowest  spent  less  Among iron  was the  by  55.1% of by  lower  when  mothers,  anemia  4.2% o f  the  ferritin  (28.6%)  anemic  deficiency  About  evidenced  for  on  to  the  mothers  property  than  on  The the  the  was  mothers  biochemical  and  measured  education  food  and were  and  two and  the  the  diets  but  there  occupational income  to  mothers  to  mothers,  farmers.  Indian mothers able  amount  of  however,  was  no  anemia.  compared  not  the  homogeneous  races,  Indian  Malay  a  by  or  The M a l a y  had h i g h e r  (19.6%)  The  economy  from  between  Chinese  the  cash  status.  other  Malay  was  came  background  though  food.  and  studied  the  Chinese  Even  money  money  of  these  relationship  anemia.  (41.9%). less  of  educational  money  spent  as  socioeconomic  schooling  and  they  folate  anemia  used.  deficiency.  husbands  Indians  was  with  their  and  iron-deficient  Therefore,  The m o t h e r s  mainly  was  a n e m i a was  10 g / d L  ownership  food.  years  There  68% w e r e of  that  indices.  on  relationship  indicate  prevalence  hemoglobinopathy  occupation,  population  The  and  findings  deficient.  socioeconomic  spent  < 11 g / d L )  than  folate  hematological The  (Hb  biochemical  16 n g / m L .  level also  and  the  were were their  the  three  of  and  spent  The  prevalence  Malays better  less  meet  levels  more  (28.0%) educated  educated,  nutritional  requirements. There  was  some v a r i a t i o n s  The M a l a y  mothers  mainly  rice,  but  of  a minimal  ate  a  substantial  plantains  amount  of  in  and  meats.  amount  fruits. Fish  They was  of of  carbohydrate  also  eaten  racial  ate  daily,  a  lot but  groups.  consisting of in  vegetables smaller  of  161  quantities.  The Chinese, usually had more frequent meals with a more  varied d i e t .  Meats, namely pork and chicken, together with f i s h were eaten  at almost every meal.  Their meals were comprised of r i c e with side dishes  of meats, f i s h and vegetables.  Soyabean products were also favorite items.  Their vegetables were usually s t i r - f r i e d where most heat l a b i l e vitamins were retained. two races.  The Indians ate less meat and f i s h compared to the other  They consumed more legumes and l e n t i l s .  These pulses and  vegetables were usually prepared i n curry dishes where the foods were allowed to simmer f o r long periods for f l a v o r . destroys the heat l a b i l e vitamins.  This cooking method usually  They were the only group that consumed  dairy products i n the form of fresh milk. The general n u t r i t i o n a l status of the study population was poor.  The  anemic mothers were taking subnormal levels of nutrients compared to the suggested d a i l y dietary intakes for pregnant mothers.  The two main  hemopoietic nutrients of major concern were protein and i r o n .  Since the  iron status of the anemic mothers was low, the only way of getting adequate iron at a late stage of pregnancy was by taking prophylactic iron therapy. Only about one t h i r d of the mothers complied with iron  supplements.  No d e f i n i t e effect of compliance was observed towards the improvement of hemoglobin l e v e l s . long enough.  It was possible that the supplements were not taken  This was shown by the fact that these mothers came to the  c l i n i c s for the f i r s t time i n their t h i r d or second trimesters of pregnancy when they were already anemic.  Compliance c h a r a c t e r i s t i c s with iron  therapy were predicted by a number of variables including race, economic status, presence of problems, frequency of v i s i t s , attitude towards iron tablets, gestation stage, stool color and presence of food b e l i e f .  162  There although  was  this  problem of was m i n o r  no  association  since  good c o n t r o l  deworming  to  the  of  pregnancies. highest  for  Indians  (2.1  the  the  Chinese  the  years).  of  tion of  mother  were  increase  be her  Among It  in  0.63 to  could,  which were  infestation  measures  were  the  (70%)  average  in  in  and  and  in  the  place.  children  were the  last  duration (2.7  The anemic and  between to  followed  mothers  pregnancies  of  causal  fourteen  year  of  elsewhere  parasite  years),  Malay  anemia  Malaysia.  population  These  The  studied  interventions  spraying  their the  by  of  the  years)  first  insecticides  (2.8  pregnancies to  2.0  between  the  was  years)  was  significantly  interval  third  pregnancies  Chinese  compared  had  and  present  between  mothers  shorter  compliance,  found.  They w e r e ,  average for  anemic protein null  therefore,  and  the  duration the  was  hypotheses  significantly  in  order  dietary between  mother  by  ranked  by  20  g per  and  signifi-  years  for  shorter previous  and  different  that  iron  intake.  0.72  status,  Only  priority,  regression  two  the  significant  average  dura-  A suggested  resulted  The  nutri-  in  relative  times  if  the  Chapter  1,  three  a  increase relative  odds  mother  for  the  woudl  day.  mentioned  concluded  of  anemic.  be  logistic  factors.  pregnancies  being to  the  socioeconomic  and h e a l t h  calculated  intake  be  was  representing  and  times  the  factors  variables  between pregnancies  one  risk  The  the  supplements  variables  infestation  pregnancy.  A hierachy analysis  parasite  established  between  (3.3  Indians.  between  present  tion,  Malays  and  been  among  mothers  duration  for  between  larvae.  the  The  longer  duration  campaigns  mosquito  Majority  cantly  had  worm and m a l a r i a l  include k i l l  relationship  in  there  between  are  the  two m a j o r  anemic  and  were  rejected.  characteristics nonanemic  163  mothers. null  These  hypotheses  infestation,  Suggestions  Once they  characteristics which were  sanitation,  for  the  should  Future  anemic  be  The m o t h e r s  suitable  for  this  accepted  compliance  mothers in  who a r e  the  success  of  tion  of  the  newborn  infants.  loss  of  blood,  of  of  APGAR  would  scores,  be  therefore  used  personnel, of  and  in  of  to  The  and  and  parity.  The  status,  parasite  cultural  beliefs.  and  for  their  trimester  of  pregnancy  which  future  population  should  and  the  complications be  infants  deficiency  health  for  These  the to  in  dealing  district  condidelivery,  the  the  health  in  terms  variables  mothers  recommendations the  be  assessed  be a s s e s s e d  of  will  during  findings.  known,  health  be  indicators  shall  other  iron  anemia  on  will  and  of  anemia  like,  The  causes  puerperium  reports  of  the  factors  labor,  iron  degree  a guideline  third  Measures  storage  the  effects  their  infants.  administrators  and  health with  cases  anemia. Another  bility  of  mothers. these be  as  supplements  of  clinical  weight,  correlated  with  status  socioeconomic  and  pregnancy,  other  the mothers  include  identified  study.  include  status  are  terms  follow-up  and  nutritional  Studies  assessed  status.  are  dietary A  method'  to of  of  and  diets.  and diet  their  nonpregnant iron  an a d d i t i o n a l  iron  simulated  mothers  fed  these  aspect  iron could  food  female  tagging  could  study  fortified be  is  to  foods  formulated  frequency  determine in  the  from  pattern.  students  at  the  be u s e d  to  quantify  diets  the  The  of  dietary  simulated  university. the  the  iron  The  bioavailathese intakes diets  of  could  'extrinsic  absorption  from  164  The form of iron f o r t i f i c a t i o n could be f e r r i c sodium ethylenediaminetetraacetic acid (FeNaEDTA) which can be e a s i l y added to sugar.  Sugar i s  usually used i n the diets of these mothers i n their coffee or tea.  This  i r o n f o r t i f i c a n t does not affect the taste and appearance of the beverage. The findings  from this study would be helpful i n recommending food f o r t i f i -  cation program to improve the iron status of these pregnant mothers.  165  REFERENCES  Abrahamson, J . H . and Kosovsky, S.C. epidemiologic tool. Am. P u b l i c Addison, G.M., Beamish, M.R., L l e w e l l i n , P. 1972. An serum of normal s u b j e c t s overload. J . Clin Patho  CITED  1963. Health  Food frequency 53:1093-1101.  Interview  as  an  H a l e s , C . N . , H o d g k i n s , H.M. J a c o b s , A . , and immunoradiometric assay f o r f e r r i t i n i n the and p a t i e n t s w i t h i r o n d e f i c i e n c y and i r o n l. 25:326-329.  Ali,  J . , K h a l i d , H . , and Hamid, A. 1982. M a t e r n a l and c o r d f o l a t e vitamin B^ levels In Malaysians at parturition. Med. J . of Malaysia 37(2):160-164.  Ali,  J . , K h a l i d , H . , and Hamid, A . 1981. 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WHO B u l l . 4 8 : 1 5 .  1973. 1,000  I r o n , f o l a t e and v i t a m i n women f r o m s o u t h e r n  177  APPENDIX  Definitions  Respondents  of  terms  used  —  Pregnant  for  the  mothers  subdistricts  of  A  purpose  attending Tanjung  of  the  the  study.  