EXPERIENCE AND REASON |
Low Compliance of Iron Supplementation in Infancy and Relation to Socioeconomic Status in Israel
* Departments of Pediatrics
Biostatistics, Edith Wolfson Medical Center, Sackler School of Medicine, Holon, Israel 58100
Israeli Clalit Medical Services, Tel Aviv, Israel
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONPARTICIPANTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Objective. To evaluate the compliance of parents in purchasing iron-containing drugs for their infants. In addition, we looked for possible socioeconomic characteristics of the parents who prevent their infants from accessing these medications.
Design. All infants (4–12 months) whose parents bought (from January to August 1999 and from January to August 2000) the iron-containing drugs as recommended by the Israeli Ministry of Health were retrieved from a database. The socioeconomic status of the citizens was determined according to the "mean real income" (INCMV) and "relative income" (INCMS). The percentage of parents who purchased the medication from each district was compared with the socioeconomic status of this population.
Results. Forty-four pediatricians’ offices in the Tel Aviv metropolitan area were included. The data of 4929 infants was summarized. Only 27% of the parents bought the drugs. Only 11.5% to 20% of parents from the 5 highest socioeconomic classes purchased the medication compared with 43.6% to 57.1% of the parents from the 5 lowest socioeconomic classes.
Conclusion. There was low compliance by parents in obtaining iron-containing medications for their infants, mainly among parents from high socioeconomic classes.
Key Words: anemia • iron deficiency • in-fancy • ferrum-containing medication
Abbreviations: ID, iron deficiency
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONPARTICIPANTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Iron deficiency (ID) continues to be one of the most prevalent single nutrient deficiencies in the world.1 ID anemia in infancy may affect psychomotor development as well as mental and motor functioning for >10 years to come.2 According to the recommendations of the Israeli Ministry of Health, all infants (4 months to 12 months) are expected to receive iron supplementation (7.5 mg iron daily to age 6 months and 15 mg to 1 year). The day care nurses and Israeli pediatricians repeatedly emphasize the importance of iron supplementation for infants’ growth and psychomotor development.
Unfortunately, there is still a high frequency of ID among infants and children in Israel,3 as well as in the United States4 and developing countries.5
We conducted this retrospective study to investigate the compliance of parents in supplementing iron-containing medications to their infants. We looked for possible socioeconomic characteristics of the parents who declined to give their infants these drugs.
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PARTICIPANTS AND METHODS |
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TOPABSTRACTINTRODUCTIONPARTICIPANTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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The study involved pediatricians’ offices in the Tel Aviv metropolitan area, encompassing children of varied socioeconomic status. We used a database to locate the infants whose parents bought (from January to August 1999 and from January to August 2000) the iron-containing medication as recommended by their pediatricians and nurses in the day care. A prescription from a physician is required to get the medication. The information has been gathered from all available pharmacies.
The socioeconomic status of the citizens was determined according the following parameters: "mean real income" (INCMV) and "relative income" (INCMS). The percentage of parents, who purchased the medication from each district, was compared with the socioeconomic status as reflected by the INCMV and INCMS of this population.
Statistics
Descriptive statistics are presented as means + standard deviation. In separate linear regression analyses (least squares method) mean community "real" and "relative income" values were used to predict the number of prescriptions written for oral iron supplementation in community clinics. All tests are considered significant at P < .05.
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RESULTS |
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TOPABSTRACTINTRODUCTIONPARTICIPANTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Forty-four pediatricians’ offices in the Tel Aviv metropolitan area were included. The physicians take care of
600 000 people. The data of 4929 infants, age 1 to 12 months, was summarized. All parents were instructed to give ferrum-containing medication to their infants. Only 27% (mean) of the parents bought the medication. More precisely, only 11.5% to 20% of parents from the 5 highest socioeconomic classes purchased the medication, compared with 43.57% to 57.14% of parents from the 5 lowest socioeconomic classes. The difference between the compliance of the highest and the lowest socioeconomic classes was statistically significant (P = .003).
The regression of ferrum purchase using INCMV as the predictor variable was significant (P = .003). There was an inverse association between income level and percentage of children whose parents received the drug.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONPARTICIPANTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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ID is the single most common nutritional disorder worldwide and the main cause of anemia in infancy and childhood. Much has been written on the nutritional aspects of ID and the ways to prevent this problem. Little information, however, is available regarding parents’ compliance in providing iron-containing medications to their infants.
In this study we showed that only 27% (mean) of parents buy the drug to comply with the official recommendations of iron therapy to infants. Kruske et al6 reported 12% compliance in iron administration to anemic children. The compliance rate of adolescents taking their prescribed medication for ID was higher (67%).7 Reasons for noncompliance with ID treatment include the following: inadequate program support, insufficient service delivery, and patient factors (misunderstanding instructions, side effects, frustration about length of treatment, and fear of side effects related to the medication).8 It may be speculated that compliance of preventive treatment for a long period is even worse than that of therapy for an actual disease.
Because most infants in this area of Israel do not breastfeed and not all milk substitutions are sufficiently iron-fortified, it is the role of iron supplementation to combat ID and ID anemia.
It is interesting that the low-income parents purchased the drug more often than higher-income parents. There was an inverse correlation between the socioeconomic status and the percentage of parents who bought the medication.
We are aware of the differences among the populations of various countries in mentality, education, culture, and civil obedience. Our results are valid only to the involved populations. Two reasons may explain the differences in compliance between the 2 socioeconomic groups: 1) higher-income parents tend to supplement their infants with iron-fortified "alternative" medications, and 2) low socioeconomic groups tend to obey the authorities more readily compared with wealthy citizens.
In conclusion, a meticulous and intensive public campaign is needed to augment awareness of the importance of iron supplementation for infants’ well-being.
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FOOTNOTES |
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Received for publication Nov 14, 2001; Accepted Apr 17, 2002.
Address correspondence to Ami Ballin, MD, Edith Wolfson Medical Center, Holon, Israel 58100. E-mail: ballin{at}netvision.net.il
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REFERENCES |
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- Olivares M, Walter T, Hertrampf E, Pizarro F. Anemia and iron deficiency disease in children.
Br Med Bull.1999; 55
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- Ballin A, Amsel S, Tavdi A, et al. High prevalence of iron deficiency in the pediatric population of Israel. Int J Pediatr Hematol Oncol.2001; 7 :407 –912
- Bogen DL, Krause JP, Serwint JR. Outcome of children identified as anemic by routine screening in an inner-city clinic.
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[Abstract/Free Full Text] - Galloway R, McGuire J. Determinants of compliance with iron supplementation: supplies, side effects, or psychology? Soc Sci Med.1994; 39 :381 –390
PEDIATRICS (ISSN 1098-4275). ©2002 by the American Academy of Pediatrics
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