ANEMIA IN CHILDREN UNDER FIVE IN CÔTE D’IVOIRE: A SOCIOLOGICAL PERSPECTIVE

DOI: https://doi.org/10.26758/16.1.41

Address correspondence to: Adou Serge Judicaël ANOUA, Department of Anthropology and Sociology, Alassane Ouattara University, BP V18 Bouaké 01, Bouaké, Côte d’Ivoire. Ph.: +225 0707070136; E-mail: anouaadou@gmail.com, https://orcid.org/0000-0001-9434-0839

Abstract

Objective. Anemia is the third leading cause of morbidity among children under 5 years of age in Côte d’Ivoire. However, the reduction of risk factors remains a major challenge. This study aims to analyse the cultural perceptions of mothers and their prevention and care practices for anemia in children under 5 years of age in Côte d’Ivoire.

Material and methods. An explanatory sequential mixed-methods design was conducted from 4 November to 23, 2024, with 200 mothers from the Dar-Es-Salam neighbourhood. Data were collected through a questionnaire and an interview guide focused on knowledge and practices related to childhood anemia, and then analysed using SPSS software and a thematic approach.

Results. A majority (62%) of mothers were unaware of childhood anemia, with higher rates among adult mothers (68%), married women (35%), and merchants (26.5%). Additionally, 13.5% of mothers underestimated disease severity. Regarding prevention, 40% combined nursing care with traditional medicine, and 39% adopted a dual therapeutic approach. The use of mixed care was influenced by the proximity, cost, and perceived effectiveness of treatments.

Conclusions. Sociological resistance perpetuates delays in recognising anemia and accessing appropriate care. Continuous health education tailored to cultural realities is essential for improving the management of this disease in children under 5 years old.

Keywords: anemia, child, representation, sociological resistance, child health

Suggested citation (APA):

Anoua, A. S. J. (2026). Anemia in children under five in Côte d’Ivoire: A sociological perspective. Anthropological Researches and Studies, 16, 645-668. https://doi.org/10.26758/16.1.41

Introduction

Anemia in children under 5 years old is a child health issue at the heart of this research. It is the third leading cause of childhood morbidity in Côte d’Ivoire, with an incidence of 158.66‰ (MSHPCMU, 2021, p. 65).

This widespread issue manifests as a complexity that leads to dramatic consequences for children. Anemia during early childhood has a major impact on cognitive development, growth, and mental health. In this regard, iron deficiency, the main cause of anemia, is associated with impaired cognitive, motor, and socio-emotional development from the earliest years of life (Pasricha et al., 2021). These developmental delays, by affecting cognitive, emotional, and behavioral functions, compromise children’s social interactions and school integration (Scott et al., 2014). Moreover, anemia is believed to reduce children’s ability to form social relationships, manage their emotions, and follow group routines at school and daycare (Prado & Dewey, 2014, pp. 129–138). These factors create barriers to social inclusion, which are often invisible but profound. As a result, these impacts may, in the long term, affect children’s academic performance and their future economic opportunities (Arizmendi et al., 2025).

Beyond this major social challenge, childhood anemia has serious health consequences. Indeed, it is associated with increased child mortality and greater vulnerability to infections (Ekholuenetale et al., 2022). In this regard, a study conducted in the Tonkpi region revealed a high prevalence of anemia among children under the age of 7, closely correlated with the presence of malaria (Ehouman et al., 2022). Additionally, research conducted in Madagascar highlighted several key determinants of anemia, such as iron deficiency and intestinal inflammation, among preschool children living in disadvantaged neighbourhoods (Randrianarisoa et al., 2022). Furthermore, a study conducted in Burkina Faso showed that severe acute malnutrition and malaria infestation were among the main factors associated with a very high prevalence of anemia in rural areas, thus confirming the multifactorial nature of the health risks linked to this condition (Cissé et al., 2020).

This observation reinforces the idea that childhood anemia results from multiple and interconnected factors, including socioeconomic conditions, nutritional practices, parental knowledge, and cultural beliefs. First, several studies emphasise the central role of chronic malnutrition, often associated with anemia, whose causes include food insecurity and low maternal education levels (Ake Tano et al., 2010). Furthermore, household, maternal, and child characteristics significantly influence the prevalence of anemia due to their impact on access to a balanced diet, healthcare, and nutrition education (Kakou Niaminin, 2014). From a nutritional standpoint, inappropriate weaning practices and a diet low in bioavailable iron have been identified as key determinants of anemia (Yessoufou et al., 2015). Additionally, the persistent lack of knowledge about childhood anemia among many mothers, both regarding its causes and prevention, contributes to the persistence of the problem (Segbedji et al., 2017). While some mothers had heard of anemia, their understanding of its links with malnutrition, infections, or malaria remained limited (Azagoh-Kouadio et al., 2023). Moreover, cultural representations strongly influence the caregiving practices. Anemia is sometimes perceived because of modern practices such as early weaning or stopping exclusive breastfeeding (Akindès, 2023) or interpreted as a transgression of food taboos or a symbolic act, such as the killing of a gecko (Silué et al., 2023). These beliefs can delay or divert appropriate care. Simultaneously, the insufficient involvement of healthcare professionals in raising mothers’ awareness constitutes a significant barrier to prevention. Most mothers (90%) have never attended an information session on childhood anemia (Guedenon et al., 2016), and despite a high rate of outreach, more than half display inadequate knowledge of the signs, symptoms, complications, and management measures (Ofori et al., 2020). Finally, other predictive factors have been identified, such as low birth weight, not eating meat and vegetables, and consuming tea or milk, which inhibit iron absorption. These inadequate dietary practices are closely linked to the lack of maternal nutrition education and contribute significantly to the persistence of anemia in young children (Kejo et al., 2018).