antenatal  Karang,  Ijok  and  clinics  in  the  Batang  Berjuntai. Compliance  —  Respondent's  characteristics  regularly  determined  as  by  of  taking  compliance  the  pills  questions.  Noncompliance  —  F a i l u r e to t a k e the i r o n p i l l s as i n d i c a t e d by c o m p l i ance questions, lowered hemoglobin l e v e l s leading to anemia, and n e g a t i v e s t o o l color.  Food  —  The p r e s e n c e o f a c u l t u r a l p r a c t i c e by t h e r e s p o n d e n t s where f o o d s o r o t h e r o r a l l y i n g e s t e d compounds like p i l l s or medicine are c l a s s i f i e d 'hot' or ' c o l d ' , etc.  'Heaty'  —  The p h y s i c a l e x p r e s s i o n o f t h e body a f t e r i n g e s t i n g m e d i c i n e o r f o o d where symptoms l i k e body h e a t , c o n s t i p a t i o n , or d i a r r h o e a , rashes and o t h e r s are noticed.  Anemic  —  R e s p o n d e n t s h a v i n g b l o o d h e m o g l o b i n l e v e l s b e l o w 10 g p e r 1 0 0 mL o f b l o o d a s d e t e r m i n e d b y t h e c y a n m e t h e m o g l o b i n method.  Nonanemic  —  R e s p o n d e n t s h a v i n g b l o o d h e m o g l o b i n l e v e l s a b o v e 10 g p e r 1 0 0 mL o f b l o o d a s d e t e r m i n e d b y t h e c y a n m e t h e m o g l o b i n method.  beliefs  Socioeconomic  Education  Iron  status  levels  supplements  a  — The r e l a t i v e p o s i t i o n o f t h e r e s p o n d e n t , h e r family or environment which represents d i f f e r e n c e s i n h e a l t h . The c h a r a c t e r i s t i c s c h o s e n f o r the s t u d y to r e p r e s e n t Socioeconomic s t a t u s (SES) i n c l u d e l e v e l s of e d u c a t i o n , o c c u p a t i o n , ownership of p r o p e r t i e s and cash economy.  — The number received.  of  years  of  schooling  or  of  formal  education  — P i l l s or t a b l e t s i n the forms of ferrous fumarate or ferrous sulphate preparation r o u t i n e l y given to a l l pregnant mothers attending antenatal c l i n i c s . One p i l l c o n t a i n s 6 5 mg o f e l e m e n t a l i r o n o r 1 7 0 t o 2 0 0 mg o f the ferrous salts.  178  Kampong  (village)—  A  rural  people Kati  —  A kati after  Apgar  score  —  A  settlement  consisting  in  Malaysia.  is  603  g.  metrication  system  for  It  is  of  weights  assessing  of  dwellings  a common m e a s u r e  the  was  state  of  the  used  rural  even  implemented. of  newborn  infants.  A t one m i n u t e and 5 m i n u t e s a f t e r b i r t h , observations a r e made o n t h e h e a r t r a t e , r e s p i r a t o r y e f f o r t , muscle t o n e , r e f l e x i r r i t a b i l i t y and c o l o r , and the r e s u l t s e x p r e s s e d a s a s c o r e o f 0 , 1, o r 2 . For example, a b l u e or w h i t e c o l o r s c o r e s 0, b l u e e x t r e m i t i e s but p i n k b o d y 1, a n d c o m p l e t e l y p i n k , 2 . The s c o r e s f o r e a c h o b s e r v a t i o n are added t o g e t h e r ; t o t a l s c o r e s of 0-2 a r e a s s o c i a t e d w i t h a high m o r t a l i t y r a t e , 8-10 w i t h a low mortality rate. It i s said that the 5-minute score is a more a c c u r a t e p r e d i c t i o n t h a n the 1 - m i n u t e s c o r e . The s y s t e m was d e v i s e d by t h e A m e r i c a n a n e s t h e s i o l o g i s t , V i r g i n i a Apgar, 1909. I MR  —  Infant  mortality  TMR  —  Toddler  MMR  —  Maternal  Gravida  —  A pregnant  Parity  —  A woman h a v i n g  rate/1,000  mortality mortality  live  rate/1,000 rate/1,000  births  (1-4)  years.  livebirths.  woman. borne  viable  (0-1)  offspring.  year.  179  APPENDIX  A Brief  Description  Malaysia Malaysia the  and  south  island  The coast  of  Borneo  63% o f This  of  Peninsular has  them a r e  indicates  women o f  climate  and an  average  rainfall  West  and  North  from  in  the  East  is  Malaysia  Malaysia  is  Kuala  is  made up  is  a  of  small  Sabah and  Lumpur.  of  14.3  reproductive  relative  such  and  Peninsular  appendage  Sarawak  on  to  the  2)  the The  as  Asia  It  is  situated  on  the  west  Malaysia.  plans.  seasons  East  a population  ranges  East  Peninsular  Malaysia  health  temperature  South  whereas  (Figure  capital  in  Malaysia.  Thailand  Malaysia  Malaysia  located  East  of  of  is  of  B  of  million age  importance is  (15-44)  with  inches  (2,500  75°F-90°F country,  a  cm)  rainfall  months  (April  is  to  1980)  children  and  child  relative  (24°C-32°C).  but  and  maternal  tropical  100  monsoons  of  (Malaysia,  year.  There  are  care  heaviest and  The no  about  (below  humidity  per  June  and  in  of  15). any  80%  average  distinct  during  November  the to  South January,  respectively). The residing Sarawak  geographical in  Peninsular  (Dept.  of  50% o f  40% C h i n e s e , tion  the and  Malaysia  Statistics,  The M a l a y s i a n prises  distribution  population indigenous  30% I n d i a n s  is  rural,  mainly  smaller  extent  the  Malays  Indians  of  and  the  7.9  Malaysia, has  population  percent  of  live  in  in  the  of  which  and E u r a s i a n s . engaged  82.6  Sabah and  percent 9.5  percent  in  1980).  a diversity  population  in  is  race  culture.  the m a j o r i t y  About  60  agriculture. urban  and  areas  and  to  are  70% o f  The are  It  Malays,  the  Chinese  com-  popula-  and  descendants  to of  a  180  immigrants largely  from  industries Indian  to  Southern  the  country  principally  trade  and  commerce.  as  origin  work  on rubber  Shafiite  of  School,  Christians  and  religious the the  the  are  well  terms  over  China  as  In  of  who came  Indians  century.  engaged The  in  Indians  The  Chinese,  mining, mainly  rubber of  southern  plantations.  affiliations,  Chinese  last  are are  mainly  the  Malays  Bhuddhists  Hindus.  are with  Muslims a  of  sizeable  the number  APPENDIX  Detailed  Descriptions  Among  the  population two  of  three about  agricultural  The m a i n largest the  district  is  also  village  clinics.  clinics  in  It  rice  six  has  a  of  are  other  An average  The  1,300  calendar  year,  center.  Every  pregnant  mother  is  required  at  once  a pass  or  a card  to  deliver  either  deliver  at  location The  the  and  of  The  This  In  of  in  about  Ijok  hospital  concerned  with  of  to  has  has  are  The  group  largest  in  a  Karang  the  quarters  signifying  to  the the  is  the  home.  If  they  has  to  be n o t i f i e d  of  and  health rural-  these  main  health  health  choice  at  the  two  at  main  or  and  hospital  and  and  four  this,  addition,  located  oil  590 m o t h e r s  at  estate  register  one  has  two  this  in  of  decide the  center  place  to  to  exact  rubber  a  and  found  two  center  in  and  of  There  only  is An  about are  in a  private a  Five  year.  estates  mines  people.  clinic.  population  one m i d w i f e  hospital at  6,000  subdistrict.  clinic a  tin  center,  about  subsidiary  this  palm and  are  subhealth  this  and  Berjuntai  there  one  in  of  a  valley.  main  register  attend  and has  river  district  coming  Study  12 v i l l a g e s  from  mothers  population  register  Batang  one  a  one m i d w i f e  350 mothers  addition  and  of  villages  subdistrict  center, total  centre  about  Five  midwife  coalfield  subdistrict  people. here.  the  district  is  Tanjung  Aside  to  the  the  mother.  one  subhealth  average  the  subdistrict  villages one  at  home,  of  obtain  largest  for  has  and  cllnic-cum  one  least  the  town of  here.  mid-wife about  area  Selangor.  located  is  subdistrict  coastal  Kuala  of  Chosen  Tanjung Karang This  growing.  office  has  Subdistricts  people.  district  health  it  Three  sub-districts, 20,000  the  center,  the  estates.  activity town i n  of  C  this  3,000  located area.  subsidiary clinics.  calendar  year.  A  182  Each The  health  resident  health three  doctor  personnel to  four  center is  are  student  has  one  available  the  clinic during  staff-nurses,  nurses  and  day the  a week clinic  usually  midwives.  two  for  antenatal  days. in  each  The  checkups. residing  center  and  about  183  APPENDIX Antenatal  Attendance  in  Antenatal  Kuala  Selangor  Attendance  in  New  1982  109  77  655  255  56  203  Karang  1049  241  Selangor  355  Berjuntai  Ijok Jumlah  I  District  428  298  3037  514  1118  231  810  2159  43  1333  4377  890  166  5433  186  109  650  980  428  317  1725  149  56  114  318  703  227  424  1355  2277  647  546  3470  9489  2204  2016  13709  Attendance  in  Kuala  Selangor  1983  463  106  76  645  250  50  176  Karang  1090  223  Selangor  355  Tanjung  1983  2311  C  Berjuntai  and  Repeat M  M  Batang  1982  I  New  Jumlah  T  the Years  C  Antenatal  Jeram  for  Selangor  469  Tanjung  Ijok  Kuala  C  Batang  Kuala  District  M Jeram  Kuala  D  I  T  T  District Repeat  M  C  I  T  2184  481  290  2955  476  1319  171  835  2325  32  1345  5413  1105  130  6648  138  143  636  2005  568  733  3306  188  45  171  404  935  162  828  1925  2346  562  598  3506  11856  2487  28166  17159  184  Appendix  Introduction  Let  to  of  experience  with  mothers weak. that  Due are I  by  do  valuable  working  community  to  this  problem,  born  tend  to  some  meaningful, me t o  the  I  that  and  interview  you.  you. here  here  I  format  (English)  sometimes and  practical  suggestions.  