In a study that represented health professions students including pharmacy, medicine, nursing and other students. We found high level of knowledge about anemia before or after taking study material on the topic under nutrition course which was offered as part of curriculum. Females were more likely to participate in this study and refugee camps were underrepresented in this study group. Duration of taking the course on nutrition, vitamin D deficiency, mother, father education and SES tended to modulate the total score on anemia awareness specifically for female who tended to have the best knowledge of anemia if their mother had high education and income and the lowest level of knowledge on anemia if their fathers had less income and education.
Vitamin B12 is common in Palestinian territories, but the awareness about the relationship between vitamin B12 and anemia is lower than that for other nutrients (i.e Iron and folate). In a study done on Palestinian female university students, iron deficiency anemia was present in 20.4% of the studied group, whereas vitamin B12 was lower in anemic group (212.9 ± 62.8 pg/mL) relative to healthy group (286.9 ± 57.1 pg/mL)(Sirdah et al., 2014). In this group 20.5% reported having vitamin B12 deficiency and 10.3% reported having anemia, but this was not associated with better knowledge about anemia. Vitamin B12 deficiency can is reversible megaloblastic anemia and demyelinating neurological disease. Its deficiency is common in elderly and people who lacks intrinsic factor necessary for its absorption(Stabler, 2013). Awareness of vitamin B12 supplementation in high risk groups such as diabetics was very low (Chaitanya Shree et al., 2021). In another study among regular blood donor, 42% and 31.6% of study group were aware of aspects of anemia and vitamin B12, but only 20% knew about accepted level of hemoglobin to donate blood. This is important because of the prevalence of low vitamin B12 in Palestine and its possible impact on neurological health of Palestinian population.
In general, the students had good basic knowledge of anemia which is consistent with what was found before (Yadav et al., 2014; Sivapriya and Parida, 2015; Malay et al., 2018). Most of the study participants knew the good sources for iron and that tea and coffee interferes with iron absorption. Since majority of the study are premenopausal females and young adults, awareness of anemia is particularly important for better control of anemia in the society. However, 40.5% of the study participants did not know about the relationship between anemia and pollutants and majority of the study participants did not know about delaying the clamping of pulsing umbilical cord could help decrease anemia in infancy that regardless of taking a course in nutrition. This indicates that in our society, even students who learned about anemia in their medical curriculum fail to value the importance of this global and local health problem. It is well known that anemia is a health condition that is associated with morbidity and mortality and hence special educational programs should target youth to educate them about the significance of the problem(Malay et al., 2018).
The score for anemia awareness was the lowest for students who did not take the course on anemia, and was slightly higher for the ones who took it last year and the highest for the ones who covered the material in the same year, but specialty did not influence the score on anemia as there were no difference between medicine, pharmacy and nursing students
Education is associated with anemia awareness (Waggiallah and Alzohairy, 2013). Paternal education affected the score on anemia, with students who have father with bachelors and college degree having highest score. In this study there was interaction between mother, father education, gender of student and income. When we scored the socioeconomic status based on mother, father education and income, females with lowest SES scores had the lowest score on anemia and the middle SES scores had the highest scores on anemia. When we further stratified score based on either mother education or father education, father education had more significant on total study group and on female participants specifically. The students with lowest score were females with low SES score based on father education and income, whereas the highest score was for female students with highest SES scores for income and mother education. In a study on Indian children from National Healthy survey, poverty index and mother education were significant predictors of anemia(Goswmai and Das, 2015). Parents education plays role in other aspects of health(He et al., 2014; Al-lela et al., 2014). In this study we did not assess the level of parents' awareness of anemia but rather scored their education as yes or no because the data was not available to us. It is worthy to mention that parents relationship to health awareness may vary according to specialty and background and location in SES stratum(Al-lela et al., 2014). In a study by Erola, father education had more effect on offspring during young adulthood in comparison to mothers who had more effect during childhood. The effect of parents education on awareness level could be related to relationship between education, income, poverty and psychological wellbeing at different stages of life(Erola et al., 2016). On the other hand, academic achievement and motivation could be higher in females relative to males during university as was shown by others(Nasir, 2012).
Vitamin D deficiency is associated with improved score on anemia knowledge. This could be thought of as health consciousness which controls how patients receive and behave towards health information. Individuals with higher health consciousness are ready to undertake preventive measures(Hong, 2009). As the measurement of the relationship between health consciousness and health behavior is still emerging in literature, more work in this aspect is needed to understand how understanding health impact anemia in a specific population.
This study is not without limitation including its cross sectional design, inclusion of convenient sample number because data was collected during time of corona. Also males and participants from refugee camps were under-represented. However, this study according to author knowledge is the first to address knowledge about anemia is related to health and general education.
In conclusion, in a sample of female and male students from schools of medicine, pharmacy and nursing schools who were taught on anemia as part of teaching material in a clinical nutrition offered as part of curriculum. Students show good level of nutrition awareness especially on causes and consequences of anemia. Aspects such as anemia in infancy and some forms of anemia such as favism and sickle cell anemia needs further work. Amongst several micronutrients deficiency, vitamin D deficiency was associated with better knowledge of anemia indicating better health consciousness. Income, gender, parents education seem to be important factor in health knowledge achievement.