Furthermore, the fight against childhood anemia requires the integration of social approaches tailored to local contexts. In Côte d’Ivoire, although the symptoms of anemia are generally well known to mothers, cultural beliefs still influence their understanding of the causes of the disease, sometimes leading them to adopt inappropriate treatments (Akindès et al., 2016). Therefore, the integration of social sciences is essential to better understand these perceptions and adapt health and nutrition interventions to the cultural realities of communities. Among the effective strategies, parental nutrition education has shown positive results, notably a significant improvement in children’s haemoglobin levels, highlighting the importance of parental involvement in prevention efforts (Kamo et al., 2024). In this dynamic, community education focusing on caregivers’ knowledge and good dietary practices also represents a promising approach to reduce the prevalence of anemia (Nwaba et al., 2022). Furthermore, integrated social interventions combining nutrition education, access to healthcare, and strengthening community capacities help overcome obstacles linked to the lack of coordination between the nutrition, agriculture, and health sectors (Abu &Agbadi, 2021). Such approaches have been successfully implemented through programs that combine improved nutrition, malaria control, and community awareness (Mbunga et al., 2021). Moreover, studies have shown that nutrition education programs targeting mothers of anaemic children improve their knowledge and practices and enhance the overall effectiveness of child health interventions (Metwally et al., 2020). Similarly, an integrated program of food assistance, health, and nutrition has proven effective in addressing childhood anemia by strengthening synergies between different sectors (Leroy et al., 2016). Finally, parental education combined with iron supplementation provided by community health workers constitutes an effective complement to medical treatments, promoting a more comprehensive and sustainable approach to the management of anemia (Shet et al., 2019).

An in-depth review of existing studies allows for a better understanding of the scope, complexity, and multiple determinants of childhood anemia. Considering this state of knowledge, several factors emerge that call for critical reflection on current approaches to prevention and management. These findings highlight the need to refocus attention on the specificities of the Ivorian context to better understand the issues surrounding the persistence of this morbidity. Anemia among children under the age of 5 in Côte d’Ivoire constitutes a major public health issue, both due to its scale and severe repercussions on the child’s physical, cognitive, emotional, and social development. This morbidity has a multifactorial origin, combining nutritional, infectious, socioeconomic, and cultural causes. Despite the available medical knowledge, the continued high prevalence of childhood anemia reveals limitations in classical approaches focused solely on nutrition or health. The role of mothers, often poorly informed or influenced by cultural beliefs, appears to be central to prevention, as does the lack of involvement of health professionals in community awareness efforts. Furthermore, integrated programs that combine education, care, and community approaches show promising effectiveness but remain underdeveloped or poorly adapted to local contexts. Consequently, how do mothers’ cultural perceptions influence the prevention and care of anemia among children under 5 years old in Côte d’Ivoire?

From this perspective, the present study aims to analyse the cultural representations of mothers and their practices regarding the prevention and care of childhood anemia in the Ivorian context. To carry out this analysis, it is necessary to describe mothers’ level of knowledge about anemia in children under five, assess the ways of thinking they develop concerning this illness, identify the prevention practices they adopt, and catalogue the different care practices they use to treat anemia in their children. This scientific approach seeks to deepen the understanding of cultural representations associated with childhood anemia, as well as local practices in matters of prevention and care. It also sheds light on the interactions between traditional beliefs and the use of biomedical services while identifying the sociocultural barriers and facilitators that may influence the management of this condition. Thus, the results could provide a solid foundation for developing culturally appropriate public health strategies, contributing to improved prevention and treatment of anemia among children under five years of age in Côte d’Ivoire.

Theoretical Framework

This study is informed by Social Representations Theory, originally developed by Serge Moscovici (1961). The theory explains how shared beliefs, values, and socially constructed knowledge influence individuals’ understanding of health and illness and shape their behaviors. Within the context of childhood anemia, mothers’ perceptions regarding its causes, severity, prevention, and treatment are viewed as social representations developed through cultural traditions, family experiences, and community interactions. Consequently, this theoretical perspective provides an appropriate framework for examining how cultural beliefs influence mothers’ prevention and care practices toward childhood anemia in Côte d’Ivoire.

Materials and Methods

Justification for the choice of study site

This study was conducted in Dar-Es-Salam, a neighbourhood located in the northern part of Bouaké, which is the second largest city in Côte d’Ivoire. The choice of this site was based on several scientific, health-related, and methodological criteria. First, Dar-es-Salam has a high prevalence of anemia among children aged 0 to 5 years. According to data from the Bouaké Nord-Ouest health district, 192 cases of severe anemia and 1,540 cases of moderate anemia were recorded in this age group in 2024. This alarming situation fully justifies the selection of this neighbourhood as the study site to examine the preventive and care practices implemented by the mothers. Additionally, the presence of a nearby health center, regularly frequented by mothers of young children, is an important methodological asset. This center not only facilitates the identification and recruitment of participants but also provides a favourable setting for analysing mothers’ real-life experiences and their interactions with healthcare structures. Finally, the site allows for a comparative approach based on the diversity of mothers’ demographic profiles, particularly considering age range, distinguishing women aged 15–30 years from those 31 and older, marital status, whether married or not, and type of professional activity, whether formal or informal. These variables serve as relevant reference points for a better understanding of the social, cultural, and economic dynamics that influence prevention and care practices in response to childhood anemia. In summary, the choice of Dar-Es-Salam is justified by the convergence of health, cultural, and methodological criteria, in line with the objectives of this study.

Methodological framework and inclusion criteria

From this perspective, the study was conducted according to a sequential explanatory mixed-methods design (Creswell & Plano Clark, 2011), structured in two distinct chronological phases: a quantitative phase, followed by a qualitative phase, carried out between November 4 and 23, 2024. The study population consisted of mothers with children under five years of age before the start of the survey. To be included, they had to have lived in the neighbourhood for more than six months, be available during data collection hours in the morning and afternoon, and give their consent to participate in the study. Conversely, mothers who were only passing through the neighbourhood, those who did not have sufficient command of French, the language used for the questionnaire and interviews, and those whose husbands opposed their participation were excluded.

