Prevalence of Anemia Among Displaced and Nondisplaced Mothers and Children --- Azerbaijan, 2001

In the early 1990s, the war between Armenia and Azerbaijan over the Azeri region of Nagorno-Karabakh resulted in approximately 600,000 internally displaced persons* and 200,000 refugees^† in Azerbaijan (1). After years of displacement and despite sustained humanitarian assistance, these internally displaced persons and refugees (IDP/Rs) are still coping with unfavorable living conditions and limited employment opportunities (2). Results of a 1996 CDC survey in Azerbaijan revealed high rates of malnutrition and anemia among both the IDP/R and resident populations (3) and prompted further study of the nutritional status of these populations. This report summarizes results of a 2001 survey of IDP/R and non-IDP/R mothers and children with anemia in Azerbaijan. Findings indicated that more than one third of mothers and children were anemic, with no significant difference in the overall prevalence between IDP/R and non-IDP/R populations; however, among the IDP/R population, anemia was associated with various socioeconomic factors such as education, socioeconomic status (SES)^§, and area of residence. Future studies should focus on identifying causes for the high rates of anemia in Azerbaijan and developing effective interventions such as iron supplementation and behavior modification.

Data for this report are from the Azerbaijan Reproductive Health Survey, 2001 (AZRHS01), the first nationally representative reproductive health survey in Azerbaijan, which was conducted with technical assistance from CDC at the invitation of the U.S. Agency for International Development (USAID) (4). AZRHS01 was a face-to-face household survey of a probability sample of 8,246 women aged 15--44 years; a total of 7,668 (93.0%) women responded. To examine differences between IDP/R and non-IDP/R women and children, the survey oversampled those regions heavily populated by IDP/Rs.

The survey also included a nutritional assessment module consisting of anthropometric (i.e., height and weight) and hemoglobin (Hb) measurements. This module was administered only to mothers with at least one child aged 3--59 months and to those mothers' children aged 12--59 months. A total of 2,206 mothers and 2,274 children were eligible to participate in this anemia substudy. Before fingerstick blood samples were taken, mothers were asked to provide written consent for collection of blood from themselves and their children. Trained personnel measured Hb levels on the HemoCue^® (HemoCue, Inc., Lake Forest, California) hemoglobin test system. Mothers were informed immediately of their results and those of their children. Blood samples were collected from 1,913 (90.2%) mothers and 2,047 (89.7%) children. After respondents with missing Hb results or outlying levels (i.e., <6 g/dL or >17 g/dL) were excluded, the final sample consisted of 1,906 mothers (356 IDP/Rs and 1,550 non-IDP/Rs) and 2,017 children (373 IDP/Rs and 1,644 non-IDP/Rs).

Anemia was defined according to the 1998 CDC criteria (5) as an Hb level of <12.0 g/dL for nonpregnant mothers, adjusting for weeks of gestation for pregnant mothers^¶. Among children, levels for anemia were age-specific (<11.0 g/dL for children aged 12--23 months and <11.1 g/dL for children aged 24--59 months). Survey results were weighted to adjust for the sampling design. Because <2% of the survey participants were refugees, data for refugees and IDPs were combined as one group (IDP/Rs). Data were analyzed by using SAS and SUDAAN. Two-sided t-tests were used to determine the difference in anemia prevalence between IDP/Rs and non-IDP/Rs and among subgroups within those populations. Associations between sociodemographic variables and anemia prevalence were determined by using chi-square tests, which were calculated separately for the IDP/R and the non-IDP/R groups. All differences are statistically significant (p<0.05) unless otherwise noted.

The IDP/R and non-IDP/R mothers and children had similar sociodemographic characteristics, with the exception of housing arrangements (Table 1). At the time of the survey, approximately half (48.5%) of the IDP/R mothers were living in temporary housing (e.g., public buildings, shelters, railroad wagons, and tents); 2% of non-IDP/R mothers were living in temporary housing. Among the IDP/R mothers, 44.2% had reported receiving humanitarian assistance (e.g., food supplies, household goods, clothing, and shelter) during the previous year.

Both IDP/R and non-IDP/R mothers had a high prevalence of anemia (39.0% and 40.1%, respectively) (Table 2). Anemia prevalence also was high among children, in both the IDP/R and non-IDP/R groups (35.5% and 33.2%, respectively). The prevalence of anemia did not differ significantly by IDP/R status among mothers or among children.

Anemia prevalence was significantly higher among IDP/R mothers with less than secondary education (64.2%), compared with non-IDP/R mothers (37.5%) with a similar level of education. Among IDP/R mothers, anemia decreased with higher education (64.2% for less than secondary, 37.5% for completed secondary, and 27.3% for technicum** or university education). Among IDP/R mothers, anemia prevalence also was associated with other socioeconomic factors, including living in rural versus urban areas (48.9% versus 31.9%); low versus medium-high SES (48.3% versus 27.4%); and receiving humanitarian aid (48.2% versus 31.2%).

For both IDP/R and non-IDP/R children, the prevalence of anemia decreased with age and was significantly higher for those whose mothers also were anemic (Table 2). Within the IDP/R group, children living in households with low SES had higher levels of anemia than those living in medium-high socioeconomic households (41.0% versus 27.6%). Children who were stunted^†† were more likely to be anemic than children who were not stunted (48.8% versus 32.8%).

Reported by: S Rahimova, PhD, Adventist Development and Relief Agency, Azerbaijan. GS Perry, DrPH, Div of Nutrition and Physical Activity; F Serbanescu, MD, PW Stupp, PhD, TM Durant, PhD, C Crouse, MSc, Div of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion; LI Bhatti, MBBS, EIS Officer, CDC.

