STUDY DESIGN

Analytical and cross-sectional study. A secondary analysis of the information contained in the ENDES 2021 database⁹, and information collected by the INEI 2021 was developed. The impact of CRED on anemia in Peru in 2021 was analyzed.

POPULATION, SAMPLE, AND SAMPLING

The population of this study consisted of children under five years of age residing in homes within the Peruvian territory.

The statistical and cartographic information from the XII National Population Census and VII National Housing Census of 2017 was used to select the sample. The sample type was two-stage, probabilistic, balanced, stratified and independent, at the departmental level, by urban and rural area. The sample size was 36,760 households, grouped into 14,840 households in the headquarters area (departmental capitals and the 43 districts that make up Metropolitan Lima), 2,260 households in the rest of the urban area, and 12,660 households in the rural area. The sample distribution was estimated after evaluating the results obtained with the implementation of the ENDES surveys carried out from 2012 to 2020 and the design guidelines previously established for this purpose¹⁷.

After filtering, 22,741 children under five years of age were taken from the ENDES database.

INCLUSION AND EXCLUSION CRITERIA

All children under five years of age of mothers interviewed in the field were included.

Children whose mothers were not interviewed in Module 1634 and 1638, were excluded.

Children who did not have data in the variable Hc57 were also excluded.

According to the aforementioned criteria, a final sample size of 20,614 children under five years old was obtained.

VARIABLES

The study variables were taken from the data present in ENDES 2021.

As the dependent variable: Anemia level (Hc57) and as independent variables: She had any growth and development control (S466). The growth and development control was performed by: doctor (S466aa), obstetrician (S466ab), nurse (S466ac), nursing technician (S466ad), health promoter (S466ae), other (S466ax). They performed growth and development control (S466b); and as intervening variables: Area of residence (Hv025), Wealth index (HV270), sex (Hc27), age in months (Hc1), mother's highest educational level (HC61)⁽¹⁸⁾.

DATA COLLECTION TECHNIQUES AND INSTRUMENT

The present investigation used a secondary data source collected by the household and individual questionnaire of the modules household characteristics (1629), housing characteristics (1630), weight and height - anemia (1638) and immunization and health (1634) of ENDES 2021⁽¹⁸⁾, which can be found at http://iinei.inei.gob.pe/microdatos/. Therefore, ENDES was the source that provided the information on the study variables for this research.

ANALYSIS PLAN

To collect the data, we accessed the INEI of Peru web page, followed by the microdata option, query by survey, and selected ENDES for the year 2021 with a single period. Subsequently, the files of the study variables were downloaded. We continued with the database merging of the four modules, and then debugged and left only the variables of interest and adjustment variables, the weighting factor (HV005), stratum (HV022), and cluster number (NCONGLOME).

The SPSS Statistics Data Document Version 25 statistical package was used for the statistical analysis. The data were estimated in point and relative frequencies, with weighted proportions considering complex sampling, with an analysis of the dependent and independent variable, through the Chi-square test.

ETHICAL ASPECTS

The survey database provided by INEI is accessible to the general public, so the confidentiality of the participants was respected.

GENERAL ASPECTS

For the analysis, 20,614 children from the different departments of Peru were included. The results show that 67.9% of the children under five years of age were from urban areas and 32.1% from rural areas. According to sex, 50.7% corresponded to males and 49.3% to females; 3-year-old children predominated with 22.9%; 21.3% of 4-year-olds and 15% of children under 1 year of age.

According to the mother's educational level, 66.1% had high school and only 1.2% corresponded to the item with no education. According to the wealth index, 30.3% were the poorest and 9.3% were the richest (Table 1).

GROWTH AND DEVELOPMENT CONTROL

According to Table 2, 56.2% of children under five years of age underwent a CRED, and 61% corresponded to rural areas.

Likewise, according to where the CRED was performed, 41.4% corresponded to a health post and 39.4% to a Minsa health center.

According to Table 3, 48.7% of the health personnel who performed CRED on children under five years of age were nurses.

ANEMIA IN CHILDREN UNDER FIVE YEARS OF AGE

According to Table 4, the prevalence of anemia in children under five years of age was 31.4% and 22.9% corresponded to mild anemia.

According to area of residence, 38.3% were from rural areas, while 28.2% were from urban areas. According to sex, 34% of men and 28.8% of women had anemia. And according to age, 56.9% of children under one year of age had anemia, while only 15.9% of children under four years of age had anemia. Of these, there was a statistically significant difference (p<0.001).

