SOCIAL REPRODUCTION AND ANEMIA IN INFANCY

Disponible en castellano/Disponível em língua portuguesa SciELO Brasil www.scielo.br/rlae 1 Study funded by the National Council for Scientific and Technological Development, CNPq, Process no 478872/2004-6; 2 PhD in Public Health, Associate Professor, e-mail: efujimor@usp.br; 3 Nursing undergraduate student. University of São Paulo, School of Nursing, Brazil; 4 Doctoral Student, University of São Paulo, School of Nursing, Professor at Faculty of Medical Sciences of Santa Casa Sao Paulo, Brazil; 5 M.Sc. in Nursing; 6 M.Sc. in Nursing, RN, Secretary of Health, Itupeva City Administration, Brazil SOCIAL REPRODUCTION AND ANEMIA IN INFANCY


INTRODUCTION
Iron deficiency anemia is the most common nutritional disorder worldwide.However, its magnitude is higher in the poorest regions, where about 40% of the children below 4 years old are anemic, a proportion twofold greater than that estimated for industrial countries (1) .
The recognized relevance of anemia is not only because of the magnitude of its prevalence, but mainly due to the deleterious effects that it leads to.In children it has been associated with psychological and motor development retardation, compromised cellular immunity, and decrease in the intellectual capacity, with effects in cognitive development (1) .
In the body, anemia occurs from the inability of the erythropoietic tissue to keep a normal hemoglobin concentration, because of poor iron supply.Thus, anemia is defined as a state in which abnormally low hemoglobin concentration results from a previous iron deficiency that led to depletion of iron stores (1) .In this perspective, iron deficiency is an organic problem resulting from biological processes; it is consequence of poor iron absorption and/or depletion of this mineral.However, its occurrence has been associated with adverse social and economic conditions frequently due to inadequate food intake and depletion from parasitic infestation, in places where sanitation is poor (7) .
The field of collective health sees healthdisease process as socially determined.In this view, articulation between the social and the biologic occurs through social reproduction, that is, through the way each social group is inserted in work and life (8) .The

METHODOLOGY
This is a descriptive analytical cross sectional study that assessed data from a broader project called "Prevalência de anemia e fatores de risco em crianças menores de dois anos de idade" ("Prevalence of anemia and risk factors in children below 2 years of age"), developed in the city of Itupeva, SP, Brazil.In this greater study, the sample size was calculated based on an estimate of the number of children below 2 years of age, the number of houses in the urban area of the city, and considered estimated prevalence of anemia at 45% in order to assure representativeness of the population (6) .Based on the procedure of conglomerate samples, a sample size of 274 children was obtained, error accepted was up to 5%, and the prediction for losses and refusals was 10%.Randomization was performed into 3 stages (census sectors, blocks, and individual households) and the final sample was composed of 261 children.
Hemoglobin measure was obtained from 254 children.
A pilot study was performed into around 10 families.At this time, instrument of interview was tested and the logistic of field work was put into practice to assess its performance.For data collection, household interviews were performed between July/ August 2001 by nurses and trained nursing students.
The instrument of interview included closed questions with details on ways of working and living, as well as biological and health data.
Profiles of the social reproduction of the families were characterized using theoretical, methodological, and operational bases (9) .This base Anemia was diagnosed based on the concentration of hemoglobin (Hb) determined by HemoCue system, which with only one drop of capillary blood presents the immediate result on the screen.Hb concentration < 11.0 g/dL was used as a cut off point to define anemia (1) . The

RESULTS
Anemia prevalence was 41.7%.    ; greater risk of anemia for children with two or more siblings below 5 years of age (3) .A study assessing the efficiency of fortified cow's milk for anemia prevention in children below 4 years of age showed a significantly greater decrease of anemia in families with only one child below 5 years of age, in comparison to those with two or more children below 5 years old (13) .For these authors, data suggest that in families with more young children, the demand for food is greater and they might not be always available in reasonable quality and quantity.Furthermore, it is known that the greater the number of small children in families, the less attention is given to each of them, including care regarding food and health in general (3) .
Maternal insertion at work was high and did not differ among the groups.Its relationship to anemia could be analyzed in two ways: lower risk of anemia because a paid job can increase/complement family income and though determine better conditions of life, or greater risk due to difficulties in maternal care (14) .
Studies however, have not found association between this variable and the development of anemia (2,4)   .Anemic children characteristics did not show differences according to social groups, although there was a mild tendency of worse nutritional status, less access to medical appointments, greater frequency of health problems, and presence of intestine parasites in the less favored groups.This result point out the importance of a social approach to the problem of anemia, not only as a problem focused on the biological aspect (7)   .