Editorial Note:

The findings in this report indicate a high prevalence of anemia among both mothers and children in Azerbaijan, with no overall differences in prevalence between IDP/R and non-IDP/R populations. Similar high levels of anemia have been reported among women in neighboring central Asian countries (6).

Iron deficiency is the leading cause of anemia in most developing countries and disproportionately affects groups with the highest iron demands (7,8). The pattern of higher levels of anemia among younger children and women of reproductive age in Azerbaijan, along with no evidence of high prevalence of hookworms, malaria, or other micronutrient deficiencies (e.g., vitamin A) suggests that iron deficiency is the most probable cause. However, additional assessments and research are necessary to determine the causes of the high rates of anemia in Azerbaijan more conclusively.

At least two factors might have contributed to the similarity in anemia prevalence between IDP/Rs and non-IDP/Rs. IDPs outnumbered refugees by approximately 10 to 1; unlike refugees, IDPs are part of the host population, sharing the same background characteristics, food preferences, lifestyles, and risk factors for anemia as the established population. In addition, nutritional deficiencies among the IDP/R population at the beginning of displacement might have attenuated because of the humanitarian aid provided for several years by USAID and other international agencies.

Higher rates of anemia were found among IDP/R mothers receiving humanitarian aid, likely because aid was provided to those groups who were still not self-sufficient and at higher risk for anemia. The higher prevalence of anemia among other subgroups of IDP/R women and children (e.g., those in rural areas or with low SES) indicates the existence of more vulnerable groups within the general population. Special attention should be focused on improving the nutritional status of these groups through targeted interventions such as iron supplementation (7). In addition, iron fortification of staple foods like flour is a key public health intervention strategy that would benefit all mothers and children in Azerbaijan (7).

Comparing the data from the present study with the 1996 study, by using the earlier 1989 CDC criteria for defining anemia (9), indicates no significant change in overall anemia prevalence either among children (43.5% in 1996 versus 35.6% in 2001) or nonpregnant mothers (36.1% in 1996 versus 40.2% in 2001) (3,4). The lack of improvement indicates a need to enhance health intervention programs in Azerbaijan by including nutritional counseling, micronutrient supplementation, and fortification of staple foods. Because anemia is more prevalent in younger children, interventions are particularly needed among children aged <24 months, including promotion of 1) exclusive breastfeeding, 2) commercial or in-home fortification of complementary foods, and 3) dietary practices that produce improvement of iron bioavailability.

The findings in this study are subject to at least four limitations. First, the CDC Hb levels used to define anemia are based on data from the National Health and Nutrition Examination Survey of the U.S. population. These levels are higher than World Health Organization (WHO) cutoff levels, which are used primarily for developing countries and might produce overestimates of anemia prevalence. Second, higher inherent variability in capillary blood-sampling techniques used for screening anemia might introduce errors in Hb estimates. Third, enough information on food history and dietary risk factors was not collected to assess whether iron deficiency was caused by low iron intake or other factors. Finally, information on other factors (e.g., inflammation or infection) that might affect Hb levels was not available.

WHO considers anemia prevalence of >40% in a population as severe and warranting immediate public health action (7); certain subgroups of mothers and children in Azerbaijan had anemia prevalence of >40%. With prevalence at these levels, WHO recommends the following daily iron supplementation regimen: for children aged 6--23 months, 2 mg/kg body weight per day; for children aged 24--59 months, 2 mg/kg body weight up to 30 mg per day for 3 months; for nonpregnant women of child-bearing age, 60 mg/day of iron and 400 µg of folic acid for 3 months; and for pregnant women, 60 mg/day of iron and 400 µg of folic acid daily throughout pregnancy.

National efforts to prevent iron deficiency should involve community, government, the private sector (e.g., food industry), and nongovernmental organizations to develop long-term strategies that incorporate behavior modification, food fortification, and integration of iron deficiency--control into ongoing public health programs. Surveillance systems should be implemented to monitor development of these strategies and track the success of interventions.

Acknowledgments

This report is based on contributions from U.S. Agency for International Development Azerbaijan; Adventist Development and Relief Agency Azerbaijan; Azerbaijan Republic Ministry of Health. United Nations Population Fund; United Nations High Commissioner for Refugees.

References

1. United Nations High Commissioner for Refugees. The state of the world's refugees: fifty years of humanitarian action. New York, New York: Oxford University Press, 2000.
2. Norwegian Refugee Council/Global IDP Project. Profile of internal displacement, Azerbaijan: global IDP database, 2002. Available at http://www.idpproject.org.
3. CDC. Health and nutrition survey of internally displaced and resident population of Azerbaijan. Atlanta, Georgia: U.S. Department of Health and Human Services, CDC, 1996.
4. CDC. Reproductive health survey Azerbaijan, 2001: final report. Atlanta, Georgia: U.S. Department of Health and Human Services, CDC, 2001.
5. CDC. Recommendations to prevent and control iron deficiency in the United States. MMWR 1998;47(No. RR-3).
6. U.S. Agency for International Development, CDC. Reproductive, maternal and child health in eastern Europe and Eurasia: a comparative report. Atlanta, Georgia: U.S. Agency for International Development, U.S. Department of Health and Human Services, CDC, 2003.
7. United Nations Children's Fund (UNICEF), United Nations University, World Health Organization. Iron deficiency anaemia assessment, prevention and control: a guide for programme managers. Geneva, Switzerland: World Health Organization, 2001. Available at http://www.who.int/nut/documents/ida_assesment_prevention_control.pdf.
8. Yip R. Iron deficiency: contemporary scientific issues and international programmatic approaches. J Nutr 1994;124(suppl 8):1479S--90S.
9. CDC. CDC criteria for anemia in children and childbearing-aged women. MMWR 1989;38:400--4.

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