According to the mother's educational level, 38.1% of children of mothers with primary education and 22.2% with higher education had anemia.

Likewise, according to the wealth index, 40.8% of the poorest compared to 17.5% of the richest with children under five years of age had anemia. There was a statistically significant difference (p < 0.001) in these selected characteristics.

CREDIBILITY AND ANEMIA IN CHILDREN UNDER FIVE YEARS OF AGE

According to Table 5, the prevalence of anemia in children under five years of age in relation to whether they had a CRED was 32.4% and in children who did not have a CRED was 30.2%, with a statistically significant difference (p<0.05).

And according to the place where the CRED was performed, there were no significant differences.

Likewise, it was observed that 32.4% of children treated in a health facility had anemia, as well as 35.6% of children treated in a hospital, 33.3% in a health center and 31.7% in a Minsa health post.

And, finally, according to Table 6, there were no significant differences in relation to the health personnel who performed the CRED, except in the CRED performed by the nurse where 32.9% had anemia, and a statistically significant difference was evidenced (p < 0.001).

ANEMIA IN CHILDREN UNDER FIVE YEARS OF AGE

Anemia is a public health problem that not only affects Peru but also several countries in the world. It mainly affects children, who are the most vulnerable group negatively, since it has serious consequences,¹⁹affecting even the growth and cognitive development of children.²⁰It has been shown in various investigations that the prevalence of anemia is worrying and alarming since it carries a great risk in the development of the country²¹.

According to the results found in the study, anemia in children under five years of age is 31.4%; according to the type of anemia, 0.1% is severe, 8.5% is moderate and 22.9% is mild. In studies conducted in other countries, there are similar data, among which is the one conducted by Kebede et al.²², who found a prevalence of 48.9% of anemia: 25.0% was mild and, in contrast, 15.8%, moderate and 8.2%, severe. In contrast, a study conducted in Brazil by Dos Santos et al.²³, estimated a prevalence of anemia of 56.6%. It is evident that anemia is a serious public health problem in our country that affects children under five years of age.

In addition, a higher concentration of anemia prevalence was observed in children living in rural areas at 38.3% compared to urban areas at 28.2%; several studies agree with this result, such as Moyano et al.¹⁹, who mentions that anemia is mainly related to living in a rural area. In his study of Ecuadorian children, he found that 67.3% of children living in rural areas and 32.7% living in urban areas had anemia, with a statistically significant difference (p < 0.05). With this, it can be assumed that the disparity is very critical in the provision of health services in rural areas, since it is limited by lack of resources, geographic accessibility, among others.

Likewise, Moyano et al.¹⁹report that the prevalence of anemia is higher in boys than in girls, which may be related to the absolute physical growth of boys compared to girls. According to the results found, this reference can be evidenced where 34.0% of boys compared to only 28.8% of girls. It is worth mentioning that, according to Puente et al.²⁴, the sex variable is an associated factor, but not a risk factor, as well as the fact that boys are more likely to have anemia than girls.

Li H et al.²⁵identified that, in the six to 11 months age group, the prevalence of anemia was the highest with 22.3%, which we can contrast with the results obtained in the study, which shows that 56.9% of children under one year of age have anemia, being the highest value compared to the other age groups. In a study conducted by Li S et al.²⁶in China, also, it was evidenced that the prevalence of anemia among children from zero to 23 months was high with 22.15%; in another study, Mboya et al.²⁷mentioned that it is a problem mainly in children from six to 23 months; the results found in the study are related to these studies, as shown in the group of children under one year and one year old, the percentages are high compared to the rest of the age groups.

According to the other selected characteristics, the level of education of the mother has statistically significant differences, since it was found that children of mothers with no education or only primary and secondary education have anemia in 33.5%, 38.1% and 32.0%, respectively, in contrast to mothers with higher education who have only 22.2% of anemia. According to Al et al.²⁸, the prevalence of anemia is 40% more frequent when the mother has a primary education or no education at all; in addition, she mentions that children of mothers with higher levels of education consume more protein and iron from animal sources. Thus, it can be inferred that the prevalence of anemia decreases with the increase in the mother's educational level and that it could be related to better healthy practices.

