We conducted a cross-sectional study with both descriptive and analytical components over a 4-month period, from February 1 to May 31, 2023. A questionnaire was administered during an interview to mothers of children aged 6 to 59 months attending the vaccination, pediatric hospitalization, and pediatric outpatient departments of the Dschang Regional Hospital Annex (DRHA), which receives an average of 3000 to 3500 children per year. For the analytical component, we compared participants with poor or insufficient knowledge to those with harmful practices. The DRHA is a 3^rd-category hospital, according to the national health pyramid in Cameroon, offering curative, preventive, and health-promoting pediatric care. It is located in a semi-urban and university zone.

The study population consisted of mothers of children aged 6 to 59 months who visited the inpatient and outpatient pediatric and immunization departments of the Hôpital Régional Annexe de Dschang between February 1 and May 31, 2023. We excluded mothers who were unable to complete the questionnaire.

Data was collected anonymously after participants provided informed consent. The questionnaire was divided into three sections, and the variables collected included socio-demographic characteristics (age, marital status, profession, religion, and level of education), mothers’ knowledge of anemia (definition, causes, symptoms, information received on preventing anemia, treatment, and the risks incurred by an anemic child), and practices (measures taken when faced with a child with anemia and means of prevention used).

Knowledge: Theoretical knowledge possessed by mothers of children under the age of five relating to the causes, symptoms, treatment, and prevention of anemia. Knowledge levels were assessed based on mothers’ correct answers to questions about the definition of anemia, as well as its causes, symptoms, and risks for anemic children. Each correct answer was worth 1 point, and each incorrect answer was worth 0. The participants’ correct answers to these questions were divided into four categories. The percentage of correct answers < 50% was associated with a poor level of knowledge, [50% - 65%[ with an insufficient level of knowledge, [65% - 85%[ with an average level of knowledge, and >85% of correct answers corresponded to a good level of knowledge.

Practices: all actions (transporting the child to the hospital, consulting a traditional healer, administering homemade treatments, administering iron or paracetamol, or receiving a blood transfusion) reported by mothers of children aged 6 to 59 months regarding the management of anemia. Levels of practice were assessed based on participants’ correct answers to questions about the treatment and prevention of anemia in children. Each correct answer was worth 1 point, and each incorrect answer was worth 0. Correct answers were divided into three categories. A percentage of correct answers below 50% was associated with harmful practices, 50% - 85% with inadequate practices, and above 85% with adequate practices.

This study was approved by the Regional Ethics Committee for Human Health Research in the West Region, Cameroon (ethical clearance n˚ 278/29/03/2023/CE/CERSH-OU/VP). Informed consent forms were signed by mothers who agreed to participate in the study. Participation was voluntary, and data confidentiality was ensured.

Data was entered into an Excel spreadsheet and then exported to Statistical Package for the Social Sciences v22 for Windows (SPSS, IBM, Chicago, IL, USA) for statistical analysis. Variables were presented as percentages with 95% confidence intervals (CI) and mean ± standard deviation (SD) in figures and tables where appropriate. Logistic regression was applied to assess associations between variables.

The average age of the mothers was 27.7 ± 5.8 years, with 137 (38.8%) aged between 20 and 24 years. In terms of educational level, 238 (58.5%) of the mothers had secondary education, 101 (24.9%) were employed, and 279 (68.9%) were married. The most represented religion was Christianity, 182 (94.3%). More than half the mothers had a child under the age of five 214 (52.2%). ( Table 1 )

The average age of the children was 7.6 ± 0.2 months, with the most common age range between 1 and 9 months. Females were most represented (53.1%), with a sex ratio of 1.1 in favor of girls.

Of the 405 participants, 347 (85.7%) had already heard of anemia. The mothers’ primary sources of information were health professionals (72.3%), school (65.4%), television (61.5%), family (59.9%), and social networks (52.3%). Over half of the mothers (59.3%) reported that they had never heard of anemia prevention. For the 160 (40.7%) who had, the primary sources of information were health personnel (35.3%), school (26.7%), and family and friends (25.7%).

