The Impact of a Haitian Anemia Prevention Protocol

After years of working in the United States as a registered nurse and completing an MPH at Brigham Young University and a PhD at the University of Utah, assistant professor Marc-Aurel Martial’s (BS ’00) love for his native home of Haiti has taken him back to study the impact of an anemia prevention protocol in Timo, a remote, ancestral Haitian village.

In 2010, an earthquake of 7.0 magnitude struck Haiti and killed an estimated 300,000 people. Three months after that, Haiti was hit with a cholera epidemic that made things even worse. To address a great need for access to basic public health, nursing, medical, and dental services in rural parts of the country, Dr. Martial founded the nonprofit organization Haiti Health Initiative (HHI) and joined an effort with a Haitian sister organization Inisyativ Sante Peyizan (ISAP).

Currently, Martial’s research is centered in Timo, a small community located at the base of the mountains, accessible only through steep footpaths by foot or mule. Medical help and resources are scarce in this community. Martial’s work is focused on (1) evaluating the outcomes of health services provided by HHI/ISAP, Marc-Aurel Martial, Assistant Professor, PhD, MPH, RN including the Timo Anemia Prevention Program (TAPP) for children and pregnant women, (2) understanding social determinants or factors that contribute to disease in the community, and (3) making culturally congruent recommendations for managing complex health problems in settings with limited resources.

Anemia is a moderate-to-severe public health epidemic in Haiti, affecting 49 percent of women of reproductive age (15–49 years) and 66 percent of infants, toddlers, and preschoolers (6–59 months). The mortality rate for children under five in Haiti is more than twice the child mortality rate of the Dominican Republic. In such a compromised community as Timo, anemia prevalence rates are much higher. In a child’s early life, the presence of an anemic condition means experiencing shortness of breath, fatigue, stunted growth, a weak immune system, and learning deficits. As children grow into adults, lack of improvement in their condition can contribute to psychiatric disorders, lower productivity, and social disadvantage. In short, a child’s untreated anemia can lead to a much lower quality of life for the rest of their lives.

This iron deficiency is a multifaceted global health problem. In developing countries, it tends to be intergenerational because social disadvantage, cultural norms, and sanitary conditions often cause it to endure, and lifestyles are passed down from parent to child. Anemia can perpetuate poverty because it is likely to interfere with an individual’s ability to work. Despite collaboration between the Haitian Ministry of Health and Population and local and international partnerships to address the problem, anemia’s prevalence has increased. The TAPP is an effort to implement an evidence-based, multifaceted, and transcultural program to curb the anemia epidemic among children and women and meet the people’s social and safety needs.

In implementing the TAPP, Martial has organized biannual outreach clinics since 2011, staffed by local Haitian nurses and community health workers aided by American and Canadian nurses, doctors, and pharmacists. During free outreach clinics, clinicians administered anemia treatment (vitamin A and Albendazole, an anti-worming medication) to local children with their parent’s permission. They also dispensed iron-rich multivitamins for the child’s daily consumption at home and offered medication counseling and education related to water, sanitation, hygiene, and nutrition to parents. Following this education, parents received hygiene kits and shoes for their children, which decreased their child’s exposure to soil-borne helminths, leading cause of anemia in underdeveloped countries. HHI/ISAP also sponsored a community water project that provided water from underground springs to 53 fountains.

Martial’s research demonstrated that TAPP was important in improving or stabilizing anemia in children aged Research ZAK GOWANS Educating families is part of Dr. Martial’s research to understand the factors that contribute to anemia. 6–59 months. Following its implementation, anemia prevalence among this age group decreased from 83.2 percent to 62 percent if they attended three clinics or more. Overall, children showed improvement in their anemic conditions, and parents reported similar observations reflected in the child’s health. Parents also said that several positive factors that influenced clinic attendance were (1) receiving an invite or a reminder from a friend or a nurse and (2) having a short waiting time once they arrived. If the lines were too long, parents would often leave before receiving treatment. The number of clinic visits was the strongest indicator of improvement, demonstrating a distinct additive effect of multiple clinic visits.

The research also exposed areas for the TAPP to improve. For example, there was no direct effect attributed to the iron-rich multivitamin. However, many mothers reported that their children refused to take the vitamin pill because they did not like how it tasted. In some families, the lid was left off the bottle, and the vitamin’s oxidation caused it to lose potency. Older siblings and even parents would often take some of the vitamins rather than the children, which leads to underdosing. Study results showed that Haitian mothers were aware of the food groups that make up a nutritious diet. Still, those healthy foods were unaffordable due to a lack of employment opportunities in the country. Some mothers reported that nurses were not aware of their financial state, “which may diminish our ability to follow what they told us,” as one mother says. This mother explained an important phenomenon: the primary cause of malnutrition was not a lack of knowledge but rather a lack of compliance with dietary guidelines due to social disadvantage.

This social disadvantage was further evidenced by the consumption of contaminated river water, which is the only drinking water option for many living further in the countryside. Several families also reported they did not buy shoes for their children or build or maintain sanitary facilities because of their economic circumstances. Many families also consume cornmeal multiple times every day, which is an iron-rich food. However, cornmeal has low bioavailability, which means that the body does not absorb much iron from it.

Martial’s work in Haiti is making a significant contribution to the health and development of a remarkably impoverished community and nursing science. The anemia study results among children show that improvement is possible but complex and difficult. Martial’s research demonstrates that often vulnerable individuals know about problems and generally intend to follow health guidelines, but many experience nearly insurmountable social barriers that prohibit them from doing so. Martial believes that the first step to providing culturally congruent care is recognizing and acknowledging that compliance with health recommendations is complex. Rather than tell patients what to do, nurses and other health providers should show compassion as they inform patients of the impact of health behaviors and help them explore locally feasible alternatives. Finally, healthcare providers should be responsive by adjusting clinic protocols, workflows, and processes to accommodate special populations’ needs.

Martial’s work to lift the people and improve their quality of life will continue to bless the isolated community of Timo and other marginalized and underserved communities worldwide. His research in Haiti will progress as he received BYU IRB approval to study anemia in pregnant and lactating women. Even during a pandemic, he continues recruiting and training local research assistants via video conferencing to proceed with interviews, following Haitian Ministry of Health and BYU COVID-19 guidelines.

Full Name: Marc-Aurel Martial
Grad Year: BS '00
College: Nursing
Original Post Date: Spring 2021
Author: Marc-Aurel Martial

Originally published in Learning the Healer's Art, BYU College of Nursing magazine