Collection and analysis of quantitative data

More specifically, in the quantitative phase, convenience sampling (Etikan et al., 2016) was chosen to select mothers of children under five years of age, due to the lack of data on the total number of this target population. Based on this approach, a basic survey was conducted to form a sufficiently large sample of 200 mothers, selected according to their availability, accessibility, and relevant criteria, such as age, marital status, and occupational activity. A sample size of 200 mothers was determined to be adequate. This number of participants would allow enough variability in sociodemographic characteristics and allow for stable descriptive estimates for the quantitative portion of this explanatory sequential mixed-methods study. Sample size was also based on available time, access, and resources. The dependent variables (knowledge, perception, and mothers’ preventive and care practices regarding childhood anemia) were measured using a closed-ended questionnaire. The data collected were analysed using SPSS software. The sociodemographic characteristics of the participants were described using descriptive statistics, such as means and percentages. Finally, a descriptive statistical analysis (De Veaux et al., 2016) was conducted to assess the influence of mothers’ beliefs and practices on risk factors associated with childhood anemia.

Collection and analysis of qualitative data

Following the quantitative analysis, a qualitative phase was conducted to better understand the underlying logic behind mothers’ knowledge, perceptions, and practices regarding childhood anemia, as identified in the first phase. This approach aimed to enrich the interpretation of statistical data by exploring the individual meanings, narratives, and experiences. Purposive sampling (Patton, 2015, pp. 264–270) was used to select 20 mothers from the quantitative survey, considering variables such as age, marital status, knowledge level, and type of reported prevention and care practices. Twenty mothers from the quantitative sample were purposefully selected for qualitative study. Qualitative sampling is guided by in-depth understanding over statistical representativeness. Therefore, mothers who participated in interviews were selected based on variation in age, marital status, occupation, knowledge level, and prevention and treatment practices determined during quantitative phase of research. Interviews continued until data saturation occurred. Saturation is met when no new themes develop from the interview data. This selection maximised the variety of viewpoints and identified typical or contrasting cases. Data were collected through semi-structured interviews guided by an interview guide developed based on the main findings of the quantitative phase. The topics addressed included representations of childhood anemia, motivations and constraints related to prevention and care practices, and the influence of family, cultural, and institutional contexts on health decisions. Furthermore, these themes were validated based on comments spontaneously shared by five other participants, which made it possible confirmed that saturation of ideas had been reached. Finally, the interviews, conducted in French, were recorded with the participants’ consent using a mobile phone equipped with an audio recording application and then fully transcribed. Following data collection, qualitative data analysis was conducted using a thematic approach, combining inductive and deductive coding (Saldaña, 2016). This analysis enabled the identification of recurring patterns, discontinuities, and rationales explaining the at-risk behaviors observed in the quantitative phase of the study. The interview guide and thematic analysis were informed by the Social Representations Theory, with particular attention to mothers’ shared beliefs, interpretations, and caregiving practices regarding childhood anemia.

Results

Results 1

Awareness of anemia in children under 5 years old

The knowledge of anemia in children aged < 5 years is presented in Table 1. The collected data revealed that 76 mothers (38% of the sample) reported being aware of this illness in this age group. In contrast, 124 mothers (62% of respondents) were not aware of it.

Table 1

Distribution of Participants According to Knowledge of Anemia (to see Table 1, please click here)

This table highlights the gap between formal biomedical knowledge and local cultural representations. This situation was particularly evident in the remarks of an adult mother, who said:

Frankly, I did not know that a lack of blood in children could be so serious. I thought it was just some tiredness that would pass, that you just needed to give them a bit of food or some traditional remedies and everything would be fine. They don’t really explain these things to us. (P8, adult mother in Dar-Es-Salam).

It should also be noted that the testimonies of young mothers highlighted a pronounced lack of awareness of the issues associated with childhood anemia. This finding illustrates the ongoing lack of access to health information and education. One of them expressed this reality as follows:

I had never learned that anemia could make a child so weak. I thought it was just when the child was not eating well or was tired. No one ever really explained what it was, or how to recognize the signs. (P2, young mother in Dar-Es-Salam)

This perception, frequently reported by the participants, underscores the need to examine the socio demographic profiles associated with this lack of knowledge. Table 2 presents the distribution of the 200 respondents according to their socio demographic characteristics and their level of knowledge of childhood anemia. An analysis of these data revealed several significant trends. On one hand, young mothers (n = 100) generally had better knowledge of anemia than adult mothers, with 44% affirmative responses compared to only 32% in the latter group. Regarding marital status, married mothers (n = 100), although the most numerous to report knowing about anemia (23%), still represented less than half of their group. Widowed mothers (n = 33), single mothers (n = 35), and mothers in common-law unions (n = 16) showed particularly low levels of knowledge, with positive responses at 2.5%, 8%, and 4.5%, respectively. Professionally, all civil servants (n = 5) and students (n = 3) reported knowledge of anemia (100%). Conversely, among traders (n = 86), although they constituted the largest group, only 16.5% were aware of the disease. Seamstresses (n = 39) reached a rate of 9%, whereas housewives and unemployed mothers (n = 67) showed very low levels (1% and 7.5%, respectively).

Table 2

Socio-demographic Characteristics of Participants According to Knowledge of Anemia (to see Table 2, please click here)

Among the women surveyed, certain socio-professional categories appeared particularly vulnerable to a lack of awareness of childhood anemia. This was especially true for mothers who were unemployed or working in the informal sector.

On the one hand, statements collected from unemployed mothers suggested that they were generally confined to the domestic sphere and, as a result, had limited exposure to information channels, whether healthcare facilities, broader social networks, or awareness campaigns. This domestic withdrawal seemed, according to them, to perpetuate a lack of knowledge about the signs and consequences of anemia in children, as illustrated by this unemployed stay-at-home mother living in Dar-Es-Salam:

I have been staying at home since I had my child. I had never heard of this illness, neither on TV nor anywhere else. The information usually came from women who visited the clinic. I hardly ever went out, so I didn’t know that a lack of blood could make a child so tired. (P14, Unemployed Woman in Dar Es Salaam)

However, among mothers working in the informal sector, the interviews revealed that the precariousness of their working conditions was a major barrier to accessing health information about childhood anemia. These mothers, often traders, endure long and exhausting days in an economically unstable environment. Consequently, concerns related to the prevention of childhood anemia were pushed into the background. As this trader put it:

I sell at the market from morning until night. When I get home, I feel exhausted. The first thing I think about is what I will feed the kids. We do not have time to listen to people at the hospital or in meetings. Even if it’s on the radio, I don’t listen very often. (P5, market vendor mother in Dar-Es-Salam)

Results 2

Perception of anemia in children under 5 years old

Table 3 presents the perceptions of anemia in children under 5 years of age within a sample of 200 participants. Two main points emerged from this distribution: the majority of participants (n = 173), or 86.5% of the sample, considered anemia to be a serious illness. In contrast, 27 participants (13.5%) believed that anemia was not serious.

