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Pattern of knowledge and consumption of iron among teachers of reproductive age group in Jammu region: a cross sectional study

Iron is an essential nutrient for humans, and as a cofactor for several enzymes it participates in many metabolic processes essential for sustaining life including oxygen transport, deoxyribonucleic acid (DNA) synthesis, and electron transport. In healthy humans, the body iron input is generated by gastrointestinal absorption of dietary iron. Despite iron’s plenteousness on earth, iron deficiency is extremely common in humans, and is the most prevalent cause of anaemia worldwide. Body iron losses are composed of basal (obligatory) losses, which are quite similar in men and women. In addition, women in the reproductive age have considerable physiological iron losses associated with menstruations, and pregnancies. The iron requirement is significantly increased during pregnancy due to increased iron utilization by the developing foetus and placenta, as well as blood volume expansion. Both iron deficiency and iron overload will affect body functions in negative ways and impair quality of life and survival.


INTRODUCTION
Iron is an essential nutrient for humans, and as a cofactor for several enzymes it participates in many metabolic processes essential for sustaining life including oxygen transport, deoxyribonucleic acid (DNA) synthesis, and electron transport. 1 In healthy humans, the body iron input is generated by gastrointestinal absorption of dietary iron. Despite iron's plenteousness on earth, iron deficiency is extremely common in humans, and is the most prevalent cause of anaemia worldwide. Body iron losses are composed of basal (obligatory) losses, which are quite similar in men and women. 2 In addition, women in the reproductive age have considerable physiological iron losses associated with menstruations, and pregnancies. [3][4][5] The iron requirement is significantly increased during pregnancy due to increased iron utilization by the developing foetus and placenta, as well as blood volume expansion. 6 Both iron deficiency and iron overload will affect body functions in negative ways and impair quality of life and survival. 7,8 According to the World Health Organization approximately half of the 1.62 billion cases of anaemia worldwide are due to iron deficiency, one of the leading risk factors for disability and death worldwide. It can be caused by a low dietary intake of iron, poor iron absorption, or excessive blood loss. 9 Dietary iron bioavailability is low in populations consuming monotonous plant-based diets. The high predominance of iron deficiency in the developing world has health and economic consequences, including poor pregnancy outcome, impaired school performance, and decreased productivity. 10 Iron is present in foods in two forms, as non heme iron, which is present in both plant foods and animal tissues, and heme iron, which comes from hemoglobin and myoglobin in animal source foods. Heme iron is highly absorbed and its bioavailability is relatively unaffected by dietary factors. Nonheme iron is the main form of dietary iron has a lower rate of absorption, depending on the balance between iron absorption inhibitors (phytates, tannins, calcium and phosphate) and iron absorption enhancers (ascorbic and citric acids, cysteine -containing peptides and ethanol)present in the diet. 11 Further, meat, fish, and seafood all increase the absorption of nonhemeiron. 12 This study aims to assess the knowledge and understanding of dietary iron consumption practices of the school teachers.

METHODS
It was a cross-sectional study conducted for a period of three months i.e. September to November 2019.

Ethical considerations
Aims, objectives and purpose of the study were explained to the teachers. Subsequent to this, they were asked to participate in the study. Teacher's knowledge and consumption regarding iron consumption and associated factors was studied using a pre-tested; self-administered questionnaire after obtaining verbal informed consent from them.

Study population
School teachers from selected government and private schools, in Jammu district, Jammu and Kashmir.

Sample size
The sample size was calculated using Open Epi Info software. Based on 50% expected proportion of the awareness of iron, 95% CI, and allowable error of 20, non-response rate of 10, estimated sample (n) came out to be 110.

Sampling method
Office of the Chief Educational Officer (CEO), Jammu was approached and briefed about the purpose of the study. Thereafter, list of schools falling under Jammu municipal corporation (JMC) was obtained from the office.
A total of 15 schools (primary/middle/secondary/higher secondary) were selected using simple random sampling technique. A separate list of the selected schools was prepared their respective principals were approached till the desired sample size was reached. Thereafter, they were explained about the purpose as well as the procedure of the study. Assurance that confidentiality of the study participants i.e. teachers at every step shall be maintained was also given.
Teachers, at different educational levels, who were present on the day of their respective school visit, were made part of the study. All the teachers were approached individually and briefed about the study. After seeking informed verbal consent, questionnaires were distributed among them during the lunch break.

Study tool
The questionnaire consisted of socio-demographic information of the participants e.g. age, gender, income, marital status etc. Data collection tool was selfadministered questionnaire after extensive literature research. The questionnaire was developed according to our cultural setup. It included variables knowledge and consumption of iron; assessed through various relevant questions in each section. Question format in both the sections was closed ended and no open-ended question was included.

Inclusion criteria
Women of reproductive age group ≤49 years of age.

Exclusion criteria
Pregnant women, Females with congenital/chromosomal deformities, women over 49 years of age, those on leaves.
The data were collected in excel and presented in numbers and percentages. Table 1, more than half (58.3%) of the teachers were in the 30-39 year age group. Maximum percentage of the study participants were married (85.45%), maximum were post-graduates (61.81%) and majority were teachers in higher-secondary schools (42.72%). 60.90% of the teachers had a family income of >Rs. 30000. Table 2 depicts pattern of knowledge regarding iron consumption among study participants. As per table, 70.90% were of the view that foods are the best source of iron. 57.27%, 53.63% believed that menstruation effects body source of iron. Iron has a role in pregnancy was stated by 80.90% and 85.45% of the study participants were of the view that iron rich foods and tablets are sufficient to maintain body stores of iron.

DISCUSSION
This study was conducted to assess the knowledge and intake of iron among teachers in the reproductive age group as this is an educated cohort and teachers have command over the budding students to mould them into a more aware group, making them the incharge of their own health and well-being.
70.90% believed that foods were the best source of iron but only 53.63% were of the view that non-vegetarian source of food was rich in iron which is in line with other studies. 13  reported by others as well. 14 74% of the women had taken iron in the past which is quite high as reported by others. 15 Intake of tea in our study was 71% in line with that reported by few. 16 Major barrier between iron intake and the woman was reported to be limited information which is in contradiction to some studies where main reason reported was forgetfulness. 14

Strength and limitations
Strength of the study was its uniqueness as the study group is teachers, the educated and impactful section of the society.
This study is not free from limitations which includesmall sample size, all the teachers have been selected from the urban area, it would be interesting to assess the knowledge and intake among the rural area teachers as well.

CONCLUSION
As iron deficiency leading to anaemia is an intergenerational cycle and is passed on to the newborns as legacies and awareness motivates behavioural changes, so, awareness should be generated through appropriate nutritional counselling during Out-patient and antenatal visits and through media as well.
Targeted estimation of hemoglobin levels in adolescent girls and women in reproductive age group, intensive counselling and motivation of women to consume Iron and ensuring adequate supply to them would help in reducing the incidence of anaemia and recurrent infections among women.