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Under-utilized approaches to control anaemia in developing countries

Prinsen Geerligs, P.D.

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Citation for published version (APA):Prinsen Geerligs, P. D. (2004). Under-utilized approaches to control anaemia in developing countries.

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Download date: 16 Jan 2021

5.. ACCEPTABILITY OF THE USE OF IRON COOKING POTS TO

REDUCEE ANAEMI A IN DEVELOPING COUNTRIES

P.D.. Prinsen Geerligs1 MD B.. Brabin1' FRCPC A.. Mkumbwa2 MB, ChB R.. Broadhead2 FRCP L.. E. Cuevas1 MD

11 Child and Reproductive Health Group, Division of Tropical Medicine, Liverpooll School of Tropical Medicine, Liverpool, United Kingdom

22 Department of Paediatrics, Medical College, Blantyre, Malawi 33 Emma Kinderziekenhuis, Academic Medical Centre, University of

Amsterdam,, The Netherlands

Correspondencee and address for reprints: Professor B. J. Brabin Liverpooll School of Tropical Medicine, Pembroke Place, Liverpooll L3 5QA, UK email:: LJ.Taylor@liv.ac.uk

Sourcee of support: Bush Hospital Foundation Runningg head: Acceptability of iron pots Keyy words: iron cooking pots, anaemia

688 Chapter 5

ABSTRACT T

Objective: Objective: Too evaluate acceptability, compliance and attitude towards the use of iron pots comparedd to aluminium pots, for cooking in a community which traditionally didd not use iron pots.

Design: Design: Randomisedd trial

Setting: Setting: Twoo rural Malawian villages

Subjects: Subjects: 522 households received iron pots and 61 aluminium pots.

Results: Results: Pott characteristics were assessed by a questionnaire after 3, 6, 11 and 20 weeks off use. Within households using iron pots there was a significant decrease in acceptabilityy score with usage, from an initial value of 13.7 to 11.4 (range 1-20), (pp = 0.01). Answers to questions concerning cooking characteristics showed that afterr 3 weeks use the aluminium pot scored better, whereas after 20 weeks fewer answerss differed between the iron and aluminium pot groups. Almost a third off the households planned to continue using iron pots daily after 20 weeks, althoughh they had ready access to their former aluminium pot. The presence of aa group of consistent pot users suggests that if households were convinced about dailyy use, then they were likely to maintain consistent use. Some householders consideredd that iron pots required less firewood for cooking than aluminium pots.. The main problems related to lower acceptability were rusting and pot weight.. About 25% of problems with iron pots were unrelated to their cast iron characteristics.. Overall 23.4% of the households indicated they would buy an iron pot. .

Conclusions: Conclusions: Thee low acceptability of iron pots for cooking could limi t their value as an interventionn to control iron deficiency anaemia. Design modifications and better instructionss on pot use should improve acceptability. The study highlights the needd to assess acceptability of interventions in order to facilitate their adoption in traditionall communities.

Acceptabilityy of the use of iron cooking 69

INTRODUCTION N

Ironn deficiency and iron deficiency anaemia continue to be a major public healthh problem. An estimated 3.6 billion people are iron deficient and of these 22 billion are anaemic despite the introduction of preventive interventions.1 The twoo main interventions, iron supplementation and food fortification have various limitationss related to costs, logistics and compliance.2-3-4

Inn 1991 the WHO reported on the use of iron pots for cooking as an innovative wayy for reducing iron deficiency anaemia.5 Two studies have been undertaken inn children which have shown the efficacy of this approach,6-7 which in rural communitiess could offer an effective and sustainable means of combating iron deficiencyy anaemia. Further evaluation is required particularly concerning their acceptabilityy and compliance. We conducted a randomised controlled trial in rurall Malawian households of the effect of cooking in iron pots on haemoglobin concentrationn in adults and children.8 This study demonstrated a significant improvementt in iron status of children and adults and of mean haemoglobin valuess in adults.8 Here we report the results of that part of the study which aimed too evaluate acceptability, compliance and attitudes to the use of iron pots in a communityy which traditionally had not previously used them.