Table 3

Distribution of Participants According to the Perception of Anemia (to see Table 3, please click here)

Mothers possess empirical knowledge of risk—proven by the high perception of severity (86.5%)—but they have a low level of formal medical literacy. According to the statements of the mothers interviewed, a minority of participants viewed anemia as a temporary condition, often equating it with fatigue or a lack of appetite. For these mothers, this trivialisation stemmed from a lack of clear information about the serious medical consequences of anemia. It was this downplayed perception of risks that a young mother in Dar-Es-Salam confided:

Anemia is not that serious. It is only when a child does not eat well or is a little tired. It goes away with a good soup or juice. Personally, I don’t think it can really make a child sick. (P11, young mother in Dar-Es-Salam)

It also emerges from statements collected from certain mothers that anemia was often interpreted as normal weakness in children, linked to growth, and not as an illness that requires medical attention. This perception, deeply rooted in local beliefs, may have led these women to minimise the true severity of childhood anemia, as another participant affirmed: “At home, we say it is normal for a child to have slightly yellow eyes or to be tired while growing up. Our parents didn’t go to the hospital for that, and the children always ended up getting better” (P3, single mother in Dar-Es-Salam).

These representations, although a minority, reveal the influence of local beliefs on risk perception. To better understand the variability of these perceptions, an analysis was conducted based on respondents’ socio-demographic characteristics. Table 4 illustrates the trends observed among the 200 mothers surveyed regarding the perceived severity of anemia in children under 5 years old. Notable differences appeared according to the participants’ age, marital status, and professional situation. Regarding age, the perception of anemia as a serious condition remained largely predominant in both groups: 85% of young mothers and 88% of adult mothers considered anemia to be a severe illness. Although the difference was minimal, adult mothers demonstrated slightly greater awareness of the associated risks. From the perspective of marital status, widows (97%) and women in common-law relationships (93.8%) were the most likely to perceive anemia as a serious disease. Single (85.7%) and married (82.8%) women showed slightly lower levels of perception than single women. Notably, married women, although the most represented group in the sample, also included a higher proportion of participants who minimised the seriousness of anemia (17.2%). Analysis by professional status highlighted significant disparities in the perception of the severity of anemia among children under 5 years old. All civil servants (n = 5) and students (n = 3) recognised the seriousness of anemia, with a 100% level of awareness. Although these groups represented a small proportion of the sample, they stood out because of their complete awareness. Merchants (n = 86), the most represented professional group, also predominantly displayed a correct perception, with 89.5% considering anemia to be serious. However, this rate was slightly lower than that observed among the housewives (94.1%). Conversely, seamstresses (76.9%) and unemployed women (84%) showed lower levels of awareness. Seamstresses, in particular, included a significant proportion of participants who underestimated the seriousness of anemia (23.1%).

Table 4

Socio-demographic Characteristics of Participants According to Their Perception of Anemia (to see Table 4, please click here)

The accounts from the interviews revealed that, for some mothers, anemia was perceived as a minor issue, often left to the husband’s judgment when making decisions about their child’s health. Indeed, the mothers interviewed seemed to lack autonomy, which limited their involvement in seeking information about anemia. This family dynamic contributed to downplaying the seriousness of the illness, as highlighted by a married mother:

I do not worry too much. When the child is tired, I tell my husband, and he decides whether we go to the hospital. He says it is not serious and that it will pass on its own, just like with other children. So, I wait. (P16, married mother in Dar-Es-Salam)

In contrast, the experiences shared by other mothers indicated that their understanding of infant anemia was largely based on informal knowledge passed down within their circle. The lack of direct contact with healthcare facilities or the absence of regular access to reliable sources of health information thus seemed to encourage a trivialisation of the symptoms of the illness, as illustrated by the following participant:

When a child is tired or doesn’t eat well, we give them bissap juice or broth; often, that’s enough, said a nurse. Personally, I do not think it is a serious illness. If it were serious, we’d see children collapsing every day. (P7, seamstress mother in Dar-Es-Salam)

Results 3

Prevention practices for anemia in children under 5 years old

Table 5 presents the distribution of participants according to anemia prevention practices among children under 5 years old, based on a sample of 200 women. Three main forms of care were identified: modern nursing care, African traditional medicine, and a combination of the two types of care. Nearly half of the women surveyed (n = 95, or 47.5%) reported exclusively using modern nursing services. A minority of participants (n = 25, or 12.5%) relied solely on African traditional medicine. Finally, 80 women (40%) stated that they combined nursing care with African medicine.

Table 5 

Distribution of the Sample According to Anemia Prevention Practices (to see Table 5, please click here)

The interview findings showed that many mothers reported using African medicine, either alone or alongside nursing care, as a preventive measure against childhood anemia. This practice was mainly based on the trust placed in traditional remedies, particularly those made from medicinal plants or kaolin, handed down from generation to generation within families. According to them, these remedies helped strengthen the child’s blood and prevented signs of weakness from appearing. Furthermore, some mothers expressed mistrust of modern treatments, which they sometimes considered unsuitable for their living conditions to effectively prevent anemia. This point of view was clearly stated by one participant as follows:

Since I was little, I have seen my grandmother use the leaves to strengthen children. Therefore, even when I visit the hospital, I prepare decoctions at home. I do this to prevent the child from becoming weak, because at least I know that helps prevent anemia. (P1, adult mother in Dar-Es-Salam)

Furthermore, the collected testimonies highlighted another key motivation: economic constraints. Indeed, faced with the high cost of consultations at the Dar-Es-Salam health center and the difficulties in accessing medications available at the pharmacy, some mothers chose traditional treatments as a preventive measure. These remedies, considered more affordable, were prepared using ingredients easily accessible in their immediate environment. For these mothers, preventing anemia through local and inexpensive means represented a pragmatic solution. One mother shared her experience as follows: “When you don’t have the money to buy the syrups to strengthen the child, you make do with what you have, she said. The leaves, they’re in the yard, so you prepare them so the child doesn’t lack blood” (P12, widowed mother in Dar-Es-Salam).