will  know e x a c t l y have  feel I  free will  I  to  ask  would  kurang  make  sure  students.  In  are  they  during  what  before  causes  some  with  that  and would  But,  appreciate  discuss  die  the  there  darah as  babies  problem  you  to  that  from  National our  many  are  pregnant  pale  birth,  and  while  those  weak.  with  to  this  Arshad  the medical  we o b s e r v e  levels  small  am F a t i m a h  with  concerned  have I  be  information.  cooperate  to  low hemoglobin  am v e r y  giving  myself  Malaysia  having  Interview  Respondent  me i n t r o d u c e  University  E:  this  very  me y o u r  a l l  I  questions it  like  to  c a n do  help  solve  anything  problem. which w i l l  In  order  give  much i f  you  will  experience  in  this,  information  it  be k e p t  for  me  as  I  confidential.  185  Brief  note This  about is  the  form i t s e l f . made  to  the  was  other  done  and  The least  tape  by  the  format:  format  of  on  assistant  of  conducted.  pooled  at  full  Explanations  The c o d i n g were  interview  the  The  later  were  for  Some o f  revised  before  next  day.  and  the  coding to  was  conduct  responses  were  done  after  straight  into  a  the  statistical  were  recorder  The  and ways  questions  entered  interviews the  interview  ended  researcher.  recoded  the  interview.  done it,  on  the  was  interviewers.  open  codes  the  responses  Some r a n d o m the  coding the  interviews book.  questions  This were  tests.  immediately  to  to  the  after  they  interviews  questions  were  were  were  conducted,  recorded  checked.  on  or a  IDENTIFICATION  OF  RESPONDENT  Column Respondent's and  Card  name:  RN  1-3  address:  number:  4-4  Name o f  interviewer:  5-6  Date  interview:  7-8  of  Place Age  of  of  interview:  respondent:  9-9 yrs  10-1  187-  Meal  Lunch  (yesterday  Afternoon  Dinner  After  time  Ingredients  afternoon)  snacks  (last  night)  dinner  snacks  Breakfast (this before coming  morning, to the clinic)  Total  (g)  188  24-HOUR DIETARY CARD NO. 2  On t h e for  for  amount of  table  example,  like  plain  lunch  rice  way  The  at  I  3.  tell  get  of  China  food  For  example,  and...etc.  So,  now I  cakes,  sweets,  morning.  Please  true  evaluation  questions  was  estimate  not  were  feeling else  of  well  that  you ate  bowl  we u s e  etc.  measures  as  2 heaped  a  small you  drinks  etc.  since  of  in  what  time,  you ate  I  would the  China  to  tell  bowls me  yesterday's  for  since  it  is  this  is  the  diet. cases  and d i d  you ate  your  home;  guide,  like  take  at  What  would  your  used  measures  spoon,  yesterday.  know what  where:  not  eat  much;  yesterday?  I  even  though  you were  feast—even  though  yesterday  then  am  not  ask  s t i l l feeling  too  yesterday.  The  respondent  day  for  you,  went  could  to  where  to  everything  disclose  an unusual ate.  day  for  a  you  A situation  you  kinds  these  anything  to  me,  an accurate  a  there  all  using  this  probing  interested  have  including  can get  her—is  2.  lunch  respondent  good  to  breakfast  Standard 1.  is  I  dessertspoon,  you ate  that I  do  you ate  until  important only  to  food  everything  here,  teaspoon,  you  of  RECALL  the  please  tell  respondent  you,  that  she  s t i l l  I  me w h a t  ate ate;  too  you ate  much t h e  well,  at day  yesterday  am i n t e r e s t e d  to  was the  an  unusual  feast?  before—ask might  have  know e v e r y t h i n g  her  been that  189  FOOD F R E Q U E N C Y CARD N O . 3  As and to  DATA  you know,  drink  in  a day.  review with  like the  you past  example, start  you have  to  you  tell  In order some  food  me w h e t h e r  month.  Please  you eat  fish  first  been v e r y for  indicate  every  me t o  items you  day  cooperative use  which  have  I  eaten  how o f t e n or  eat  this have  in  in  you eat  chicken  two  my l i s t the  them i n times  Daily  groups  Rice  BEANS  (mee/beehoon)  & NUTS  Tofu/sprouts Peanuts/green  grams  etc.  FISH/EGGS/MEATS Fish/shellfish/crabs Eggs Chicken/beef/mutton/pork FRUITS ex:  citrus,  papaya,  pineapples  VEGETABLES ex.  swamp c a b b a g e ,  M I L K AND M I L K Fresh,  spinach  PRODUCTS  powdered  Sweetened,  would I  week,  condensed  etc.  etc.  of  Week  ate  like  would or  a week,  in  you  in  for  a week.  I  with:-  CEREALS  Noodles  I  here.  past  Frequency Food  me w h a t  information, in  them,  telling  intakes Month  will  190  A.  D E G R E E OF U N D E R S T A N D I N G  ON  SUPPLEMENTATION: Column  IRON  1.  IRON 2 .  How m a n y t i m e s s i n c e you were  ) ) )  4.  Others  (  )  Have iron  you been g i v e n these t a b l e t s g i v e n by the  IRON 5.  IRON  6.  tablets? clinic).  Yes  (Show  ° Cannot  )  * < remember (  any  of  BELIEF  I  Others  Do y o u h a v e  some 13-13  (  N  -1. -2. 8 9.  4.  12-12 ( ( (  4.  IRON  clinic  First visit Second v i s i t More than 2  l' 3.  3.  the  1. 2. 3.  1.  IRON  have you v i s i t e d pregnant?  these  tablets  ) J  14-14  left?  Yes Finished ... Skip No r e s p o n s e  15-15  >Why?  L^Do  1  you know what  these  tables  are  16-16  for?  1. 2.  Yes No  ( (  )  8. 9.  Skip No r e s p o n s e  ( (  ) )  Can you  please  explain  t o me w h a t  IRON  they  are  1. 2. 3.  Healthy Healthy Improve  baby mother appetite  ( ( (  ) ) )  4. 5. 8.  Improve Others Skip  blood  (  )  (  )  9.  No  (  )  response  for:  (  8  17-17  )  No.  Column IRON  7.  Where 1. 2. 3. 4. 8. 9.  IRON 8 .  COMPLIANCE  COMPL  COMPL.  you get  this  information?  Doctor Nurse Friend Others Skip No r e s p o n s e  ( ( (  18-18 ) ) )  1.  2.  • COMPL )  ( ( (  Doctor or nurse did not The e x p l a n a t i o n was t o o Did not understand .. Cannot remember what i t Others  1  ) )  What was t h e p r o b l e m t h a t c a u s e d y o u n o t u n d e r s t a n d what t h e s e t a b l e t s a r e f o r ? 1. 2. 3. 4. 5. 8. 9.  B.  did  to 19-19  explain. brief...  •• • • •  was  Skip No  response  WITH IRON  PRESCRIPTIONS  Some women t h i n k t h a t t h e y s h o u l d n o t t a k e t h e s e t a b l e t s when t h e y a r e p r e g n a n t : o t h e r s t h i n k t h a t t h e y a r e OK. What do y o u t h i n k ? Do y o u f e e l that t h e s e t a b l e t s w i l l make t h e b a b y b i g , 'heaty', h e a l t h y , bad f o r the baby or what? 1. 2. 3. 4. 5.  Good t o t a k e 'Heaty' Baby be t o o b i g D o n ' t know Follow doctor's  6. 8. 9.  Others Skip No r e s p o n s e  Why d o  you  say  advice,  take  them  ( ( ( ( ..(  ) ) ) ) )  ( (  ) )  (  this?  20-20  )  21-21  No.  192  Column COMPL  COMPL  COMPL  COMPL  3.  4.  5.  6.  R e g a r d i n g t h e t i m e t h e s e t a b l e t s a r e t a k e n , some mothers t a k e them a f t e r b r e a k f a s t , l u n c h o r d i n n e r o r a t o t h e r t i m e s ; when do you u s u a l l y take yours? 1.  Breakfast  (  2.  Lunch  (  )  3.  Dinner  (  )  (  )  ( .......(  ) )  4.  Bedtime  5.  Others,  8. 9.  Skip No r e s p o n s e  (  This morning a f t e r b r e a k f a s t , d i d you take tablet? (Substitute with other meal times d e p e n d i n g o n r e s p o n s e i n (COMPL 3 ) . 1. 2. 3.  Yes No Don't  8. 9.  Skip No r e s p o n s e  remember  How many  times  week  you  did  Everyday •. Six times • Five times Four times Three times Two t i m e s . None a t a l l  8. 9. 10.  Skip No r e s p o n s e Others  it  in  take  1. 2. 3. 4. 5. 6. 7.  Why i s  )  specify ..  that  a week, your  for  the  whole  23-23 ) ) )  ( (  ) )  last 24-24  tablets?  (  you are  )  your  ( ( (  of  22-22  not  taking  them  everyday?  )  25-25  No.  193  Column COMPL  7.  S o m e t i m e s y o u may o r may n o t n o t i c e t h a t y o u r s t o o l s change c o l o r to b l a c k or brown. Did you n o t i c e any c o l o r change the l a s t time you had b o w e l movement? 1.  Yes  (  )  2. 3. 8.  No Cannot Skip  ( ( (  ) ) )  9.  No r e s p o n s e  (  )  D.  HEALTH PROBLEMS  PROB  1.  PROB  PROB  2.  3.  26-26  remember  RELATED  TO I R O N  TABLETS  Some p r e g n a n t w o m e n , w h o t a k e i r o n tablets seem t o h a v e p r o b l e m s b u t , some d o n ' t . What a b o u t y o u , do y o u have any p r o b l e m s when t a k i n g these tablets? 1. 2. 3. 8.  Yes, Yes, No Skip  9.  No r e s p o n s e  What  always .. sometimes -• BELIEF  kind  of  problems  do  you have?  28-28  Stomach p a i n s Constipation Diarrhoea  ( ( (  ) ) )  4. 