METHODS S

StudyStudy site Thee study was undertaken between May to November 2000 in the Shire Valley in southernn Malawi. Small-scale agriculture of maize, sorghum, cotton and sugar-canee are the primary sources of food and income. Traditionally people used clay potss for cooking and more recently aluminium pots.

Twoo villages (Meja and Tsamba) were selected because of their accessibility by road,, willingness of the population to participate and their appropriate size. A censuss showed that the villages comprised 132 households. Households were invitedd to participate after village meetings were held to explain the study aims.

PotPot characteristics Householdss who agreed to participate received either an iron or an aluminium pot.. Pots were allocated using a random number selected by drawing lots. The aluminiumm pots were 6-litre in volume (Near East Ltd, Blantyre, Malawi), with a flatt base, two insulated handles and a lid with an insulated handle. The cast iron potss had a 10-litre volume (Falkirk size 4) and weighed 12 kg. They had a round basee with three legs for standing, two side handles and a lid with a handle which weree not insulated (figure 1). These were imported from Zimbabwe (Zimcast, Zimbabwe). .

700 Chapter 5

Figuurr 1. Iron cooking pot

AssessmentAssessment of pot acceptability

Participantss were requested to use the pots for the daily preparation of their food. Too encourage use a cooking demonstration was given in each village using the ironn pot. The participating households were visited at 3, 6, n, and 20 weeks after pott distribution by a field worker who interviewed the householder responsible forr cooking and completed a questionnaire. The questionnaire included questionss on acceptability and cooking characteristics. At 11 and 20 weeks of pot usee additional information was sought (tables 2 and 3). The frequency of oil use

Acceptabilityy of the use of iron cooking 71

inn the villages was assessed after n weeks of pot use since this could be a factor influencingg the occurrence of rusting in iron pots. Questions were open and not pre-formulated. .

Thee acceptability score {range i to 20) was determined using a beads method. Participantss were asked how good the cooking pots were, one bead represented thee worst possible cooking pot and 20 beads the ideal cooking pot. This method wass used because of the high illiteracy rate {approximately 70%) amongst women.99 The replacement value of the iron and aluminium pot was set at 100 Kwachaa {approximately US $ 1.5), because this was an average price for a cooking pott in the area. This cost was used as an economic indicator of the willingness to buyy an iron cooking pot for a "normal" price.

InclusionInclusion and exclusion criteria Inclusionn criteria were households that gave their consent, and who were willin g too participate in a trial to study the effect of the consumption of food prepared in ironn pots on haemoglobin and who had their residence in Meja or Tsamba village. Theree were no exclusion criteria.

SampleSample size and statistical methods Thiss article reports on pot acceptability as a component of a randomised controlledd trial to study the effect of eating foods prepared in iron pots on the levell of haemoglobin. The sample size was calculated to detect a difference in haemoglobinn level of 10 g/1 between the two groups after 6-week follow-up. Thiss required a sample size of 41 households per study arm with an average of 4 individualss per household to be able to detect this difference with 95% confidence andd 80% power. We assumed that the difference in acceptability between the twoo groups {aluminium or iron pot users) would be greater than the increase in haemoglobinn given the popularity of the aluminium pots and the unfamiliarity of thee people with using iron pots.

Statisticall analysis was based on intention to treat (whether participants had receivedd a pot or not). We compared the two groups by use of the Wilcoxon two samplee test, Fisher exact test and x2 tests.

Ethicall approval was obtained from the Ethics Committee of the Liverpool Schooll of Tropical Medicine, Liverpool, UK and the Health and Science Research Committeee of the College of Medicine in Blantyre, Malawi.