The use of traditional treatments was part of a broader set of preventive practices, the modalities of which varied according to mothers’ socio-demographic profiles. Table 6 presents an analysis of anemia prevention practices among children under the age of 5, based on the characteristics of the 200 participants. Three approaches were identified: exclusive nursing care, traditional African medicine, and a combined approach involving both. The analysis revealed that young mothers resorted to modern nursing care more frequently (31%) than adult mothers (16.5%). Conversely, adult mothers showed a stronger preference for combined practices (24.5%) or traditional African medicine alone (9%) than the other groups. Marital status also influenced the participants’ practices. Married mothers were the most likely to report using combined care (22.5% of the sample). Widowed mothers (8.5%) also made significant use of this mixed approach. In contrast, single mothers (6%) and mothers in common-law relationships (3%) were underrepresented in the combined practice. Differences were also notable according to the professional status. Civil servants (2.5%) and students (1.5%) exclusively chose nursing. Traders were largely represented in the combined practice category (19.5%). Seamstresses, for their part, focused mainly on nursing care (13%) and used little other forms of treatment. Finally, unemployed women and housewives, who often belonged to more vulnerable groups, showed diverse practices, including the exclusive use of African medicine.

Table 6

Sociodemographic Characteristics of the Participants According to Anemia Prevention Practices (to see Table 6, please click here)

The statements collected in the field revealed that many mothers, drawing on their past experiences with several children, had developed prevention strategies for childhood anemia. They relied on their own experiences to use remedies they considered effective, particularly those from African medicine. This experience, acquired over the course of multiple pregnancies, strengthened their ability to anticipate signs of weakness and assess the need to combine modern healthcare with traditional treatments as a preventive measure. An adult mother stated the following:

Me, I have already raised four children. So that they do not become weak, I do not rely solely on hospital medicine. From time to time, I also give them the leaves my mother used to strengthen their blood. That has always helped prevent anemia in my children. (P9, adult mother, Dar-Es-Salam)

Moreover, the merchant mothers, who were often very active and had little time to spare, explained that they adopted a pragmatic approach by combining modern healthcare and traditional remedies for preventive purposes. Aware of the risks associated with childhood anemia, they sought to continuously strengthen their children’s health to prevent episodes of weakness or illness. For them, preventing anemia protected the child and helped maintain stability in their economic activities. One of them confided:

Me, I do not wait for my child to get sick before doing something. I give him hospital medicine, but I also boil the leaves I was shown to strengthen his blood. That way, he stays healthy, and I can keep working at the market without worry. (P4, market vendor mother, Dar-Es-Salam)

Results 4

Anemia care practices in children under 5 years old

The different care practices used by the participants to treat anemia in children under 5 years old were identified and organised into two main categories, as shown in Table 7: exclusive use of nursing care and an approach combining nursing care and African medicine. In this respect, most participants (n = 122, or 61%) reported using only modern nursing care to treat anemia. Furthermore, a significant proportion of mothers (n = 78, or 39%) indicated that they combined nursing care with African medicine practices. Notably, no participant reported relying exclusively on African medicine to treat anemia.

Table 7

Distribution of the Sample According to Care Practices in Response to Anemia (to see Table 7, please click here)

The feedback gathered during the interviews revealed that some mothers combined nursing care with traditional remedies to optimise the effectiveness of practices against childhood anemia. Indeed, for these mothers, modern medicine provided an accurate diagnosis and basic treatment, while African medicine complemented this care by strengthening or accelerating the child’s recovery. This complementary approach reflects their desire to act on several fronts to prevent further weakening of the child. As one mother explained, “The hospital is good for diagnosing the child’s condition, but sometimes the medication is not enough. I add plants as well, that way I know he regains his strength quickly” (P15, adult mother in Dar-Es-Salam).

Moreover, some mothers combined nursing care with African medicine to address not only the physical causes but also the symbolic or spiritual dimensions they attributed to childhood anemia. For these mothers, the illness was not limited to its biomedical aspect; it could also result from spiritual imbalances, mystical influences or violations of social norms. By combining these two types of care, they aimed to address all aspects of the illness to increase the chances of recovery and ensure complete protection for the child. As one mother put it:

There are illnesses that cannot be cured with medication alone. Sometimes, it is something hidden or spiritual. I go to the hospital, but I also perform rituals and use plants I have learned about. That way, I’m sure it will be okay. (P6, married mother in Dar-Es-Salam)

The diversity of care practices appeared to be closely linked to the mothers’ sociodemographic characteristics, influencing their therapeutic choices when faced with infant anemia. Table 8 highlights these connections by comparing the types of recourse—nursing care only or a combined approach—with variables such as the participants’ age, marital status, and employment situation. First, no participant reported relying exclusively on traditional African medicine. However, young mothers (34.5%) made greater use of nursing care alone, whereas adult mothers (23.5%) were more likely to combine nursing care with traditional medicine. Regarding marital status, married mothers (22.5%) were most likely to resort to combined care. Widowed (7.5%) and single mothers (6%) also used combined care, but to a lesser extent. Socio-professional status also played a decisive role in the study. Civil servants (2.5%) and students (1.5%) systematically relied on modern nursing care. In contrast, traders represented the group most involved in combined care (19%), followed by unemployed women (9%), two groups that may be more open to a plurality of therapeutic approaches.