8.  Others Skip  ( (  ) )  9.  No  (  )  response  do  you  do when t h i s  taking  1  •.  1. 2. 3.  What  27-27  the  happens?  tablets  29-29  1.  Stop  (  )  2. 3. 4.  C o n t i n u e t a k i n g them Sometimes take them Talk to nurse/doctor  ( ( (  ) ) )  5. 6. 8. 9.  Forget about Others Skip No r e s p o n s e  ( ( ( (  ) ) ) )  them  No.  194  Column PROB  4.  Did you continue taking the t a b l e t s t r e a t i n g t h e p r o b l e m t h i s way? Yes No Others Skip No r e s p o n s e  1. 2. 3. 8. 9.  C.  PRESENCE  BELIEF  1.  OF FOOD  will  will  think?  Are  ( (  ) )  the  give  that baby  twin any  overnight big,  or  births. foods  rice  eating  )  What  that  you  do  when 'twin' you  avoid  when  1. 2.  Yes No  3. 8.  Others Skip  (  )  9.  No  (  )  ( (  response  are  these  BELIEF  3.  Do y o u a v o i d  foods,  these  1. 2.  Yes, Yes,  3. 8. 9.  No Skip No r e s p o n s e  name  foods  2 of  •  avoid  PARITY  1  )  them.  when n o t  pregnant? 33-30  always ... sometimes  you  ) ) (  What  Why d o  30-30  pregnant?  2.  E.  believe  there  BELIEF  4.  ) ) (  make  bananas you are  ( (  BELIEFS  Some m o t h e r s eaten  BELIEF  after  , ...  these  85-86  foods?  PARITY  PARITY  1.  Now, I w o u l d l i k e t o a s k y o u a f e w q u e s t i o n s about you and f a m i l y . What y e a r d i d y o u g e t 34-35  married?  PARITY  2.  How o l d  were  you when you  got  married?  36-37  No.  195  Column PARITY  3.  How m a n y you got  times  have  4.  Was  PARITY  5.  How m a n y m o n t h s  Now,  PARAS  1-4.  pregnant  since 3 8 - 38  married?  PARITY  PARASITE  you been  there  any  No,  miscarriage? pregnant  3 9 - 39  are  you  4 0 - 41  now?  INFESTATION  I would  like  Where  do  to  you  following  ask  and  family  Drinking  on water  get  water  for  supply.  the 42-45  Cooking  Washing  Bathing  water  well  (own)  well  (shared)  river rain  your  information  purposes?  Source piped  you  water water  pond/lake others  PARAS  5.  Have  you  ever  experienced  1.  Yes,  2. 3. 4. 8. 9.  Yes, sometimes No, never Others Skip No r e s p o n s e do  water  always  you do  to  6.  What  PARAS  7.  A b o u t d r i n k i n g w a t e r , do y o u a l w a y s , or never b o i l i t before drinking? Yes,  2. 3. 4. 8. 9.  Y e s , sometimes No, n e v e r Others Skip No r e s p o n s e  always  (  )  ( (  ) )  ( (  ) )  Q PARAS (  PARAS  1.  46-46  shortage?  overcome  this  9  )  47-47  problem? sometimes  48-48 (  )  ( (  ) )  ( (  ) )  (  196  Column PARAS  8.  Why d o y o u d o  PARAS  9.  Is  PARAS  PARAS  10.  11.  your  toilet  G.  12.  HISTORY  DISEASE  DISEASE  or  outside  the  house?  50-50  I n s i d e the house Outside the house Others  ( (  ) )  8. 9.  Skip No r e s p o n s e  ( (  ) )  What  kind  of  toilet  (  is  51-51  1.  Pour  (  )  Pump  (  )  3. 4. 4. 8. 9.  Pit River 'overhang' Others Skip No r e s p o n s e  ( (  ) )  ( (  ) )  Does  that  Who d o e s  OF  flush  everyone  not  in  the  does  use  (  house  not  the  )  it?  2.  use  use  it  or  is  )  there  it?  toilet  52-52  and why?  53-53  DISEASE  1.  Do y o u  ,  1. 2. 3. 8. 9.  2.  in  49-49  1. 2. 3.  anybody  PARAS  this?  No.  remember  having  malaria?  Yes No Others Skip No r e s p o n s e  Do y o u  remember  54-54 ( (  ) )  ( (  ) )  (  when you  got  it?  )  55-56  197  Column DISEASE  H. SES  3.  Have y o u e v e r problems?  sick  or  had  other  medical 57-57  1.  Yes  (  )  2.  No  (  )  8.  Skip  (  )  9.  No  (  )  SOCIOECONOMIC 1.  been  No.  response  STATUS  Lastly,  I  would  like  you  about the occupants i n working status. Let's  Age  Occupant  to  tell  me a  l i t t l e  y o u r h o u s e , t h e i r age start with yourself.  (yr)  more  58-70  and  Highest level of education  Job  Respondent Husband Children  1 2 3 4 5 6  Others  1 2  SES  SES  10.  12.  Are you p r e s e n t l y r e n t i n g own. If you are r e n t i n g ,  a house or i s i t your how much i s i t a m o n t h ?  1.  Own h o u s e  (  )  2. 3.  Renting Others,  (  )  specify  8.  Skip  (  )  9.  No  (  )  Do y o u  response own a n y  1.  Yes  2. 3. 4.  No Others, Renting  8. 9.  Skip No r e s p o n s e  land?  How m a n y (  )  SES  SES (  71-74  1 1 M$ )  acres? 13  75-78 acres (  )  (  )  ( (  ) )  specify  (  )  mth  198  Column SES  SES  SES  14.  16.  17.  Do y o u g r o w a n y they? 1. 2.  Yes No  3.  Others  8. 9.  Skip No r e s p o n s e  crops  on  (  this  )  land,  SES  and what  15  are  ( (  ) )  ( (  ) )  79-80  (  )  A b o u t f o o d i t e m s , some p e o p l e s h o p e v e r y d a y , others go s h o p p i n g once i n e v e r y t h r e e o r f o u r d a y s . How o f t e n i s s h o p p i n g done f o r your f a m i l y i n a week? 1. 2.  Everyday Six times  ( (  3.  Five  times  (  )  4.  Four  times  (  )  5.  Three  6.  Two  times  7. 8. 9.  Once Skip No r e s p o n s e  times  The l a s t t i m e what were the l i s t the food  goods  Dry  goods  81-81  ) )  (  )  (  )  ( ( (  ) ) )  you or your husband went s h o p p i n g , food items t h a t were bought. Please i t e m s and e s t i m a t e d c o s t ? Price  Wet  No.  82-84 estimate  ($)  Total/week Total/month  Thank  you  for  being  so  patient  with  me.  I  hope  you  have  a  safe  delivery.  199  APPENDIX  This  is  the  Actual  F -  Interview  Translated  format  (Malay)  (Malay)  Interview  Format  Used  in  the  Study  TEMUDUGA:  ANEMIA  1983  PENERANGAN BERKENAAN SOAL Saya  ingin  memperkenalkan  diri  saya  daripada bertugas di  di  sini.  ibu-ibu letih  sini  hamil  serta  mereka  Oleh  yang mengalami  pucat.  lahir  tidak  kerana  untok menolong darah  i n i .  kami  Masalah sesehat  ini  saya  Tetapi,  masalah  sangat  darah yang  di  s a y a membuat  sebab-sebab  mengapa m a s a l a h  Jadi  membolehkan  saya  soalan ingin  yang  dan  puan memberitahu  amatlah saya  penting  saya  akan  kembali  berkaitan saya  hargakan.  juga  gunakan  butir-butir  Temuramah  ini  berbuat  Saya  akan  perakam  yang  juga  untuk  ini  a k a n memakan masa  kami  mereka  lihat  senantiasa  ramai  kelihatan  b o l e h menyebabkan  bayi  untok  dengan  saya  kurang  ini  anggaran  saya  20-30  saya  mungkin.  bertanya darah  seperti saya  tidak minit  kurang  harus  soalan-  i n i .  dan kerjasama  membolehkan  y a n g mana  masalah  setepat  perlu  sendiri  soalan  bertanggungjawab  tindakan  timbul  puan  lakukan  puan b e r i k a n  kepaniteraan  mengatasi  apa-apa  dengan masalah  suara  Malaysia  sini,  dan berasa  demikian,  pengalaman  di  ialah  lain.  sini  mengetahui untuk  Kebangsaan  darah dan  ini  cenderung  hamil  Nama s a y a  yang menjalankan  kurang  bayi-bayi  sebelum  puan.  dengan masyarakat  kurang  semua i b u - i b u  kepada  Universiti  membimbing mahasiswa  Dalam pengalaman  SELIDIK  Saya puan  ini  temuramah  dan  menyemak sempat  sahaja.  menulis.  200  BUTIR-BUTIR  RESPONDEN  No.  Nama r e s p o n d e n dan alamat Nombor k a d Penemuduga T a r i k h __ Tempat  R.N.  Column 1  -  3  4- 4 5- 6 7-8 9-9  Alamat 10-11 Umur  2,0.1  24-HR  DIET  CARD N O .  RECALL  2  S E J A R A H MAKANAN 2 4  Di  atas  seperti  sudu,  makanan yang saya  ingin  gula,  meja  kueh  ada  senduk, biasa  dan  saya  mangkuk,  digunakan  sekiranya  pagi  dan  tadi.  Adalah  senarai sangat  piring  di  makanan  mustahak  ini untuk  pengukur  pengukur  Dengan p e r t o l o n g a n  yang  semua makanan  dimakan  saya  ambil dapat  saya menganalisa  alat-alat  ini  garam,  puan bangun putih  yang  puan dengan  tidur  semasa  masa mungkin  butir-butir diet  bekas  termasuk  semenjak  sebanyak  makanan  atau  2 c a w a n membumbung n a s i  Tolong  supaya  jenis  lain-lain  kembali  jumlah  dlln.  beberapa  dan  rumah.  Misal-nya,  tengahari  memberi  sediakan  puan mengingat  lain-lain  semalam h i n g g a makan  ini  JAM  untuk  tepat. setepat  mungkin. Soalan-soalan 1.  kes-kes  yang mengaku k u r a n g  lain-lain  lagi  tahu  makanan yang  butir-butir  Responden  pergi  merupakan  hari  makanan 3.  untuk  Responden  ingin 2.  panduan  yang  yang  atau  biasa  puan makan  Responden makan makanan yang  pesta  ini  terlalu  diambil  di  sihat  yang dan  puan makan walaupun  untuk pesta  tidak  lalu  makan  selain  dari  ini  puan  kenduri  tertentu:  tidak  berapa  walaupun  puan,  bolehkah  adakah  semalam. sihat  semalam  Saya  semalam. tidak  puan nyatakan  semua  itu?  banyak  samada banyak  tolong atau  berikan  sedikit.  butir-butir  semua  202  Waktu Makan  Tengah h a r i  Petang  semalam  semalam  Makan malam  Pagi  Bahan-bahan  tadi  semalam  (sebelum  datang  keklinik)  Jumlah  (g)  203  FOOD F R E Q U E N C Y  DATA  3  CARD N O .  S E J A R A H K E K E R A P A N P E N G A M B I L A N MAKANAN MENGIKUT Puan semua  telahpun  dengan  sukarela  yang  puan makan  bahan makanan  menanyakan makanan  berapa  yang  Senarai  kali  dalam  saya  senaraikan  akan  memberi  sehari  Makanan  Roti Mee/meehun KACANG  Tauhu/taugeh Kacang  tanah/kacang  hijau  dlln.  IKAN/TELUR/DAGING I k a n / u d a n g / k e tam Telor Ayam/lembu/kambing/babi  dlln.  