To our knowledge, this is the first study to investigate local concepts of blood and various anemia-related illnesses among school-aged children and young women, and their potential public health implications for risk-related and help-seeking behaviors, in a multiethnic setting of West Africa. Using a mixed methods approach to examine quantitative and qualitative data, we found that although the biomedical term anemia does not exist in the main local languages, the semantic form of the ancient Greek term ἀναιμία, meaning without blood, corresponds to the concepts used in local folk languages to report this condition. Our results reveal biomedical and sociocultural features of the knowledge of children and women for anemia-related illnesses. These representations appear to be connected to the risk-related and help-seeking behaviors reported by children and women and to differ from professionally recognized causes of anemia.
Limitations
Our study has several limitations. First, although we identified different terms related to mild and severe anemia during the initial meeting with traditional authorities, no distinction was made between these two categories in our questionnaire survey. Such a distinction would have required very subtle terminology, particularly for school-aged children, but this was not feasible given our tight time schedule and limited human and financial resources to conduct the study. Future KAPB surveys pertaining to anemia might investigate the implications of “relative” and “absolute” terms in relation to people’s behaviors and practices. In turn, such knowledge might provide important information for locally adapted communication strategies to prevent anemia.
Second, our study lacks direct observational components, which might have given more credibility and weight to the findings from the questionnaire survey. Indeed, previous studies have shown that reported and observed results differ quite considerably [23]. Nevertheless, such observations would have been challenging in the case of anemia, since cases are difficult to identify without clinical examinations. We suggest that future similar studies, particularly hospital-based surveys, might integrate an observational component.
Representations of blood and anemia-related illnesses
The difference in representations of blood across study settings might be associated with the main activity of the population that differs in rural and urban areas. Whilst inhabitants of villages and hamlets are mainly engaged in subsistence farming, a considerable number of individuals living in Taabo Cité are occupied in the tertiary sector (e.g., merchants and staff of the hospital, the school and management of the Taabo dam), or are attending high school. This observation might explain why people’s conception of blood mainly refers to strength in the more rural areas, where this condition is crucial for being productive in daily agricultural activities. People use semantic constructions associated to the ill-health aspects of anemia. These constructions are related to relative and absolute concepts of anemia-related illnesses. Relative concepts include “blood decreased” and “blood is not enough” and these descriptions relate to non-severe forms of anemia. This concept of anemia-related illnesses is found in other communities of West Africa and throughout the world [13, 15]. “Blood is over” indicates the absolute concept of anemia. Hence, anemia is also considered as a severe illness and, indeed, a cause of death.
The important differences we observed throughout the interview between spontaneously reported and probed answers might be explained by different levels of importance in the association that people construct between etiological agents and anemia. The large number of individuals who spontaneously reported djékouadjo (malaria-like illnesses) as a cause of anemia suggests that, in the Taabo HDSS, people construct a strong relationship between anemia and malaria-like illnesses. This association might be explained by the severity of some malarial anemia, which forces people to seek care at the hospital. As people do not frequently visit health centers, the information they receive there might stick into their mind. In contrast, illnesses like schistosomiasis were not spontaneously reported, most likely because there are no obvious causes of anemia for the population. However, probing schistosomiasis as a potential cause of anemia showed that most people think this relation exists. This observation seems quite obvious by the local terminology of schistosomiasis, which refers to “the one who urinates blood”. A similar explanation can be given for HIV/AIDS; although people do not spontaneously think about it as a cause of anemia, they considerate AIDS as a blood-related disease which renders people weak. Hence, upon probing, people agree that AIDS can cause anemia. Another factor which might explain the discrepancy between spontaneously and probed answers is, particularly among children, that they are shy or unable to give their own opinion. However, the very low proportion of participants who positively answered to absurd questions such as “Is health a consequence of anemia?” indicates that most respondents understood the questions and gave meaningful answers.