Al et al.²⁸, mentioned that the poorest and poorest wealth indexes were found to have 23% and 19%, respectively, more prevalence of suffering from anemia than the average index, in addition to the richest and richest indexes having protective factors. According to the results obtained, it is observed that 40.8% of the poorest, 33.8% of the poorest, 27.3% of medium index, 22.3% of the richest and 17.5% of the richest show that there is a significant difference, since the lower the wealth index, the higher the prevalence; as mentioned by Vasquez et al.²⁹, low socioeconomic status, low educational level, among others, are factors associated with the prevalence of anemia, so this characteristic has implications for the quality and timeliness of access to health care, as well as nutritious food.

ANEMIA AND CREDIT IN CHILDREN UNDER FIVE YEARS OF AGE

Since the beginning of the pandemic, the health difficulties in the world have been evident and Peru is no stranger to this. As a result, the different health problems were not addressed as stipulated²⁹

According to ENDES, in 2021, 43.7% of children did not receive a CRED, and only 56.2% received a CRED. This could be due to the decrease in coverage during the pandemic, as they may not have attended health facilities for fear of contagion and the delay in patient care.

According to the results obtained, 32.4% of children under 5 years of age have anemia even though they had CRED and 30.2% of children who did not have CRED also have anemia. Therefore, it can be assumed that CRED is not being as effective as one of the key interventions proposed in the National Plan or that the quality of CRED implementation is not adequate.

This is also supported by the results found in relation to the place where the CRED of children under five years of age was performed; according to this, 35.6%, 33.3% and 31.7% that are performed in a hospital, health center and Minsa health posts, respectively, have anemia. To this, Vasquez et al.²⁹supported the hypothesis of whether the policies have been based on scientific evidence, since even after implementing the interventions proposed by the State, the prevalence of anemia does not decrease. In spite of this, the relationship between anemia and the place where the CRED was carried out was not found to be significant.

In a study conducted by Mansilla et al.³⁰, it was shown that the Strategy for Comprehensive Growth and Development has a significant effect on anemia. It also mentions that the educational and follow-up components could be of great help in combating anemia. According to the results obtained, 48.7% of children under 5 years of age are monitored by the nurse, who is responsible and has the function of developing the CRED according to Minsa regulations³¹; however, of these, 32.9% have anemia. It can be assumed that the CRED care provided is not of high quality or that the professional is not adequately trained to provide care, so it does not imply a change in the reduction of anemia.

Díaz¹⁵believes that the pandemic is what may increase the prevalence of anemia, but that cases can be reversed with multidisciplinary interventions in health, education, labor and economy. However, Vasquez et al.²⁹mentioned, in their analysis, that, despite the fact that national surveys show that preventive and therapeutic treatment of anemia decreased, the percentages of anemia prevalence did not increase during the pandemic, and referred that this maintains similar values to the year 2019, suggesting that anemia is not iron deficient. In addition, Zavaleta³²mentions that several studies have shown that the prevalence of anemia in the last five years has not changed, which constitutes a challenge to carry out a comprehensive work on children under five years old that involves the government, the family and the community.

ENDES is one of the most representative surveys at the national level, since it provides a database of household characteristics as well as family health; however, the present study presented factors that limited the research. First, the study's cross-sectional design does not allow establishing a cause-effect relationship. Finally, since it was a database for a secondary study, only the convenient variables from the ENDES questionnaire were used to develop the study. However, the findings are sufficiently solid to justify an immediate review of current policies and interventions related to anemia and CRED, taking into account the area of residence and socioeconomic factors.

In conclusion, anemia is a public health problem conditioned to various factors and determinants: rural residence area, children under two years of age, low educational level of mothers and low wealth index. According to the results found, CRED has a significant relationship with the prevalence of anemia; however, the impact of CRED on the reduction of anemia is neither negative nor positive, it is ambiguous, according to ENDES 2021 data. And this is corroborated by the presence of the pandemic, in which many of the interventions related to the National Plan for the reduction of anemia were limited, including CRED. According to some authors, the prevalence of anemia did not increase, so they have assumptions about whether the State's strategic interventions are having the desired and expected impact and whether they are based on scientific evidence. Despite several State initiatives, the efforts have not been sufficient to reduce the prevalence of anemia³³, since, according to the study developed, there is no evidence of this.

Finally, the findings suggest an immediate intervention by the health governing body and the State to improve the quality of appropriate CRED care practices for children under five years old in health facilities.