BUAH-BUAHAN ex.  Limau,  payaya,  nenas  dlln.  SAYUR-SAYURAN/HIJAU ex.  Kangkong,  bayam  S U S U DAN J E N I S Susu  tepong,  Susu  pekat  dlln.  MAKANAN MENGANDUNGI  segar  manis  seminggu atau  Setiap  Nasi  ex.  Sekarang,  berkenaan saya  dengan  ingin  sebulan  puan  makan  berikut:  BIJIAN  JENIS  butir-butir  semalam. atau  HARI/MINGGU/BULAN  SUSU  Hari  Minggu  Bulan  204  A.  D A R J A H KEFAHAMAN PENGGUNAAN P I L  BESI: No.  IRON  Ini  1.  kali  keberapakah  semenjak  IRON 2 .  Pertama Kedua Lebih dari  4.  Lain-lain  Saya  IRON  3.  ingin  IRON  4.  IRON  5.  IRON 6 .  (  dua  samada  (tunjukkan  Ya Tidak Tak i n g a t Lain-lain  Ada  lagi  kah  puan pil  pernah zat  Tahukah  diberikan 13-13  besi). ( ( ( (  ) ) •Q.  sebab  ( ( ( (  ) ) ) )  15-15  nya?  puan untuk  apa  pil  16-16  ini?  Tahu Tidak  ( (  ) )-  8. 9.  Skip Tak ada  ( (  ) )  jawapan  Bolehkan puan pil ini?  terangkan  kepada  saya  untuk  IRON  8  apa 17-17  Bayi sehat Ibu sehat S e l e r a makan  ( ( (  ) ) )  Kuatkan darah Lain-lain  (  )  Skip Tak ada  ( (  )  jawapan  1  14-14  1. 2.  1. 2. 3. 4. 5. 8. 9.  BELIEF  bakinya?  Ada Sudah h a b i s Skip Tak ada jawapan  Apakah  sini 12-12  tahu  ini  1. 2. 3. 4.  -1. -2. 8 9.  ke  hamil.  1. 2. 3.  p i l - p i l  puan datang  Column  (  )  No. IRON  7.  Dari  IRON 8 .  B.  mana k a h  COMPL.  1.  penerangan  Doktor Jururawat Kawan  4. 8.  Lain-lain Skip  (  )  9.  Tak  (  )  ada  ( ( (  ini?  1. 2. 3.  Apa yang menyebabkan puan tujuan p i l ini? Adakah:-  tidak  1.  Doktor atau jururawat penerangan?  tidak  2.  Penerangan  3.  Kurang  4.  Tak  5.  Lain-lain  8. 9.  Skip Tak awa  ) ) )  18-18  • (  jawapan  terlalu  ringkas  faham  jawapan  ZAT  pasti  Q COMPL  akan  memberi (  )  (  )  (  )  (  )  (  )  ( . .(  ) )  BESI:  Ada i b u - i b u p e r c a y a yang p i l k e l a b u i n i jika d i a m b i l b a i k untuk anak, ada p u l a mengatakan p i l i n i 'panas', jadi tak baik diambil. Apa pendapat puan?  2.  1.  Baik  2. 3.  Panas Anak j a d i  4. 5. 6.  Tak tahu Ikut nasihat Lain-lain  8. 9.  Skip Tak ada  Mengapa  diambil  20-20  (  terlalu  besar  doktor  ( ( ( (  (  jawapan  puan k a t a  1  )  19-19  ingat  U J I A N PENGAMBILAN P I L  COMPL  puan mendapat  Column  demikian?  )  ( (  21-21  206  No. COMPL  COMPL  3.  4.  B e r k e n a a n d e n g a n w a k t u memakan p i l i n i a d a i b u i b u yang memakannya s e l e p a s makan malam, a d a p u l a s e l e p a s makan p a g i . B i l a s e l a l u n y a puan makan pil ini? 1. 2.  Pagi Tengahari  ( (  ) )  3. 4.  Malam Petang  ( (  ) )  5.  Lain-lain  8. 9.  Skip Tak ada  ( (  ) )  Pagi tadi mengambil masa  COMPL  5.  s e l e p a s makan p a g i , a d a k a h p i l kelabu ini? (Gantikan  22-22  )  puan dengan  lain).  23-23  Ada Tidak Tak i n g a t  ( ( (  ) ) )  8. 9.  Skip Tak ada  ( (  ) )  Pada minggu pil ini?  8. 9. 10.  6.  jawapan  1. 2. 3.  1. 2. 3. 4. 5. 6. 7.  COMPL  (  Column  jawapan  lepas  Tiap hari Enam k a l i Lima k a l i Empat k a l i Tiga k a l i Dua k a l i Tidak ambil  berapa  puan  mengambil 24-24  langsung  Skip Tak ada jawapan Lain-lain  Mengapakah puan setiap hari?  kalikah  tidak  ....  (  mengambil  pil-pil  )  ini 25-25  207  i  No. COMPL  7.  Kadang-kadang  puan  ternampak  yang n a j i s  puan  b e r t u k a r warna h i t a m / c o k l a t . Adakah puan t e r nampak p e r t u k a r a n warna t e r a k h i r s e k a l i puan ke tandas? 1.  Ada  (  2.  Tidak  (  )  3. 8.  Tak i n g a t Skip  ( (  ) )  9.  Tak  (  )  ada  .  jawapan  MASALAH K E S I H A T A N YANG B E R K A I T A N DENGAN P E N G A M B I L A N P I L  PROB  1.  PROB  PROB  2.  3.  Ada d i a n t a r a i b u - i b u h a m i l d i s i n i , apabila m e r e k a memakan p i l - p i l b e s i i n i m e r e k a menghadapi masalah k e s i h a t a n . Bagaimana dengan puan s e n d i r i ? Adakah puan mengalami apa-apa m a s a l a h k e s i h a t a n a p a b i l a memakan p i l - p i l ini? Ada, senantiasa Kadang-kadang .  3. 8. 9.  Tidak Skip Tak ada  27-27  1  jawapan  puan hadapi  semasa 28-28  1.  Sakit  2. 3.  Sembelit Berak c a i r  perut  4.  Lain-lain  (  )  8.  Skip  (  )  9.  Tak  (  )  Apa  biasanya  1. 2. 3. 4.  B e r h e n t i mengambil p i l Teruskan mengambil p i l Kadang-kadang sahaja Beritahu jururawat/doktor  5. 6. 8.  Lupakan sahaja Lain-lain Skip  9.  Tak  ada  BESI:  Q BELIEF  Apakah masalah yang b i a s a memakan p i l - p i l i n i ?  ada  26-26  )  C.  1. 2.  Column  jawapan  puan buat  jawapan  pil  jika  ini  Ini  berlaku?  (  )  ( (  ) )  29-29  208 2<  No. PROB  D.  4.  S e l e p a s membuat memakan p i l - p i l  1.  adakah  Ada Tidak Lain-lain  ( (  ) )  8. 9.  Skip .. Tak ada  ( (  ) )  DI  (  jawapan  SEGI  Ada d i d a p a t i i b u - i b u h a m i l p e r c a y a n a s i s e j u k jika dimakan anak akan j a d i b e s a r ; ada p u l a t a k makan p i s a n g kembar t a k u t anak kembar. Bagaimanakah dengan puan s e n d i r i . Adakah a p a - a p a makanan yang puan t a k makan semasa h a m i l : 1. 2. 3. 8. 9.  Ada Tidak Lain-lain Skip T i d a k ada  jenis  ( ( ( (  jawapan  Apa  BELIEF  3.  Adakah puan pantangkan makanan tidak hamil?  E.  PARITI  PARITY  PARITY  1.  2.  )  MAKANAN:  2.  4.  teruskan 30-30  BELIEF  BELIEF  puan  1. 2. 3.  KEPERCAYAAN  BELIEF  tindakan i n i tersebut?  makanan,  ini  1. 2. 3. 8. 9.  Ada Tidak Kadang-kadang . Skip Tak ada jawapan  Apa  sebab  (BILANGAN  column  puan  tak  (beri  ) )—• ( ) )  dua contoh)?  ini  makan makanan  31-31  Q PARITY )  1  32-32  semasa 33-33  ini?  85-86  ANAK):  Sekarang, saya hendak menenyakan puan berkenaan dengan d i r i puan s e n d i r i . Saya i n g i n mulakan s o a l a n i n i dengan tahun puan b e r k a h w i n . Pada tahun b i l a k a h puan berkahwin?  34-45  Berapakah  36-37  umur  puan k e t i k a  itu?  209  No. column PARITY 3.  Berapa k a l i k a h  PARITY 4.  Adakah b e r l a k u keguguran semasa puan h a m i l yang lepas-lepas?  39-39  PARITY 5.  Berapa b u l a n k a h kandungan puan s e k a r a n g i  40-41  F.  puan h a m i l semenjak perkahwinan i n i ?  38-38  INFESTASI PARASIT:  Sekarang saya i n g i n j u g a menanyakan b u t i r - b u t i r yang p e n t i n g berkenaan d i r i puan dan k e l u a r g a puan. PARAS 1-4.  Dimanakah puan dan k e l u a r g a puan mendapat a i r untok tujuan i n i . Sumber A i r paip Perigi (sendiri) P e r i g i (berkongsi) A i r sungai A i r hujan A i r kolam Lain-lain (nyatakan)  PARAS 5.  Minuman  Memasak  Mandi  42-45 Membasuh  Adakah pernah keputusan a i r ? 1. 2. 3. 4. 8. 9.  Ada, s e n a n t i a s a Kadang-kadang T i d a k pernah Lain-lain hal Skip T i d a k ada jawapan  46-46 ,  ( ( (  ) ) )  > Q PARAS 9 (  )  PARAS 6.  Apa yang puan l a k u k a n untuk menghadapi masalah i n i ?  47-47  PARAS 7.  Berkenaan dengan a i r minuman adakah puan s e l a l u masakkan a i r d a h u l u , kadang-kadang s a h a j a , merebusnya a t a u j a r a n g - j a r a n g k a l i ?  48-48  1. 2. 3. 4. 8. 9.  Selalu Kadang-kadang Jarang k a l i Lain-lain Skip T i d a k ada jawapan  ( ( (  ) ) )  ( (  ) )  (  )  210  No. PARAS  8.  Apa  PARAS  9.  Adakah puan mempunyai d i l u a r rumah?  PARAS  PARAS  PARAS  G.  10.  12.  Di  2. 3. 8.  D i l u a r rumah Lain-lain Skip  dalam  9.  Tak  1.  2.  49-49  ini?  tandas  di  dalam rumah a t a u  rumah  jawapan  jenis  tandas  yang  1. 2. 3.  Tandas Tandas Tandas  curah pam lubang  4.  Sungai  (overhang)  4. 8.  Lain-lain Skip  9.  Tidak  ada  (  )  (  )  (  )  (  )  (  ada  puan gunakan  di  • (pit)  rumah ( ( (  ) ) )  (  )  (  )  jawapan  (  )  Apakah  semua a h l i  tandas  ini  atau  keluarga  ada  yang  tidak  puan yang  tidak  50-50  )  puan?  (  J i k a l a u ada yang dan kenapa?  SEJARAH  DISEASE  puan l a k u k a n  1.  Apakah  11.  DISEASE  sebab  Column  51-51  )  menggunakan 52-52  menggunakannya?  menggunakannya,  53-53  siapakah  PENYAKIT:  A d a k a h puan I n g a t samada kura atau malaria? 1. 2.  Ya Tidak  3.  Lain-lain  8. 9.  Skip Tidak  Adakah demam  demam k u r a -  ( (  ada  puan ini?  puan mendapat  ) ) — • (  ( (  jawapan  ingat  bila  agaknya  puan  54-54  Q DISEASE )  ) )  menghidapi  55-56  3  211  No. DISEASE  H.  SES  3.  STATUS  1.  Adakah lain?  pernah Tolong  1. 2. 8.  Ada Tidak Skip  9.  Tidak  puan s a k i t terangkan?  ada  sekali  mempunyai  saya  masalah 57-57  jawapan  EKONOMI K E L U A R G A  Akhir  atau  ( ( (  ) ) )  (  )  RESPONDEN:  ingin  tahu  siapakah  yang  t i n g g a l d i rumah puan, umur, k e r j a dan t a r a f pengajian mereka. Saya i n g i n mulakan dengan d i r i puan s e n d i r i . Penghuni  Column  Umur  Pekerjaan  58-70  Pelajaran  tertinggi  Responden Suami Anak-anak  1 2 3 4 5 6  Lain-lain  1 2  SES  10.  Adakah rumah yang puan d u d u k i s e k a r a n g i n i rumah s e n d i r i a t a u rumah sewa? K a l a u puan menyewanya, berapakah sebulan? 1. 2. 3. 8. 9.  SES  12.  Rumah s e n d i r i Menyewa L a i n - l a i n , nyatakan Skip Tak ada jawapan  Adakah  puan mempunyai  Berapakah  luas  tanah  ( ( ( (  tanah puan  1.  Ada  2. 3. 8. 9.  Tidak L a i n - l a i n , nyatakan Skip Tak ada jawapan  (  )  ) ) SES ( ) )  71-74  1 1 M$ )  sendiri?  