Table 8

Sociodemographic Characteristics of the Participants According to Anemia Care Practices (to see Table 8, please click here)

The experiences recounted during the interviews showed that mothers often exposed to financial insecurity and time constraints, favoured a combined approach to care. For them, this strategy allowed both limiting expenses related to medical care and ensuring a quick and diversified response to anemia in their children. By alternating or combining traditional remedies and nursing care, they hoped to maintain their child’s health while continuing their economic activities without prolonged interruptions. This reasoning was explicitly expressed by a mother who was a merchant:

I live day by day, so when I see that my child is starting to become weak, I quickly look for a solution. I take them to the hospital, but I also give them medicinal plants so that they can regain their strength quickly. I don’t have the time or the money to wait for it to drag on. (P13, market vendor mother, Dar-Es-Salam)

Moreover, unemployed mothers, who are often economically dependent on those around them, face significant barriers to accessing formal healthcare. In this context, they felt that they were frequently influenced by the advice of their family or community circle—particularly mothers, mothers-in-law, or neighbours—who recommended the use of traditional remedies, either as an alternative or as a complement to modern medical treatment. This social influence, combined with the difficulty in accessing healthcare facilities, encouraged the adoption of a mixed approach in managing childhood anemia. An unemployed mother stated the following:

I do not have a job, so I make do with what I have and what people tell me. When I do not have money for medicine, my mother tells me to prepare the leaves to strengthen the child. So, I do both—the medicine and the plants—so he doesn’t lack blood. (P10, unemployed mother, Dar es Salaam)

Discussion

This study examined the role of mothers’ cultural representations in the prevention and care practices for anemia in children under five years of age. Conducted from a socio-anthropological perspective, the analysis was based on a sequential explanatory mixed-methods design and the social representations theoretical framework. This allowed for a description of the mothers’ level of knowledge, identification of their beliefs about childhood anemia, and a survey of the different prevention and treatment strategies they employed.

Persistent lack of awareness of childhood anemia: between social vulnerability and low awareness

The results revealed a widespread lack of awareness of childhood anemia among the mothers surveyed, with only 38% reporting that they were familiar with it. This low proportion highlights a notable deficiency in health information and awareness. The quotations showed that anemia was often minimised and frequently confused with simple temporary fatigue. Young mothers appeared to be slightly better informed than adult mothers, although their overall knowledge level remained insufficient. Disparities related to marital status showed that married mothers were more familiar with the disease than single, widowed, or cohabiting mothers were. Socio-professional analysis highlighted that civil servants and students were the only groups in which all respondents claimed to know about anemia, in contrast to shopkeepers, seamstresses, housewives, and unemployed women, who had very low rates. Unemployed women, mostly confined to the domestic sphere, expressed their isolation from information sources. This isolation contributes to a persistent lack of awareness of the symptoms and risks associated with childhood anemia. For mothers working in the informal sector, precariousness and workload greatly limit their access to awareness-raising initiatives. These findings highlight the decisive influence of socioeconomic conditions on exposure to health information and, consequently, on mothers’ ability to prevent anemia in their children.

From this perspective, the results of this study confirm a general deficit in knowledge about anemia, particularly among women from socioeconomically disadvantaged backgrounds. These observations are in line with the work of Wiafe and Yeboah (2024), who found a limited understanding of anemia among women of childbearing age in the city of Tamale, Ghana, especially regarding the identification of its clinical signs. Symptoms such as fatigue or paleness are frequently viewed as ordinary and transitory occurrences, contributing to the trivialisation of anemia. This reductive interpretation, also evident in testimonies from participants in our research, highlights persistent gaps in the incorporation of this issue into health education programs targeting vulnerable populations.

Furthermore, the disparities observed in knowledge levels with respect to age, marital status, and participants’ occupations echo the results of Diégane et al. (2018), who highlighted the significant impact of socioeconomic factors on the prevalence of anemia among women in Senegal’s Kolda region. Women who are unschooled, do not have stable employment, or live in rural areas are particularly vulnerable because of their limited access to health services and information campaigns. Savadogo et al. (2019) demonstrated that economic and logistical constraints hinder access to paediatric care in Ouagadougou, compromising the early detection and management of childhood anemia. These findings converge on the idea that structural inequalities, deeply rooted in local contexts, continue to impede the prevention and control of anemia.

The finding of informational isolation among unemployed women, often confined to domestic life, supports the conclusions of Tandzi et al. (2021), who underscored the decisive influence of social determinants on knowledge levels related to anemia in urban Cameroon. Their study highlights that women in precarious situations, who combine low levels of education with a lack of professional activity, have few opportunities to access quality health information. This information deficit, exacerbated by social and economic barriers, limits their ability to adopt appropriate preventive behavior. These observations reinforce the idea that inequalities in access to information and public health education are major obstacles to the effective prevention of childhood anemia in vulnerable urban settings.

The high prevalence of ignorance revealed in this study suggests public health policies which emphasize community-based health education interventions for mothers, especially those from unemployed and informal workers groups. Promotion of health through health education programs implemented by community health workers in PHCs using effective communication strategies, which are culturally sensitive, should be developed. Enhancement of maternal understanding of the cause, symptoms, and prevention of childhood anemia may help to stimulate early care-seeking behavior and lessen preventable childhood morbidity among children under five years of age.

Variations in perceptions of childhood anemia between trivialization of the illness and decision-making dependence

The analysis showed that the majority of participants (86.5%) perceived childhood anemia as a serious illness, while a minority (13.5%) downplayed its significance. This tendency to trivialise, often linked to confusion with temporary fatigue or simply a lack of appetite, indicates a lack of information about the real risks of the disease. Some mothers thus associated anemia with normal growth, influenced by local beliefs and family narratives. Perceptions varied according to sociodemographic characteristics: adult mothers displayed a slightly higher perception of severity than younger mothers. From a marital perspective, widows and women in common-law relationships appeared to be the most aware of the seriousness of anemia, whereas married women accounted for a greater proportion of participants who minimised its effects. Civil servant mothers and students stood out for their unanimous perception of the seriousness, unlike seamstresses and unemployed women, among whom softer perceptions were more prevalent. The testimonies also revealed that the decision to seek care was often left to husbands, thus limiting mothers’ autonomy in managing their children’s health care. This reliance on decision-making reinforced a passive attitude and an underestimation of the danger posed by anemia. Finally, limited access to reliable sources of information or formal healthcare structures partly explains the persistence of mistaken perceptions and inappropriate practices. These results highlight the influence of social norms, family status, and socioeconomic conditions on risk perception and maternal health behaviors.