RESULTS S

Off the 132 households eligible for the study 52 households received an iron pott and 61 an aluminium pot; eight householders were not present during the distributionn and were not enrolled. Eleven households refused to participate. The resultss of the questionnaire after 3 and 20 weeks of pot use showed that several questionss with regard to acceptability differed significantly between the two groupss on both occasions (table 1).

722 Chapter 5

Tablee 1. Questionnaire answers after 3 and 20 weeks

Question n

Responsee rate

Absent t

Refusall to answer

General l

Cann the person that cooks read a simple

sentence e

Meann number of people who eat from the

pot t

Acceptability y

Wass food prepared every day in the pot?

Meann number of days used last week

Meann number of different meals prepared

lastt week

Onee kind of meal prepared in the pot

Nott good to cook in

Tooo heavy

Don'tt like the three legs

Wouldd buy a replacement pot

Qualityy of the pot is good

Sizee of the pot is good

Shapee of the pot is not good

Theree is a problem with rusting

Meann acceptability score

Cookingg characteristics

Takess too long before the cooking pot gets

hot t

Foodd is easily prepared in the cooking pot

Needd too much wood to cook

Foodd prepared in the cooking pot does not

lookk good

Foodd prepared in the pot tastes good

Afterr 3 weeks

Aluminium m

60/611 (98.4)

1/611 (1.6)

0(0) )

55 (8.5)

5.7 7

500 (84.7)*

6.5* *

3.1* *

13.3* *

11 (1.7)*

11 (1.7)*

533 (91.4)*

599 (100)*

444 (74.6)*

11 (1.7)*

0(0)* *

20* *

11 (1.7)

59(100) )

0(0)* *

0(0)* *

599 (100)*

Iron n

49/522 (94.2)

3/522 (5.8)

0(0) )

55 (10.2)

5.0 0

177 (34.7)

3.5 5

1.6 6

60.5 5

122 (26.7)

477 (100)

266 (55.3)

188 (37.5)

299 (63)

266 (57.8)

133 (28.3)

388 (84.4)

13.7 7

55 (11.4)

433 (100)

77 (15.9)

100 (23.8)

144 (33.3)

Afterr 20 weeks

Aluminium m

52/611 (85.2)

9/611 (14.7)

0(0) )

33 (5.0)

5.6 6

500 (96.2)*

6.9 9

2.5 5

20.8 8

0(0)* *

0(0)* *

500 (98.0)*

51(100) )

300 (57.7)

0(0)* *

0(0)* *

19.9* *

0(0) )

522 (100)

0(0) )

0(0)* *

522 (100)*

Iron n

45/522 (86.5)

5/522 (9.6)

2/522 (3.8)

44 (8.9)

5.0 0

14(31.1) )

3.0 0

1.4 4

73.1 1

199 (42.2)

411 (93.2)

299 (64.4)

15(33.3) )

188 (40)

288 (63.6)

211 (47.7)

366 (81.8)

11.4 4

0(0) )

444 (97.8)

11 (2.2)

44 (8.9)

355 (77.8)

** p <0.05 for difference between aluminium and iron pot

Brackets:: percentage

Acceptabilityy of the use of iron cooking 73

Tablee 2 Information obtained on usage of iron pots at 11 weeks

Question n

Whatt are the three biggest problems with

thee pot in order of importance?

Nott shiny

Rusting g

Tooo heavy

Threee legs

Roundd bottom

Other* *

Theree is no problem with the pot

Totall number of responses

Responsee rate: 47/52 (90.4)

Absent:: 3/52(5.8)

Refusall to answer 2/52 (3.8)

Cann you name three good things about the

pot,, in order of importance

Getss hot very fast

Durable e

Theree is nothing good about the pot

Requiress less firewood

Thee food is easily prepared in the pot

Other r

Totall number of responses

Responsee rate: 48/52 (92.3)

Absent:: 2/52(3.8)

Refusall to answer 2/52 (3.8)

Mostt important

0(0) )

199 (40.4)

111 (23.4)

88 (17.0)

11 (2.1)

55 (10.6)

33 (6.4)