75-78  ini? SES  13  bin.  ekar/relong (  )  ( (  ) )  (  dlln. )  212 No. SES  14.  A d a k a h p u a n menanam a p a - a p a t u m b u h a n d e n g a n t a n a h ini? Apakah j e n i s tumbuhan yang puan tanam? 1. 2. 3. 8. 9.  SES  16.  Ya Tidak Lain-lain Skip Tak ada jawapan  Berkenaan  15 n a m a k a n  tanaman ( ) ( ( ) ( )  dengan makanan,  ada  orang  yang  ke  pula  yang  pasar sehari  setiap  sendiri,  atausuami  17.  SES  selang puan  SES  )  dan ke  (  atau  hari,  serta  seminggu.  berapa  kalikah  puan kekedai  1.  Tiap  2.  Selang  3.  Lima  4.  Empat  5.  Tiga  6. 7. 8. 9.  Dua k a l i Sekali Skip Tak ada jawapan  ada  Bagaimanakah di  membeli  dalam  79-80  kedai kekedai  dengan  seminggu  puan  makanan?  81-81  hari sehari  .  kali kali  ....  kali  K a l i yang a k h i r s e k a l i puan ke k e d a i berapa banyak puan b e l a n j a dan apakah yang puan b e l i . Tolong s e n a r a i k a n b a r a n g - b a r a n g i n i dan b e r i t a h u j u g a harganya? Bahan  Basah  Bahan  Kering  Anggaran Harga  selamat  kasih  di  mendapat  atas  kerjasama  cahaya  mata.  puan.  Hingga  berjumpa  lagi,  82-84  $  /bulan  Jumlah:  Terima  Column  saya  ucapkan  213  APPENDIX  Problems  incurred  while  collecting  for  The  first  small of  day  number  using  globin,  the  in  patients  and  procedures busy  data  health  center  as  volume  (PCV)  cell  staff.  done  at  run  the  a l l  were  portable  University  The  coulter-counter  the  largest  done  on  analyses  not  done m a n u a l l y , precautions researcher About  10-20  records  in  subsidiary tally  by  in  the  percent the  three  centers  the  of  or  mothers.  our  smears  This us  not  on  had  been  blood,  drawn  to  the  department  brought  in.  procedures though to  field  and  the  cases  subsequent  This  once  day  a  original  analysis  of  until  first  only  an average  disrupt  wait  brought  be  taken  midwife  to  for  and  the  place,  because to  the  pathology  Even  was  simple  plan  of  hemo-  35  of  overcrowding the  routine  the of  main  center  data  into  with  was  collection.  the  bottles  laboratory  at  analyses.  were  counts have  experience,  and  for  the  done.  the  In  we h a d  No f o l l o w u p  should was  at  number  day.  were  freezers  suggestions  measures  and  the  and  be k e p t  analyses  immediately  sample  that  the  data  should  for  center,  the  interviewing  failed.  problems,  the  an  In order  these  in  sampled.  morning  To o v e r c o m e put  collection  be  one  to  remedial  should  packed  patients  less  of  G  the  clinics. extra  no  available, and  be did  the  counts thus  the  electronically.  not  centers.  meant  were  beforehand  studied  down on  Therefore,  hemoglobin  done  could  broke  day were  some  PCV  were  Therefore,  especially  when  the  contacted. not  have  They were  their  either  medical  at  the  A few were  t a k e n home  effort  time  and  was  acciden-  needed  for  214  the of 4.  study. these  Poor  mothers  turn-up  research  5.  However,  area  and  time.  The  factors  included  the  The  of  lived  most  very  lived  fortunate  to  have  community  done  tions For  to are  of  be  in  some after  some w e r e not  not  In  order  of  appreciation, after  a  data  returns far  a  in  This  required  extra  for  choosing care,  that  lot  the  of  the  homes  conditions. resulted  the  the  expanding  interviewers  two  to  three  centers  that  was  the  manpower  health  days  travelling  colection,  to  was v e r y  away. to  Of  the  the  study  prior  some m o t h e r s  drink  days  visiting  the  and  main  tech-  required  sampling  for  days  low e s p e c i a l l y  those  who  clinics.  other  report  the  by m e d i c a l  those  the  stool  They  were  probably  In  this  study,  mothers. on  returned  for  parasite  students  better  we  infestation  from  the  were for  the  National  Malaysia.  made  immediately  and  the  of  center  antenatal  Since  a recent  expected  example,  that  health  had  and  close  compared  is  living  considered  the  stool  as  It  be  busy.  health  University 7.  their  one  they  in  opportunity  sub-district.  busy,  too  the  recommended.  who  samples, in  not  percentage  mothers  at  to  that  involved  a week was 6.  had  not  us  observing  another  days  were  gave  mothers  to  was  people  and  that  the  laboratory nicians  of  i t  to  that to  blood  no m a t t e r  the  samples  delivery had  data  into  collection, clotted the  since  taken  breakfast  feeling  well,  so  each  one was  sampling.  they  fainting given  the  they  before  were  in  a box  the of  planning  something  EDTA b o t t l e s .  not  have mothers  blood  how w e l l  were  would not  Another coming  omitted clinic  to  from and  strawberry  and  preparago  wrong.  mixed  example the the  also  up was  center study.  as  a  form  flavoured  milk  215  8.  Very on  poor  rainy  was  days,  were  when i t  also  Incentive good  payments  cials  advice both  in  and  tact  one  involved.  appointments services A delay imported and 11.  more study  Having were  the  from  of  At  baking  the and  on  could  time the  cookies.  went  cash  and  of  be  the  expected study,  it  Indian mothers At  shopping  also  officers  or  the  end  of  sprees.  were  the  Those  paid  who w e r e  acknowledgement  involved together  in  the  with  consul-  at  the  main  laboratory.  Diplomacy  when a s k i n g  for  help  and  from  the  appropriate necessary  in  staff  very  area  a l l  senior  were  from  and  the  lunches  appropriate  deemed v e r y  the  centers  days.  junior  important  from in  forms  the  health  holiday)  mothers  recognition  the  were  and  collection  for  the  religious  houses  in  were  to  celebrations.  payday,  data  However,  tation  10.  their  incentives  study.  during  was  poor  mothers  (Indian  decorating  month,  of  and  'Deepavali'  busy  9.  turn-ups  services  and  offi-  every-  documents  and  letters  with  applying  for  any  formal  which  had  to  administration.  arrival the  of  United  the  serum  States  ferritin-kits  caused  a  rearrangement  of  be  schedules  programmes.  A good  rapport  maintain regard ever, he/she  to one is  a  two  with way  various  the  in  relationship. information  should  not  in  or  his  staff  expect her  the  Advice  even before  everyone  study.  study  else  centers  from  was  essential  to  them was  essential  with  conducting to  be  as  the  study.  enthusiastic  Howas  216 • /  APPENDIX Code  This  code  stored  in  book one  contains file  all  called  the  Data  coded  H  Book  variables  filed  under  six  cards  and  study.  CONTENTS OF DATA Card No.  '  STUDY  Filenames  Page  1  QUEST  83  205  2  FOOD T A B L E D I E T A R Y RECORD  219 220  3  FOOD F R E Q ,  222  4  MEDRECORD  5  BLOODS  6  BL00DS-2  83 83  83  223 226  83  227  217  FILE  NAME:  CARD N o .  QUEST  1  Description  Variable  Identification  I.D. Card  83  No.  of  of  Questionnaire:  variable  Code  respondent  Social  &  number  Columns  001-350  1-3  1  4-4  Nutrition  Interview  Names o f interviewers No r e s p o n s e  01-10 99  5-6  Date  Dates of interviews No r e s p o n s e  01-15 99  7-8  Place  Place of interviews No r e s p o n s e  1-3 9  9-9  Age  Age o f respondents No r e s p o n s e  IRON  A.  IRON  1  DEGREE OF  ex  2  Attendance to health One t i m e Two t i m e s More t h a n two  Whether Yes No Cannot Others  center  iron  tablets  were  remember  Skip No r e s p o n s e  IRON  3  Whether  f o r 22 99  yrs  10-11  UNDERSTANDING  Others No r e s p o n s e  IRON  22  any  Yes Finished Skip No r e s p o n s e  tablets  given?  1-4 1 2 3 4 9  12-12  1-4 1 2 3 4 8 9  13-13  14-14  left. 1 2 8 9  218  Variable  IRON 4  Description  Why d o n ' t  you  of  variable  have  any  Have not been g i v e n Out o f s t o c k Have  IRON 5  not  come  to  Code  tablets?  any  clinic  3 4 5 6  Skip No r e s p o n s e  8 9  these  tablets 16-16  Can you e x p l a i n  1 2 8 9  what  they  are  for?  H e a l t h y baby Healthy mother Increase appetite Improve blood Vitamin B i g baby Skip No r e s p o n s e  IRON 7  15-15  Just recently finished Now c o m i n g t o g e t some D i d not want any  Do y o u k n o w w h a t are for?  Where  did  Columns  1 2  Yes No Skip No r e s p o n s e  IRON 6  number  you get  17-17 1 2 3 4 5 6 8 9  this  information?  18-18  Doctor Nurse Friends Own o p i n i o n Siblings  1 2 3 4 5  Mother  6  Skip No r e s p o n s e  8 9  219  Description  Variable  IRON  Why a r e  8  you  of  Code  variable  not  clear  number  about 19-19  tablets? Doctor  or  nurse  did  E x p l a n a t i o n was t o o Did not understand Cannot  not  explain  brief  remember  Did  not  like  Did  not  ask  the  tablets  Skip No  COMPLIANCE COMPL  1  B.  response  COMPLIANCE  WITH IRON  Opinion  on  iron  Good  take  to  COMPL  2  20-20  tablets 1 2 3 4 5 6 7 8 9  them  response  Why d o  you  say  21-21  so?  