Assessment of Current Surveillance System of Anemia among Children 9-12-months old in Armenia

Abstract

Aims: The specific aims of the study were (1) to explore perceptions of health care workers and administrators at different levels about analysis and utilizations of anemia screening data, (2) describe and analyze the chain of information flow on anemia from primary health care facilities where the screening is performed, and (3) to develop recommendations for a system which will give an opportunity to systematically calculate periodic prevalence of anemia in 9- 12 month old children. Background: Anemia is a significant public health problem in Armenia. According to Armenia Demographic and Health Survey of 2005, 67.9% of children 9-11 months of age suffer from anemia: 20.9% of them have mild, 39.5% have moderate, and 7.5% have severe anemia. Anemia screening and the effective use of surveillance data is necessary and important to control its rates. According to the Ministry of Health order, in Armenia screening of anemia in children is done at 9(up to 12) months old, at 12 (up to 15) years old, and at the time of applying for kindergartens and schools. Despite the anemia screening performed at Primary Health Care (PHC) facilities, country does not have well functioning surveillance system, and it only relies on the data collected by the Demographic Health Surveys which are conducted once per five years. The data on anemia prevalence are not processed properly in order to have anemia prevalence, which hinders informed decision making in this sphere. Method: Qualitative cross sectional study design matches the purposes of the study by providing an in-depth assessment of perceived value and need for the proper analysis and use of anemia screening data in Armenia. Purposive and snowball sampling strategy were utilized to select the participants of the focus group and in-depth interviews. Conventional content analysis using single semi-structured interviews with a variety of stakeholders who have perspectives on surveillance policy, implementation, and outcomes was used to describe the current surveillance system for anemia in children and to propose a new or improved system. Findings: Six primary categories emerged while describing the current system of anemia surveillance. Almost all participants considered anemia as a significant problem in Armenia. Different respondents had different assessments of specific anemia prevalence rates. According to most of the respondents, many children up to 5 years old are affected by anemia, and 9-12 months old children are the most vulnerable. Anemia screening at PHC facilities is considered as a very useful tool to detect anemia. Contradicting opinions were expressed by experts and PHC facilities’ physicians on anemia screening coverage levels. The majority of polyclinics perform Sahli method for Hb testing. Some use analyzers, and some use Photoelectric Color Match method. Participants identified numerous problems with anemia screening tests performed in polyclinics that inhibit timely detection of anemia in children. Although anemia data are reported from primary health care facilities to the health care administrators/policy makers, and are presented in the Statistical yearbooks, these data incorporate both diagnoses of children based on their active visits (at the moment of taking medical advice) and diagnoses that come from some prophylactic visits (i. e. screening). However, these data are not separated from each other and cannot reflect anemia prevalence in children precisely. Besides, there is no anemia as a separate category in the Statistical yearbook: anemia data are combined with other blood diseases and are presented in the section of morbidity of children 0-14 and 15-17 years old as “blood diseases and other hematogenic disturbances”. Moreover, data are not categorized into the specific age groups and cannot depict anemia in specific age group we are interested. All participants identified that existing financing is not sufficient for well-functioning anemia surveillance system. Insufficient patient-provider communication leads to poor population coverage with screening. There is a need to set up a new surveillance system that could better reflect anemia prevalence in the children. Conclusion and recommendations: Given the limited resources of the country’s health care system, the use of anemia screening data for specific age groups, performed at primary health care facilities according to the Ministry of Health (MOH) order, is the most feasible way of obtaining anemia prevalence in 9-12 months old children. MIDAS database system which currently generates systematic reports to the State Health Agency on the specific performance indicators linked to primary health care financing is equipped with appropriate software/databases for collecting and calculating anemia prevalence and could therefore serve a basis for the anemia surveillance system. High coverage level of anemia screening is the most important condition for having reliable data. The adequate performance of physicians at PHC facilities is another important condition for appropriate anemia diagnosis and management. This study is the first conducted in Armenia that explores the obstacles for well-functioning anemia surveillance system and provides recommendations for a new or improved surveillance system.