477 (100)

144 (29.2)

88 (16.7)

100 (20.8)

11 (2.1)

144 (29.2)

11 (2.1)

488 (100)

Moderate e

importance e

11 (2.50)

7(17.5) )

177 (42.5)

55 (12.5)

22 (5.0)

8(20) )

0(0) )

400 (100)

111 (35.5)

122 (38.7)

0(0) )

22 (6.5)

44 (12.9)

22 (6.5)

311 (100)

Leastt important

22 (9.1)

44 (18.2)

88 (36.4)

33 (13.6)

0(0) )

55 (22.7)

0(0) )

22(100) )

2(20) )

1(10) )

0(0) )

5(50) )

2(20) )

0(0) )

100 (100)

** Twelve of these responses not related to cast iron characteristics

Brackets:: percentage

744 Chapter 5

Tablee 3. Additional information on the quality of the pots

Thee quality of the pot is good because:

Foodd is easily prepared

Pott is rust free

Pott is durable

Pott has a flat bottom

Pott gets hot faster

Pott stays hot longer

Other r

Qualityy of the pot is bad because:

Off three legs

Off rusting

Other r

Responsee rate

Absent t

Thee main reason why I would not buy an

ironn pot is because:

Designn with three legs

Tooo heavy

Thee round bottom

Rusting g

Other r

Wouldd buy the pot

Responsee rate

Absent t

AA heavy cooking pot is not good because:

Difficul tt to clean

Childrenn carft use the pot

Difficul tt to transport

Itt is not a problem

Responsee rate

Absent t

Aluminiumm pots

166 (31.4)

99 (17.6)

88 (15.7)*

33 (5.9)

4(7.8) )

0(0)* *

111 (21.6)

0(0)* *

51/611 (83.6)

10/611 (16.4)

6(11.8) )

6(11.8) )

1(2) )

299 (56.9)*

0(0)* *

99 (17.6)

51/611 (83.6)

10/611 (16.4)

100 (18.2)

77 (12.7)

11 (1.8)

377 (67.3)

55/611 (90.2)

6/611 (9.8)

Ironn pots

33 (16.7)

100 (55.6)

2(11.1) )

33 (16.7)

1(12) )

211 (84)

3(12) )

43/522 (82.7)

9/522 (17.3)

44 (9.3)

100 (23.3)

11 (2.3)

77 (16.3)

88 (18.6)

133 (30.2)

43/522 (82.7)

9/522 (17.3)

166 (34)

55 (10.6)

33 (6.4)

233 (48.9)

47/522 (90.4)

5/522 (9.6)

** p <0.05 for difference between aluminium and iron pot groups

Brackets:: percentage

Acceptabilityy of the use of iron cooking 75

Thee mean number of daily meals prepared per household per week in households usingg aluminium pots decreased significantly from an initial value of 3.1 to 2.5 overr 17 weeks (p=o.oi). In the households using iron cooking pots there was no significantt decrease. In the aluminium pot group the mean acceptability score of 19.99 {range 19-20) did not change significantly with time, although there was a significantt increase in the mean days of use per week from an initial value of 6.5 too 6.9 (range 5-7), (p = 0.04). In the iron pot group the mean acceptability score decreasedd significantly between 3 and 20 weeks, from a initial value of 13.7 to 11.4 (rangee 1-20), (p=o.oi). This was not accompanied by a significant decrease in thee mean days of use per week which changed from an initial value of 3.4 to 3.0 (rangee 0-7). The percentage of households which judged the iron pots to be of goodd quality decreased significantly from 63% to 40% between 3 and 20 weeks, (p=o.04). .

Answerss to questions concerning cooking characteristics showed that at 3 weekss the aluminium pot already scored better (table 1). In the aluminium groupp no significant changes occurred with time for answers to questions on cookingg characteristics whereas in the iron group a number of answers differed significantlyy with time, (p <o.o5), (table 1).