The results can also be explained through a Social Representations Theory lens (Manchaiah et al., 2019). Mothers’ perceptions of childhood anemia were influenced not only by biomedical knowledge but also by a collective set of beliefs that were communicated amongst family members and community members. Similarly, the employment of visible indicators such as tiredness, hollow eyes or frailty as signs of anemia is also objectification, by means of which, abstract biomedical knowledge is converted into embodied and socially significant forms. As described above, these common representations guided preventive and care-taking behaviors including the concurrent use of biomedical and traditional treatments. The results support Manchaiah’s view that health behaviors are motivated not only by scientific understanding but socially constructed meanings formed through daily life and experience.

In this context, the variation in perceptions observed according to the socio demographic characteristics of participants supports the conclusions of Zegeye et al. (2021), who, through an analysis conducted in several sub-Saharan African countries, highlighted a partial or ambiguous awareness of the risks related to anemia among young women with little or moderate schooling. This lack of knowledge is largely explained by the influence of the family and cultural environment, which shapes the social representations of health. In contrast, our study shows that older mothers, widows, and women in common-law relationships are generally more alert to childhood anemia. This heightened vigilance can be interpreted as the result of longer maternal experience or greater autonomy in decision-making regarding children’s health. This observation echoes the findings of Moschovis et al. (2018), who demonstrated a protective effect of maternal age on anemia risk in children, indicating a progressive decrease in risk as the mother’s age increases.

Furthermore, the influence of occupational inequality on health attitudes also appears to be significant. Our results are in line with those of Adewole et al. (2017), who showed that women holding positions in the formal sector, particularly civil servants and students, enjoy better access to health information and are more exposed to awareness campaigns, which strengthens their perception of the seriousness of childhood illnesses. Conversely, women facing economic insecurity, especially those working in the informal sector or unemployed, such as seamstresses or job seekers, are more likely to experience informational isolation. Their limited access to healthcare facilities and formal information channels exposes them to erroneous or incomplete views of childhood diseases, including anemia.

The continuation of misperceptions and gender-driven decision making also indicates that anemia prevention efforts must reach mothers, fathers, family elders and other community leaders. Ensuring that women are involved in making decisions about health care is essential in public health initiatives. Also, gender-biased cultural beliefs need to be changed through culturally appropriate education programs that may increase timely recognition of anemia in children and appropriate use of health care services.

Finally, decision-making autonomy stands out as a factor underlying the observed inequalities. The strong dependence of women on their partners regarding health decisions, particularly evident in our study, echoes the findings of Andriano et al. (2021). Drawing on data from 28 Sub-Saharan African countries, these authors highlighted the persistence of patriarchal norms that grant men a central role in decisions concerning women’s health. This relational dynamic limits mothers’ ability to act autonomously in cases of childhood illnesses, which can lead to delays in care and contribute to a tendency to downplay serious diseases such as anemia. This finding supports the growing calls to incorporate gender and domestic power dynamics into health communication and education strategies to empower women in contexts of structural vulnerability.

Hybrid preventive practices for childhood anemia: between social and economic influences

The study highlighted three main forms of preventive practices for childhood anemia: modern nursing care, traditional African medicine, and a combined approach that incorporates both. Nearly half of the mothers interviewed relied exclusively on nursing care, while a minority relied exclusively on traditional medicine. A significant percentage of participants adopted a mixed preventive strategy that combined modern treatments with local remedies. The collected accounts revealed that trust in inherited practices, especially the use of medicinal plants, remained strong within maternal communities. This trust was often strengthened by the experience accumulated through multiple pregnancies, giving mothers the sense that they were acting effectively to prevent anemia. Economic constraints also justified the use of traditional treatments, which were more accessible than paid medical care. The analyses revealed variations based on the participants’ age, marital status, and professional activities. Younger mothers more often turned to nursing care alone, whereas adult mothers more frequently adopted mixed approaches. Merchant mothers, keen to maintain their businesses, opted for combined practices that were deemed more pragmatic. Meanwhile, women from precarious backgrounds, such as housewives or the unemployed, developed alternative strategies that relied heavily on local resources to prevent anemia in their children.

The results obtained align with a trend widely reported in the literature regarding hybrid practices for preventing childhood diseases in Sub-Saharan Africa. Several studies have shown that the coexistence of biomedical and traditional medicine is a common strategy among mothers, particularly in socioeconomically constrained contexts. Tessema et al. (2021) in Ethiopia highlighted the significant prevalence of medicinal plant use in preventing and managing childhood anemia, often as a complement to clinical care. Similarly, Agbozo et al. (2018) in Ghana emphasised the importance of maternal experience in the decision to combine both systems of care, with older mothers drawing more heavily on their empirical knowledge and resources derived from traditional medicine.

Conversely, the observation that younger mothers prefer nursing care exclusively can be compared to the findings of Amugsi et al. (2019), which show that younger women, who are often more educated or more exposed to public health campaigns, tend to favour biomedical approaches. Older mothers or those who have experienced multiple pregnancies, on the other hand, adopt combined strategies that draw on both their confidence in local plants and their recognition of the effectiveness of modern care.

The disparities according to socioeconomic status observed in our study also align with the work of Ouoba et al. (2022), who noted that women without a stable income or belonging to marginalised groups (the unemployed and housewives) rely more on traditional remedies, which are perceived as economically viable and culturally appropriate. Furthermore, Amu et al. (2022) showed that merchant women or those active in the informal sector prefer mixed solutions to avoid interrupting their activities, which underscores the practical appeal of traditional treatments, which are considered faster or more accessible.

The widespread use of both biomedical and traditional preventive practices suggests that health programmes should acknowledge the cultural realities that shape maternal behavior rather than dismiss traditional beliefs. Collaboration between healthcare professionals, community leaders, and trusted traditional practitioners may improve acceptance of evidence-based prevention messages. Strengthening nutrition education, malaria prevention, and community outreach programmes could further reduce the burden of childhood anemia.

Finally, the strong persistence of trust in traditional practices, as noted in the participants’ accounts, reflects the conclusions of Jegede (2002) who emphasised the symbolic and identity-based significance of local medical knowledge. These authors remind us that such practices are not merely responses to poverty but also legitimate cultural expressions of ways of relating to the body and illness, deeply embedded in social and intergenerational dynamics.