I always sweat? No p r o b l e m s - g o o d Doctor/nurse say they are Lazy/reluctant to take Has n e v e r t a k e n m e d i c i n e Constipate/vomit/weak Good f o r m o t h e r and baby Skip No  COMPL  3  good  response  When do y o u t a k e Once/day Twice/day Thrice/day Did not take Skip No r e s p o n s e  1 2 3 4 5 6 8 9  TABLETS  'Heaty' Baby w i l l be t o o b i g Dont' know Follow doctor's orders R e f u s e to t a k e them Medical problems Skip No  Columns  the  1 2 3 4 5 6 7 8 9  22-22  tablets? 1 2 3 4 8 9  220  Variable COMPL 4  Description of variable  The most recent time, did you take the tablet? Yes No Cannot remember Skip No response  COMPL 5  COMPL 7  1 2 ) 2 3 ) 8 9  24-24 1 2 3 4 5 6 7 8 9  Why didn't you take them everyday? Scared that baby w i l l be too big Lazy/on purpose/forgot Vomit/headache/heaty Stock was f i n i s h e d Not suitable f o r me Doctor says I am healthy Force of habit Skip No response  25-25 1 2 3 4 5 6 7 8 9  Did you notice stool color? Yes No Cannot remember Did not see Skip No response  Columns  23-23  Last week, how often did you taken them Everyday Six times Five times Four times Three times Two times Did not take Skip No response  COMPL 6  Code number  26-26 1 2 3 4 8 9  221  Variable  PROBLEMS  Description  D.  HEALTH PROBLEMS IRON  PROB  1  PROB  2  3  variable  Code  R E L A T E D TO  have  taking  these  any  problems  when  tablets?  27-27  Yes,  always  1  Yes,  sometimes  2  never  3  Skip  8  No r e s p o n s e  9  What  is  the  most  frequent  complaint?  28-28  Stomach ache Constipation  1 2  Diarrhoea Weak/nausea Pains in waist/legs Headache  3 4 5 6  Skip No r e s p o n s e  8 9  What d i d problem?  you  do when y o u  have  this 29-29  F o r g e t about them Ignore the problem Skip No r e s p o n s e  4  Did  Columns  TAKING  Stop t a k i n g the t a b l e t s C o n t i n u e t a k i n g them Take them, sometimes T e l l nurse about i t  PROB  number  TABLETS  Do y o u  No,  PROB  of  you  after  continue  doing  but  taking  1 2 3 4 continue  the  5 6 8 9  tablets 30-30  this?  Yes No  1 2  Skip No r e s p o n s e  8 9  222 21  Description  Variable  C.  BELIEFS  BELIEF  1  FOOD  Are when  of  variable  Code  there  any  foods  that  you  avoid 31-31  pregnant? 1 2 8 9  Skip No r e s p o n s e  2  What  are  these  'Twin' f r u i t s Mutton, milk  foods, (e.g.  name  3  Do y o u a v o i d pregnant?  1  bananas)  2  these  foods  when  33-33 1 2 3 8 9  Yes, sometimes Skip No r e s p o n s e  4  Why a r e  you a v o i d i n g  D o n ' t know P l a i n scared W i l l vomit Hate the food Twin b i r t h Hemorrhage Wind problems 'Heaty' Weak b a b y Poisonous  3 4 5 6 7 8 9  not  Yes No  BELIEF  32-32  two.  Seafoods ( f i s h , c o c k l e s , shrimps and eggs) C o l d o r o v e r n i g h t r i c e / b r e a d crumbs Pineapple, vinegar, ginger Swamp c a b b a g e , e g g p l a n t , chilly Fermented r i c e Skip No r e s p o n s e  BELIEF  Columns  BELIEFS  Yes No  BELIEF  number  these  85-86  foods? 01 02 03 04 05 06 07 10 11 12  223  Description  Variable  BELIEF  4  of  Code  variable  have  14 15 13 16 17 18 8 9  'fits'  Dangerous f o r baby B a b y ' s h e a d / b o d y w i l l be Just simply don't take Retained placenta Baby w i l l have l o c k  big  jaws  Skip No  PARITY  E.  1  response  PARITY  When d i d No  you get  Ex.  married?  2  How o l d w e r e No r e s p o n s e  PARITY  3  What  number  Was  there  you  then?  pregnancy  is  this?  5  any  miscarriage?  How m a n y m o n t h s  Ex.  21  for 99  Ex.  3 for  pregnant  Ex.  1 for 8 9  months  months months months  Skip No  21 y r s .  36-37  3rd  38-38  1  39-39  40-41  1-7  10  34-45  are  you?  8 9  1982  9  Skip No r e s p o n s e  PARITY  for 99  No r e s p o n s e  4  82  response  PARITY  PARITY  Coluams  (cont'd) Baby w i l l  PARITY  number  response  1-7 10 11 12 8 99  Description  Variable  PARASITE  F.  WORMS A N D  of  variable  Code  number  Columns  MALARIA  for  42-42  PARAS  1  Where  do y o u g e t  water  drinking?  PARAS  2  Where  do  you get  H2O f o r  PARAS  3  Where  do  you get  water  bathing?  44-44  PARAS  4  Where do you g e t w a t e r f o r w a s h i n g ? The r e s p o n s e s f o r 1-4 a r e :  45-45  for  Piped water Own w e l l Shared  PARAS  5  1 2  well  3  River water Rain water Pond/lake Stand pipe Skip No r e s p o n s e  4 5 6 7 8 9  Did you experience shortage?  any  water 46-46  Yes Sometimes Never Others Skip No r e s p o n s e  PARAS  6  43-43  cooking?  What d i d problem?  you  1 2 3 4 8 9  do  Store water i n Use r a i n water  to  overcome  this 47-47  containers/tanks  etc.  1 2  Irrigation canals Stand pipes Neighbour's water  3 4 5  Well/pond water Estate water supply Skip No r e s p o n s e  6 7 8 9  225  Description  Variable  PARAS  7  Do y o u  always  of  variable  boil  your  Code  number  drinking  water?  48-48 1 2 3 4 8 9  Always Sometimes Rarely Never Skip No r e s p o n s e  PARAS  8  Why d o  you b o i l  Germs To g e t  rid  Stomach Force No  9  the  water?  wind  habit  family's rid  response'  Is  your  health  health  of  No  on  smell  latrine  PARAS  10  1 2 3 4 5 8 9  response  What Pour Pump  kind  of  latrine  flush  •Pit' River (overhang) Daily disposal No p r o p e r toilet Drains/ditch Skip No  response  50-50  inside/outside  I n s i d e house Outside house No p r o p e r toilet Go t o n e a r b y b u s h e s On p a d d y b u n d s Skip No  49-49 1 2 3 4 5 6 7 8 9  disease  ache,  of  To g e t Skip  PARAS  of  information  For  Columns  is  51-51  this? 1 2 3 4 5 6 7 8 9  226 2  Description  Variable  PARAS  Is  11  there  does  of  anybody  not  use  Code  variable  in  family  Who i s  12  52-52 1 2 8 9  53-53  this?  Child  0-3  Child  4-12  1  yrs  2  yrs  8  Skip No r e s p o n s e  G.  DISEASE  DISEASE  1  9  HISTORY  OF  Did  ever  you  DISEASES  experience  54-54  malaria? 1 2 3 8 9  Yes No Others Skip No  DISEASE  2  response  When was  Ex.  this?  3  Do y o u h a v e Yes No Skip No r e s p o n s e  58 f o r  1959  55-56  08 99  Skip No r e s p o n s e  DISEASE  Columns  that  toilet?  Yes No Skip No r e s p o n s e  PARAS  number  other  medical  57-57  problems? 1 2 8 9  227  Description  Variable  H.  SES  SES  1  SOCIO-ECONOMIC  Occupation  of  of  Code  variable  58-58  respondents 1 2 3 4 5 6 7 8 9  Farmer Laborer Rubber tapper Business Skip No r e s p o n s e  2  Respondent's  Columns  STATUS  Housewife Teacher Own w o r k / v i l l a g e  SES  number  highest  level  of 59-60  education. 1-6 7,10,11 12-14 15 19 8 9  Grade 1-6 Lower secondary (Forms 1-3) H i g h e r secondary (Forms 4 - 6 ) College University Skip No r e s p o n s e  SES  3  Husband's age No r e s p o n s e  SES  4  Husband's  Laborer business/farmwork  Skip No  42  for 99  response  42  yrs  61-62  63-63  occupation  Fisherman Police/army/fireman Contract/business Teacher Driver Own  Ex.  1 2 3 4 5 6 7 8 9  228  Description  Variable  SES  5  Husband's education  of  highest  variable  level  Code  64-65 1-6 7,10,11 12-14 15 19 8  Skip No r e s p o n s e  6  Number  of  99  people  staying  in  SES  7  00-07 8 9 10-98 99  response  The number respondent  that are working or husband  excluding  8  Number  of  children  9  Number  of  children  < 7 Skip No r e s p o n s e  69-69  schooling 0-7 8 9  < 7 Skip No r e s p o n s e  SES  68-68 0-7 8 9  < 7 Skip No r e s p o n s e  SES  66-67  house?  < 7 Skip No r e s p o n s e > 7 No  Columns  of  Grade 1-6 Lower secondary (Forms 1-3) H i g h e r secondary (Forms 4-6) College University  SES  number  not  70-70  schooling 0-7 8 9  229  Description  Variable  SES  10  Is  this  your  of  own  Code  variable  1 2 3 4 5 6 7 8 99  I n - l a w ' s house Government q u a r t e r Squatter Siblings Skip  SES  11  response  How m u c h  ex.  rent/month?  060  12  Do y o u h a v e  for  13  How m a n y  1 2 3 4 8 9  acres  of  land?  Ex.  14.  Do y o u g r o w a n y t h i n g Yes No Others Skip No r e s p o n s e  2.5 2.5  for acres  76-78  8.8 99.9  Skip No r e s p o n s e  SES  72-74  75-75  land?  Yes No Rent Around house Skip No r e s p o n s e  SES  M$60/mth.  008 999  Skip No r e s p o n s e  SES  Columns  71-71  house?  Own h o u s e Rent P a r e n t ' s house  No  number  around  79-79  house? 1 2 3 8 9  230  Description  What  CASH  do  you  of  Code  variable  number  Columns  80-80  grow?  Coffee Coconut/cocoa Paddy Vegetables O i l palm  1 2 3 4 5  Rubber Fruit trees Skip  6 7 8  No r e s p o n s e  99  AVAILABLE How o f t e n  do  you buy  food  in  a  week?  81-81  Everyday Six times/week F i v e times/week  1 2 3  Four  4  times/week  Three times/week Two t i m e s / w e e k Once/week Skip No r e s p o n s e  How m u c h d i d month?  you  5 6 7 8 9  spend  in  a E x . 100 M$100  No r e s p o n s e  Total  expenditure  T o t a l number = per c a p i t a No  82-84  999  (SES  17)  0-998  o f p e o p l e (SES 6 ) food expense/month.  response  for  999  85-88  231  FILE  NAME:  CARD N o .  