Thee additional information obtained after n weeks from the households which receivedd an iron cooking pot is shown in table 2. When asked to name the three greatestt problems with iron pots theree were 109 responses of which 106 (97.2%) reportedd problems. Of these 31 were not related to the characteristics of cast iron.. When requested to name three positive aspects of the iron pot there were 899 responses of which 79 reported a positive aspect. Of these 79 responses, 57 reportedd favourable comments related to the cooking characteristics of the pot. Severall responses related to requirement for less firewood. Many people also mentionedd that iron pots quickly became hot also implying a requirement for lesss firewood. The most important advantages of the iron pots were: gets hot veryy fast, food being easily prepared and their durability. The most important problemss were rusting, heaviness and the "three legs". Rusting was perceived as aa problem significantly more frequently by aluminium pot users (56.9%) than ironn pot users (16.3%).

Thee percentage of households which would buy an iron pot was 17.6% for thee aluminium group, and 30.2% for the iron group. Reasons for not buying an ironn pot were unrelated to cast iron characteristics for 16.7% of responses for thee aluminium group and for 36.7% of responses for the iron group. For the aluminiumm group 1.7% always and 28.8% sometimes used oil in cooking, whereas forr the iron group 1.7% always and 39.6% sometimes used oil in cooking. This differencee in use of oil between households in the two groups was not significant. Oill use was not associated with pot acceptability scores or with rusting. Results relatedd to information obtained at 20 weeks are summarised in table 3.

766 Chapter 5

DISCUSSION N

Thee conclusion that seems most warranted on the basis of this analysis is that the ironn pots used were not an appropriate intervention as a strategy to reduce iron deficiencyy anaemia in rural Malawian households due to their low acceptability.

Onee of the main problems related to lower acceptability was rusting. Participantss mentioned this as an important obstacle to use and it was the most importantt reason for judging the iron pot of poor quality. In contrast iron cooking potss are used widely in Zimbabwe and South Africa, where rusting apparently is nott perceived as such a significant problem. The use of cooking oil, which might reducee rusting, did not influence acceptability score values, or the frequency with whichh rusting was perceived as a problem.

AA potential problem related to lower acceptability of iron pots is their weight. Despitee this characteristic, only n .8% of aluminium pot users and 23.3% of iron pott users indicated that they would not buy an iron pot because of its weight. A factorr which may have influenced increased acceptability of aluminium pots in thiss study was the good manufacturing quality, as aluminium pots normally used inn these villages were of inferior quality compared to those distributed in the study.. The very high acceptability score for the study aluminium pots supports thiss conclusion. Some households which had received iron pots were disappointed becausee they had not received the perceived better quality aluminium pot. This mayy have evoked a negative attitude towards the iron pots. During the initial distributionn this was also noticed as some villagers commented that iron pots weree "bad pots" so as to indicate their preference for an aluminium pot. Despite thiss preference people were willin g to use iron pots and almost a third indicated theyy were willin g to purchase them.

Certainn customs may have influenced acceptability. For example, iron pots weree sometimes soaked in water for a prolonged time after use in order to make themm easier to clean. This is likely to have increased the problem of rusting. Oftenn people left their food in the pot overnight to eat the following morning. Thiss caused some change in colour and taste, especially of vegetables, and this wass experienced as a problem. During the preliminary cooking demonstrations customaryy foods were prepared in the pot and there was agreement that their colourr and taste were unaffected

AA number of positive conclusions can be drawn. Altogether 14 of 45 householdss continued to use iron pots daily after 20 weeks, despite the fact thatt they continued to have access to their usual aluminium pot. This rate of dailyy use did not change significantly over time for these consistent users. This suggestss that some households, when convinced about daily pot use, are likely too maintain consistent use at least over 4 to 5 months. The observation that the ironn pots required less fire wood for cooking could be important since that is a keyy economic factor in resource poor areas with limited fire wood accessibility. It iss probable that it takes some time for people to learn how best to utilise the cast ironn pot in order to achieve economic use for cooking.