FINAL CONSIDERATIONS
This study was carried out with the perspective of social stratification, considering the difficulties of working with the concept of social class (15) .Despite this fact, composed indicators were This fact is especially important when considering relationship theory/practice in the field of collective health, because the field of public health has traditionally based its proposals for intervention "in a knowledge that gives priority, or in fact reduces the explanation of the health/disease process to a simple biological determination, centered on the human body.
This would limit and confine finding concrete possibilities to "solve" the problem and may even hide it" (7) .
categories to study and explain how the social process interferes in collective health-disease relate to the forms of social insertion, that concern both ways of working and ways of living, with positive or negative impacts in individuals exposing them to different risks to fall ill and to die.The present study was structured under the theory of social determination of the health-disease process.The objective was to assess how infant anemia is related to the forms of social reproduction of the families.
broader research was approved by the Ethical Research Committee of the School of Nursing of the University of São Paulo.Blood sample was only obtained after written consent was given by mothers/ responsible, and the Hb result was returned to the family.Anemic children were sent to a reference health unit as previously agreed with the Municipal Health Agent.Data were analyzed using Epi-Info program version 6.04 and the module Epi-Nut to assess the nutritional state.Chi-square test (χ 2 ) was used to analyze the difference between categorical variables, and variance analysis (ANOVA) was used for statistical comparison between averages.A p < 0.05 was considered statistically significant.

a
Number of families with anemic children in each social group b There was no information for the total of the sample; value of the minimum wage at the time = R$ 180.00 c Variables that differ significantly from Chi-square test (p<0.05)d At least one family member has or practices these attributes e At least one benefit related to health Table 3 shows that the ways of insertion in work and in life differed considerably among the three groups.Mean PCFI was significantly different among the social groups, as well as the activity sectors, and position in work.In upper and intermediate Social reproduction and anemia... Fujimori E, Duarte LS, Minagawa AT, Laurenti D, Montero RMJM.Rev Latino-am Enfermagem 2008 março-abril; 16(2):245-51 www.eerp.usp.br/rlaegroups almost all families lived in houses with a bathroom inside the household and had public sanitation, which was not observed in the lower group.Home utilities and reading (one of the measures of leisure activity) also showed to be different among the groups.Table 3 -Distribution of families of anemic children, according to ways of working and living and social groups.Itupeva, SP, 2001 Table 4 -Distribution of families of anemic children, according to sociodemographic data.Itupeva, SP, 2001 a Chi-square test b There was no information for the total of the sample c Total of workers and families with anemic children in each social group d ANOVA e Number of families with anemic children in each social group Social groups were also different in relation to sociodemographic data.
used and it must be considered the limitations regarding the risk of not having chosen the variables for building the groups appropriately.Even facing those technical limitations, it was tried to explore as much as possible all the chances of getting closer to the profile of social reproduction revealed by the groups.Indeed the theoretical bases helped to explain how each social group creates a certain pattern regarding the development of anemia in children.The results reiterate that the anemia in infancy is related to inappropriate ways of working of the lower social groups and consequently inappropriate ways of living.These evidences should subsidize the interventions that aim at reaching the origin of the problem.

Table 1
shows that the distribution of children according to anemia and social groups was considerably heterogeneous, however, no statistical significance was observed (p>0.05).Frequency of anemic children was less observed in families in the upper group (13.2%), while 40.6% of anemic children belonged to families in the intermediate group, and 46.2% in the lower group.

Table 1 -
Distribution of children according to anemia and social group.Itupeva, SP, 2001 *Chi-square test

Table 2 -
Distribution of families of anemic children,

Table 4
a ANOVA b Number of families with anemic children in each social group c There was no information for the total sample d Chi-square test

Table 5
presents anemic children characteristics according to the social group they belonged to.Despite the similarities, since statistical treatment did not show significant differences, the poorest groups presented worse nutritional status, less access to pediatric appointments, and greater frequency of respiratory problems, as well as presence of parasites.

Table 5 -
Distribution of families of anemic children, according to children characteristics and social groups.Total of families with anemic children in each social group c ANOVA d There was no information for the total of the sample Social reproduction and anemia... Fujimori E, Duarte LS, Minagawa AT, Laurenti D, Montero RMJM.
a Chi-square test b