Health centers and other family members were identified as the main sources of knowledge about anemia, which corresponds to the sources of knowledge identified in a previous study about the use of LLINs in Côte d’Ivoire [24]. However, it is worth mentioning that health facilities are almost exclusively used as curative health structures. This may limit effective communication between the community and the health system for effective preventive medicine. Considering that, in the current study area, a household consists, on average, of eight individuals, it is not surprising that within-family communication was identified as an important source of information. Television and radio are less important sources of knowledge, inasmuch as the infrastructure has little or no support for this form of media. At the time of our study, Katchénou and Amani Kouadiokro were still not connected to the power grid. However, a few households owned a generator, which was used for various purposes, including watching television.
Relationship between anemia-related illnesses and local health problems
Our results revealed that the knowledge of participants about various anemia-related illnesses was based either on biomedical or sociocultural concepts and a clear distinction was often blurred. The biomedical dimension includes biomedical causes and preventive attitudes and reported behaviors against anemia, as shown in previous studies [4, 5, 9]. The sociocultural dimension groups together beliefs, attitudes, and reported behaviors, which require further in-depth investigations.
Biomedical causes include pregnancy, djékouadjo (malaria-like illnesses) and suboptimal diet, which is in line with our prior research in the Taabo HDSS [9, 10] and that of others elsewhere in sub-Saharan Africa [5, 25]. However, FGDs revealed that djékouadjo is not a synonym of malaria. Such local cultural distinctions between several malaria-like illnesses were identified elsewhere in Africa and turned out to be important parameters to take into account when developing a prevention program [26]. The perceptions of food and nutrition are also complex. People talk about good food or large quantity of food rather than iron-rich food or a diversified diet, emphasizing the divergence within the so-called “biomedical” causes as understood by the health staff and by the population.
Sociocultural causes of anemia-related illnesses include the sun, fire, and sorcerers. The relation between sun or fire and anemia mainly relates to the effect of heat; whilst sun causes anemia through sweating, fire impacts on the fluidity of blood. Interestingly, indoor biofuel smoke has been identified as a risk factor for anemia [27], and the effect of outdoor biofuel cooking on Hb levels may be worth investigating. The belief that sorcerers can cause anemia, mainly found among rural communities in the present studies, is encountered in several communities about different diseases, including malaria-like illnesses and tuberculosis [17, 28].
Color was an important parameter in the diagnosis of anemia, particularly for people living in the most rural areas. The representations of white and yellow colors as signs of ill-health are also found in the study of tuberculosis, where white cough and white body are signs of disease [29]. Although the loss, rather than the gain, of weight was associated with anemia, people also mentioned that anemic individuals might become bigger, specifying that “this is not good fat”, referring to swelling and edemas.
Both children and women identified three main consequences resulting from anemia-related illnesses: illnesses, tiredness, and death. On the one hand, most interviewees spontaneously reported death as the ultimate consequence of anemia-related illnesses. On the other hand, tiredness and illness both impact on working capacity, productivity, and financial resources, which is particularly important in subsistence farming communities, as observed here for the Taabo HDSS.
Help-seeking and risk-related attitudes and behaviors for anemia-related illnesses
Knowledge and beliefs of children and women about various anemia-related illnesses affect their attitudes and behaviors toward preventive measures against anemia. Although djékouadjo was identified as an important cause of anemia, few people mentioned the use of LLINs as an effective preventive measure against anemia. These considerations explain why few people think about sleeping under a LLIN as a preventive measure against anemia and confirm previous observations from Côte d’Ivoire, which showed that although 73% of interviewees utilized nets to prevent nuisance from mosquitoes, only 9% thought this measure may protect them from malaria [30]. According to the Taabo HDSS database, almost half of the people are now sleeping under a net, with a slightly higher coverage in Taabo Cité (the only small town) than in rural areas, which is much higher than in mid-2008 when the Taabo HDSS was established [31, 32]. The considerable increase of LLIN coverage can be explained by a recent national distribution campaign carried out between November 2010 and July 2011 and confirms that people use LLINs without being aware of their preventive effect against djékouadjo. Similar sociocultural concepts about malaria-like illnesses have been reported from other communities across the world, whose local denominations do not exactly correspond to the biomedical term malaria [12, 26, 33–37].