Acceptabilityy of the use of iron cooking 77

Altogetherr 17.6% of households using aluminium pots and 30.2% of those using ironn pots indicated that they would purchase an iron pot at a cost of US $1.5. Manyy reasons for not buying an iron pot were unrelated to the characteristics of castt iron, suggesting that changes in iron pot design could improve utilisation. Rustingg itself was mentioned significantly less frequently as the reason for not purchasingg an iron pot in the iron group, suggesting that the experience of using thee pot may modify perceptions on rusting and/or attitudes towards iron pot use. .

Too increase the acceptability of the iron pots a number of actions could be considered.. The introduction of pots should be done in the absence of the parallel introductionn of aluminium pots in order to reduce selection preference. Design featuress are critical to improve acceptability and a flat bottom design with no legs wouldd be preferred. This may also require less wood as fuel. Iron pots should be introducedd with clear instructions on best practice for pot use and with emphasis onn their useful qualities and economic aspects. For example their durability and thee requirement of less firewood as a result of better heat retention, which could bee an important marketing aspect.

Thiss study reports for the first time on the acceptability of iron pots for cooking inn rural households in a developing country. In areas where iron deficiency anaemiaa is severe and where prolonged iron supplementation is impractical, moree attention should be given to this iron supplementation strategy, and to wayss of optimising pot design for practical usage. In developing countries wheree contaminant iron contributes significantly to iron intake the range off bioavailability of non-haem iron consumed can vary up to more than 15-fold.100 Because of this the variation in efficacy will remain uncertain until the exchangeabilityy of this form of contaminant iron is determined.10 However the approachh may be a useful, low cost and sustainable adjunct to the prevention and controll of iron deficiency anaemia.

788 Chapter 5

REFERENCES S

i .. World Health Organisation (WHO). The World Health Report 1997: Conquering sufferingsuffering Enriching humanity. Geneva: WHO, 1997.

2.. Galloway R & McGuire ƒ. Determinants of compliance with iron supplementation:: supplies, side effects, or psychology?. Soc. Sci. Med. 1994; V0I39,, No 3 pp 381-390.

3.. World Health Organisation (WHO). Iron supplementation during pregnancy: WhyWhy aren't women complying? A review of available information. Document WHO/MCH/90.55 Geneva: WHO, 1990.

4.. Nestel P & Alnwick D. Iron/multi-micronutrient supplements for young children.. Summary and conclusions of a consultation held at UNICEF, Copenhagen,, Denmark, August 19-20,1996.

5.. World Health Organisation (WHO). Prevention and management of severe anaemiaanaemia in pregnancy. Document WHO/FHE/MSM/93.5. Geneva: WHO, 1991. .

6.. Borigato EVM & Martinez FE. Iron nutritional status is improved in Brazilian pretermm infants fed food cooked in iron pots. J Nutr 1998; 128:855-57

7.. Adish AA, Esrey SA, Gyorkos TW, Jean-Baptiste J, Rojhani A . Effect of consumptionn of food cooked in iron pots on iron status and growth of young children:: a randomised trial. Lancet 1999; 353: J12-J16.

8.. Prinsen Geerligs P, Brabin B, Mkumbwa A, Broadhead R & Cuevas L. The effectt on haemoglobin of the use of iron cooking pots in rural Malawian householdss in an area with high malria prevalence: a randomised trial. TropicalTropical Medicine and International Health 2003 8:310-315

9.. Verhoeff FH, Brabin BJ, Chimsuku L, Kazembe P, Broadhead R. An analysis off the determinants of anaemia in pregnant women in rural Malawi - a basis forr action. Annals of Tropical Medicine e£ Parasitology, Vol 93, No 2, 119 -133 (1999). .

10.. Harvey PWJ, Dexter PB, Darnton-Hill I. the impact of consuming iron fromm non-food sources on iron status in developing countries. Public Health NutritionNutrition 2000; 3 11375-383