Variable  I.D. Card  Food  Item  DIETARY  2  Description  Identification No.  Items  Number  Quantity  of  of  variable  respondents  Row number o f f o o d i t e m a n d q u a n t i t y p a i r s as i t appear code sheet T o t a l number i n 24 h o u r s Food i t e m t a b l e ex:  of  number peanut  Quantity of food grams, 1 decimal 400.0 g  Code  food  items  Columns  001-350  1-3  1-3  4-4  02-24  5-6  1-2579  7-10  food on  taken  according to b u t t e r - 120 items place  number  food  eaten i n ex: r i c e  (135  items)  11-15  -  R e p e a t l a s t two t r a n s a c t i o n s i.e. i t e m number and q u a n t i t y pairs u n t i l a l l food items eaten i n 24-hours are entered.  01-3000.0  232  FILE  NAME:  Variable  DIETARY  RECORD  Description  of  Code  I.D.  Identification  CARD N O .  Total where  ENERGY  Food energy decimals  MOISTURE  Amount o f m o i s t u r e 1 decimal  PROTEIN  P r o t e i n content of food 1 decimal ex: 4.6 g  FAT  Fat content of food i n 1 d e c i m a l ex: 0.4 g  CHO  Carbohydrate content grams, 1 decimal ex:  FIBER  Fiber content e x : 1.1 g  ASH  Ash content of 1 decimal ex:  CALCIUM  Calcium content of food item i n m g , No d e c i m a l e x : 2 0 0 mg  PHOSPHO  Phosphorous content of No d e c i m a l e x : 2 8 mg  IRON  Iron content of 1 decimal place  SODIUM  Sodium content No d e c i m a l e x :  K  respondents  amount o f n u t r i e n t s the nutrient i s not  Potassium gram ex:  RETINOL  of  variable  in  consumed analysed  kilocalories,  of  gm i n  in  food,  grams  grams  of food 24.7 g  food,  in  g  food  in  food item i n e x : 1 . 9 mg of 20  No  food mg of  in  1 decimal  food item 1.4 g  content 20 mg,  in  no  item  food  mg,  in  in  mg  mg,  micro-  number  Columns  001-340  1-3  2 -1.0  4-4  0-1,000  5-11  0-100.0  12-18  0-100.0  19-24  0-100.0  25-30  0-100.0  31-36  0-100.0  37-41  0.0-40.0  42-36  0-3,500  47-53  0-1,000  54-60  0.0-100.0  61-65  0-1,000  66-72  0-1,000  73-79  0-50,000  80-86  decimal  R e t i n o l content of food i n g r a m , No d e c i m a l e x : 1 , 0 0 0  micromg  FILE  NAME:  Variable  DIETARY  RECORD  Description  of  variable  Code  CAROTENE  3-Carotene microgram,  VIT-A  Total Vit A activity No d e c i m a l e x : 1 , 4 2 0  B  Thiamine content of food item m g , 2 d e c i m a l e x : 0 . 0 0 mg  B  1  2  l e v e l of food item No d e c i m a l e x : 2 0 0  in mg  i n micrograms mg in  R i b o f l a v i n content of food item i n m i l l i g r a m , 2 decimal ex: 0.05 food mg  item  number  Columns  0-50,000  87-94  0-50,000  95-101  0.00-10.00  102-105  0.00-10.00  106-109  0.00-10.0  110-114  mg  NIACIN  N i a c i n content of 1 decimal ex: 0.5  i n mg  VIT-C  Ascorbic acid content of food item, 1 decimal place in milligram, ex: 42.0 g  0-500.0  115-120  CALCIUM  Calcium content of food item i n m g , No d e c i m a l e x : 2 0 0 mg  0-3,500  47-53  234  FILE  NAME:  FOOD F R E Q ,  Description  Variable  I.D. FILE  NO.  83  of  Identification  of  Frequencies  selected  of  RICE  Rice  BREAD  Breads  NOODLE  Noodles  SOYA BEAN  Soya  OTHER BEAN  Other  beans/nuts  green  grams  SEAFOOD  Fish,  prawns,  EGGS MEAT  Code  variable  respondent food  eaten  number  001-350  1-3  3  4- 4  0-10  bean  5- 6 7-8  (wheat) (rice  Columns  or  9-10  wheat)  11-12  curd/sprouts ex.  peanuts  0-10  13-14  clams,  cockles  0-10  15-16  Eggs  0-10  17-18  Chicken/beef/mutton/pork  0-10  19-20  0-10  21-22  0-10  23-24  0-10  25-26  0-10  27-28  etc.  FRUIT  ex.  orange,  VEGETA  ex.  swamp c a b b a g e ,  FR MILK  Powdered m i l k ,  SW M I L K  Sweetened Ex:  papaya,  pineapple spinach  etc.  etc.  fresh  condensed  milk  None Once a month Twice a month T h r i c e a month 1 2 3  time i n a week/4 times/week times/week  times  4 5 6 7  times/week times/week times/week times/week/everyday  month  0 1 2 3 4 5 6 7 8 9 10  235  FILE  NAME:  Variable  I.D.  83  Description  Identification  FILE AGE  MEDRECORD  NO. 2  Medical  of  of  records  Respondent's  variable  respondent  from c l i n i c s  ex.  1  code  Occupation of husband No r e s p o n s e ex. fisherman Farmer, gardener, vege. grower B u s i n e s s m a n , own w o r k , shopkeeper Teacher Fireman Policeman Contract Clerk Army Driver MARDI, LPP, Sailor  worker,  LPN,  laborer  FAMA  (govt,  Mechanic, foreman Drainage (JTA) Tailor Attendant Director of school Pensioner Bus c o n d u c t o r Research assistant Postman Storekeeper Electrical apprentice Telecoms Factory worker OCCUPA  2  Occupation of No r e s p o n s e ex: housewife Hairdresser Teacher Clerk Factory Laborer Clerk  worker  respondents  bodies)  number  Columns  001-350  1-3  4  4-4  eaten  age Missing  OCCUPA  Code  20  for 99  20  yr  5-6  01-25 99 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25  7-8  01-11 99 01 02 03 04 05 07 08  9-10  236  Variable  Description  of  variable  Code  number  Columns  01-11 99 01 02 03 04 05 07  9-10  11-11  Indian Others  1-4 1 2 3 4  RELIGION  R e l i g i o n of respondents Islam Buddhism Hinduism Others ex. Christianity  1-4 1 2 3 4  12-12  HISTORY  Medical h i s t o r y of illnesses Not a p p l i c a b l e Ex: s u r g i c a l p r o c e d . done Twin b i r t h Hypertension Asthma, cough Retained placenta Abdominal pains, flatulance Mental problem Diabetes  0-8 9 1 2 3 4 5 6 7 8  13-13  GEST  G e s t a t i o n age information No r e s p o n s e  12-40  14-15  OCCUPA  2  Occupation of respondents No r e s p o n s e ex. housewife Hairdresser Teacher Clerk Factory worker Contract worker,  RACE  Race of Malay  laborer  respondents  Chinese  WT.  1  Weight of completed  1  on in  last completed weeks  99  respondent on l a s t i n f o r m a t i o n i n k g (1  dc)  No r e s p o n s e HB  No GEST  2  response  G e s t a t i o n age i n weeks No r e s p o n s e  16-18  99.9  Hemoglobin of respondent on l a s t completed v i s i t , g/dL, 1 d e c i . place  1  10.0-99.9  06.0-14.0  19-21  99.9 on  1st  completed  visit 12-40 .99  22-23  237  Description  Variable  WT 2  Weight  of  visit,  kg,  of  variable  respondent  on  1 decimal  Code  1st  completed  40.0-99.9  VISITS  Total  number  of  visits  including  06.0-14.0 99.0 1-- 1 0 . 0  Home v i s i t s M i s s i n g code  Imferon  injections  3 4  Routine v i t . Iron tablets  5 6 7  Diet advice Booster dose Others, ex:-  (B  MISCARR.  DURP  1  ,  folate)  0 0 0  1 1  1 1  6  3 4 5 6  of  Gravida/total  tablets  number  of  pregnancies  01-20  of  life  0-20  children  number  of  miscarriages  death of i n f a n t s m i s s i n g code  0-1  Duration  pregnancy  of  response  3 6 --36 3 7 - -37 3 8 -- 3 8  3 9 --40  4 1 --43  last  plus  0-4  4 3 -- 4 3  yr 9 to  present  0 - 9 . 98  4 4 -- 4 6  dec.  Average d u r a t i o n between 2 decimal places _ Duration  3 2 --32 3 3 --33 3 4 --34 3 5 --35  99  response  Total  3 0 --31  99  response  Number  No  1  Medication given Calcium lactate given Refer to h o s p i t a l  one, years 1 No r e s p o n s e ADURP  o  0 0 0  1 2  Refusal  No  c  Yes 1  milk  g i v e n f u l l cream Cleanliness  CHILDREN  No 0  shots  2  No  27-29  99  Present treatment 1 Ex: antitetanus  GRAVIDA  24-26  99.9  Hemoglobin or respondent on f i r s t completed v i s i t , g/dL, 1 decimal  2  Columns  place  No r e s p o n s e HB  number  99. 9 pregnacies  0.00-9 .00  between 1 s t pregnancy and p r e s e n t T o t a l number of preganancy - 1  one  99.99  4 7 -- 4 9  238  F I L E NAME: CARD N O . 5  Variable  BLOODS  83  Description  of  of  variable  Code  respondents  number  Columns  I.D.  Identification  CARD  B l o o d and s t o o l No r e s p o n s e  HGB  Pack c e l l volume, No r e s p o n s e  1 decimal  (%)  20.0-40.0 99.9  8-10  PVC  Pack c e l l volume, No r e s p o n s e  1 decimal  (%)  20.0-40.0 99.9  8-10  TWC  Total red count No r e s p o n s e  1 decimal  15.0-40.0 99.9  19-21  MCHC  Mean c e l l h e m o g l o b i n g/dL, 1 decimal  concentration  10.0-50.0  22-24  analyses  xl0  1  2  /L,  1983  No r e s p o n s e OVA & CYST  Ova a n d  001-340  1-3  5 99.9  4-4  99.9  cysts  of  parasites  in  stool  25-25  samples. Positive Negative Skip No r e s p o n s e  1 0 8 9  FERRITIN  Serum f e r r i t i n , No r e s p o n s e  FOLATE  Serum f o l i c No r e s p o n s e  ng/mL,  acid,  1 decimal  ng/mL,  1 decimal  00.0-500.0 999.9  26-29  0.1-40.0 99.9  30-32  239  F I L E NAME: CARD N O . 6  BLOODS-2  83  Description  Variable  I.D.  Identification  CARD  Serum f o l a t e ,  FOLATE  Serum f o l a t e  of  of  variable  respondents  ferritin,  FERRITIN  No  Columns  1-3  6  5  0.1-160.0  5-8  number  Serum f e r r i t i n (ng/mL) 1 decimal place  number  001-379  morphology  ng/mL  No r e s p o n s e / m i s s i n g 1 decimal place  Code  0  0.1-220.0  response  9-12  0  M0RPH0  Blood  morphology  M0RPH05  Normocytic,  M0RPH04  Ovalocytosis, Target c e l l s Others  M0RPH03  Microcytic  M0RPH02  Hypochromic,  M0RPH01  Yes 1  17  0  1 2 3  16  0  1  15  0  1  14  Anisopoikilocytosis  0  1  13  No  9  response  normochromic 1 2 3  mild  hypochromic  None 0  

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