Children and women consider food as an important issue in the prevention of anemia. However, the recurrent expressions “eat well” and “good food” had different meanings, depending on the population group interviewed. Whilst the consumption of leafy vegetables and vitamins are sometimes reported by adults, it is more the quantity than the quality that matters to children, although the final goal is the same for all age groups: to gain strength. Beside leafy vegetables and meat, children and women reported other foodstuffs and drinks they may use to prevent anemia: bissap and tomatoes were more reported in rural areas whilst Coca-Cola was exclusively quoted by people living in Taabo Cité. These fluids were also reported by traditional healers. Interestingly, the aforementioned foodstuffs and drinks, as well as local herbal teas used to prevent or treat anemia, are all dark red-colored. Such a relationship between red-colored drink and foodstuffs with anemia has been reported for other communities [38]. Our findings therefore suggest that people may build a relationship between color and anemia, not only for diagnostic purposes, but also for curative measures. Bissap may be worth further investigating as other groups of researchers reported a high content in vitamin C, one component that can improve iron absorption [39].
Most of the women interviewed (84.4%) said they would seek care at a health center if they suffer from anemia and 69.2% of the respondents who experienced anemia said they got their diagnosis from a health center. However, health workers consistently reported that people visit health centers at a late stage of disease. In case of ill-health, people usually visit traditional healers first. FGDs corroborate these findings; in case traditional medicines do not improve the subject’s health status, then he/she may visit a health center. These observations suggest that different concepts of anemia-related illnesses (relative versus absolute) may be associated with different behaviors. However, future studies should seek a clearer distinction between these concepts to investigate whether they are associated to specific behaviors and might therefore influence public health actions.
Public health implications of local cultural concepts and ideas about anemia
The discrepancy between professionally recognized causes of anemia and accompanying preventive and curative measures, and local culturally reported causes and ideas about anemia-related illnesses have important ramifications for public health. Indeed, our results indicate that there are additional local culturally identified causes of anemia (e.g., sun, fire, and sorcerers), and that so-called biomedical factors are understood differently, which influence the prevention and control of anemia by the population and the health staff.
Whilst the health staff put emphasis on the quality, rather than the quantity of food for preventing anemia, we noted a different pattern within the population. Less than 40% of the participants effectively had a balanced diet on the day before the interview. Most people reported that they have eaten meat or fish on the day preceding the interview, but this response would need to be confirmed by active food records. Indeed, in our prior epidemiological study, we found high prevalence of iron, vitamin A (in infants and children), and riboflavin deficiencies [9], which indicate that the local diet does not fulfill people’s micronutrients requirements. Moreover, the considerable prevalence of inflammation certainly contributes to the local burden of malnutrition through preventing efficient micronutrients absorption [9, 10]. The situation of the Taabo HDSS, located in the V-Baoulé where the rain forest meets the Savannah area offers many agricultural and fishing opportunities. However, our results highlight the influence of geographical origins on diet customs. Whilst food of communities from the North (e.g., Malinké and Sénoufo) is based on cereals (i.e., maize, sorghum, millet, and rice), tubers and plantain are the main staple food of ethnic groups from the South [40, 41].
The potential public health implications of various types of djékouadjo are as follows. Considering that not all djékouadjo are thought to be transmitted by mosquitoes, this affects people’s behavior, inasmuch they do not associate LLINs to malaria prevention and referral to the health system is only done for the most severe cases of malaria and anemia. Of note, as blood transfusions are not available in Taabo General Hospital, severe anemia cases are referred to other larger hospitals further away. This delay in seeking prompt and effective care and the consequence on population health has been studied in different communities throughout the world [13, 42–45]. In the case of malaria, which is responsible for most cases of severe anemia in sub-Saharan Africa, low socioeconomic status, distance to the nearest health center, cost of care, and perceived adverse events of modern medicine are among the key issues people put forward not to seek prompt care at health facilities [13, 42, 43]. The consequences include a reduced efficacy of treatment, and hence, a higher probability of complications and even death. Data from health registries at Taabo General Hospital and Ahondo health center indicate that during the year 2011, 64/5,539 (1.2%) and 33/1,138 (2.9%) consultations, respectively, were diagnosed with severe anemia. Mild and moderate cases of anemia were not systematically registered, indicating that the consequences of chronic, non-severe anemia might be underestimated by the health staff.