Therapeutic pluralism in the treatment of childhood anemia: Between social norms and material constraints

The study highlighted two main care practices used by mothers: exclusive use of modern nursing care (61%) and a combined approach with traditional African medicine (39%). No participant reported using only traditional medicine to treat childhood anemia. Mothers who combined the two types of care aimed to reinforce the treatment’s effectiveness by associating the benefits of biomedical diagnosis with the perceived effects of traditional remedies. This strategy was intended to accelerate recovery while ensuring comprehensive management, sometimes including symbolic or spiritual dimensions attributed to illness. Sociodemographic analysis revealed that younger mothers favoured nursing care alone, whereas adult mothers more often adopted a mixed approach. Married women were the most likely to combine both types of care, followed by widows and single mothers, respectively. Female traders, constrained economically and by availability, especially turned to combined practices, which they perceived to be more flexible and effective. Unemployed mothers, on the other hand, were strongly influenced by their female relatives, who guided them toward traditional solutions as a complement to medical treatments. This family and community dynamic favours the integration of medicine into a pluralistic healthcare system. Thus, practices for treating childhood anemia appeared to be closely linked to the material living conditions and social networks in which mothers were embedded.

The results of this study confirm the predominance of therapeutic pluralism in maternal care practices in sub-Saharan Africa, as documented in several recent studies. The combined use of biomedicine and traditional medicine, observed in 39% of participants, reflects the logic of functional complementarity between two systems seen as having distinct but convergent roles. In this regard, Asante et al. (2023) show that patients, notably in Akan communities in Ghana, simultaneously use biomedical care and traditional remedies to address the physical, spiritual, and symbolic dimensions of illness holistically. Thus, recourse to traditional medicine is not considered an alternative but rather a support to modern medicine, enhancing the perceived effectiveness of care and the holistic consideration of suffering.

The total absence of exclusive use of traditional medicine in treating childhood anemia, as observed here, echoes the conclusions of Sato (2012), who identified a gradual decline in exclusive reliance on traditional care in favour of mixed strategies, especially for illnesses seen as serious or linked to a child’s biological vulnerability. This trend reflects a growing recognition of the effectiveness of biomedical diagnosis while maintaining the value of local knowledge in care pathways for the elderly.

The variations observed according to mothers’ age, marital status, and professional activity are consistent with the findings of Aboagye et al. (2022), which show that younger women, who are better educated or more exposed to media campaigns, are more inclined to rely exclusively on biomedical care. Conversely, older mothers with more extensive maternal experience often draw on the traditional knowledge passed down by female relatives in their circle. Similarly, Gyasi et al. (2017) found that married women or those living in extended families use combined treatments more often, influenced by elders’ advice and community care dynamics, reflecting therapeutic pluralism that is deeply rooted in social structures.

The specific case of female traders, among whom mixed practices are especially frequent, can be compared to the analyses of Akazili et al. (2018), who showed that women active in the informal sector adapt their care use according to their professional constraints. These women combine biomedical care for technical procedures—accessed when conditions allow—with recourse to local remedies and advice from other mothers, enabling rapid management compatible with their family lifestyle.

In summary, the influence of and community networks on therapeutic practices aligns with the observations of Agyemang-Duah et al. (2019), who emphasised that the socialisation of care and management of illness in the African context often results from collective decision making framed within a logic of shared knowledge. This dynamic explains the integration of medicine in a pluralistic system, where therapeutic choices depend as much on material constraints as on social and cultural affiliations.

Conclusions

This study highlighted the decisive influence of social representations, sociocultural environment, and mothers’ living conditions on their prevention and care practices for childhood anemia. This shows that in the context of precariousness and limited access to health information, mothers often adopt hybrid approaches, combining biomedical care and traditional remedies. The use of a sequential mixed-methods design revealed a widespread lack of knowledge about anemia, a tendency to downplay it, and low autonomy in decision-making, especially among the most vulnerable mothers. Significant differences based on age, marital status, and employment were also observed, confirming the impact of social inequalities on health behaviors.

These results support the strengthening of information campaigns targeting marginalised women, with messages adapted to local cultural realities and relying on female community support. Integrating traditional medicine into public health strategies may increase adherence to interventions. It is also necessary to promote mothers’ autonomy in decision-making to reduce their dependence on male figures during the care-seeking process. An inclusive approach that combines biomedical and indigenous knowledge appears essential for a more deeply rooted and effective prevention of childhood anemia.

Limitations and Future Research

Certain limitations of this study should be noted. A primary limitation of this study lies in the marked sample asymmetry across socio-demographic strata (e.g., marital and occupational status), resulting in sparse cell counts for several cross-tabulations. Consequently, percentage differences among smaller subgroups should be interpreted strictly as descriptive trends rather than statistically robust associations. Future studies with stratified sampling are required to confirm these preliminary findings.

This study focused solely on mothers, without considering other influential actors in health decisions, such as fathers or elders. Its limited geographic scope restricts the ability to generalise the results to other contexts of the study. Furthermore, the use of self-reported data may have introduced a social desirability bias. To further investigate these findings, future research could adopt a comparative perspective between rural and urban settings, between sexes, or between generations while employing ethnographic approaches to better understand the interactions between traditional medicine and biomedicine in childhood care practices.

The cross-sectional nature of the study is another limitation. Measurements were made at one time point only. Causal relationships between mothers’ social representations, their preventive behaviors, and care practices regarding childhood anemia cannot be determined. Thus, our findings should be considered as correlations rather than causality. Longitudinal studies could provide information about evolution of perceptions and practices over time.

Finally, this research makes a significant contribution to the social anthropology of childhood morbidity by highlighting the weight of social inequalities and gender norms in care trajectories. By shedding light on the therapeutic pluralism at play and the underlying cultural logics, it opens new perspectives for public health policies that are more sensitive to the social and cultural realities of vulnerable populations.

Competing Interests

The author declares no competing interests.

Ethical Approval

The research was approved by the Research Ethics Committee of Alassane Ouattara University.

Consent to Participate

Written informed consent was obtained from the mothers of all participating children before data collection. Participants were informed about the purpose of the study, their voluntary participation, and their right to withdraw at any stage without consequences. Confidentiality of the collected information was ensured throughout the research process.

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