Each mother defined anemia according to her understanding. The most common definition was “lack of blood in the body” for 48.9% of participants, and 66.5% of mothers were able to give valid definitions of anemia. The causes of anemia

recognized by the mothers were iron deficiency (67.9%), malnutrition (67.4%), abnormal bleeding (65.7%), malaria (62.5%), vitamin deficiency (51.4%), and intestinal parasites (39%). ( Table 2 )

The symptoms that mothers were able to cite included general fatigue (73.1%), dizziness (71.6%), paleness of the eyes, hands, and feet (71.4%), headaches (55.3%), shortness of breath (53.6%), and palpitations (47.9%). Out of 405 mothers surveyed, 279 (68.9%) recognized that an anemic child runs the risk of losing weight, 271 (66.9%) the risk of dying, 258 (63.3%) the risk of losing appetite, and 249 (61.5%) the risk of poor school results. ( Table 3 )

In our study, 59 (14.6%) of mothers reported having experienced a child with anemia, and 17 (4.2%) had lost a child to anemia.

Most mothers, 289 (71.4%), stated that there was a treatment for anemia. Among the possible treatments for anemia, mothers reported using blood transfusions (62.5%), iron supplementation (60.4%), and homemade remedies (32.4%). The “homemade” treatments they used most often were a mixture of grenadine soda, tomato concentrate, and sugar-free milk (7.20%), or a potion based on a mix of cassava leaf juice and sugar-free milk (6.40%). ( Figure 1 )

When faced with an anemic child, mothers’ first recourse was to the health center (83.8%). The iron syrup was self-medicated by 28.2% of mothers, 25.6% administered “homemade” treatments, 13.8% used paracetamol syrup, and 4.5% consulted traditional healers. ( Table 4 )

The most commonly used methods for preventing anemia were good nutrition (69.6%), protecting the child against malaria by using insecticide-impregnated

mosquito nets and adequate malaria treatment (61.7%) and administering iron supplements (50.1%). Twenty-four percent of mothers used “home” treatments to prevent anemia in their children. ( Table 5 ) The “home-made” treatments they most frequently administered were a mixture of grenadine soda with tomato concentrate and raw eggs (24.74%), a decoction made from manioc leaves and sugar-free milk (20.61%), or a beet juice and sugar-free milk beverage (15.46%). ( Figure 2 )

Knowledge was poor in 138 (34.1%) participants and inadequate in 177 (43.7%). ( Table 6 )

Our study shows that having a primary (RR = 6.558; CI = [2.165 - 19.86], p < 0.05) or secondary (RR = 2.731; CI = [1.790 - 4.166], p < 0.05) level of education increased the risk of having poor or insufficient knowledge, while having a higher level of education (RR = 0.219; CI = [0.137 - 0.351]; p < 0.05) or a child who suffered from anemia (RR = 0.430; CI = [0.231 - 0.802], p = 0.008) decreased the risk of having poor or insufficient knowledge. Poor and insufficient knowledge were associated with harmful practices (RR = 83.79; CI = [39.33 - 178.51]; p < 0.05).

In our series, mothers aged 20 - 29 accounted for 63.7% of participants. This result is similar to that of Koffi et al. in Togo in 2012, where 61% of participants were between 20 and 29 years old [12] . The majority of mothers had secondary or higher education (58.5% and 36.5%, respectively). Employed mothers were the majority (24.9%), followed by housewives (21.7%) and students (16.8%). This socio-demographic profile can be attributed to the fact that the target population consisted of mothers of young children.

Of the 405 mothers surveyed, 347 or 85.7% had heard of anemia from various sources, whereas in Togo in 2012 only 60% of participants had heard of anemia, and even fewer (55.0%) in the series by Ngimbudzi et al. in Tanzania [8] [12] . This difference could be explained by the mothers’ level of education, as only 8% of participants in the Koffi et al. series had a higher level of education, compared with 36.5% in our series [12] . On the other hand, our results are similar to those of Souganidis et al. in Indonesia in 2012, where 87% of mothers had heard of anemia, and Kamo et al. in Cameroon [9] [13] . The fact that the city of Dschang in Cameroon is a university town could explain the high proportion of mothers with higher education.

Mothers’ primary sources of information on anemia were health personnel (72.3%), school (65.4%), and television (61.5%). This highlights the importance of health personnel, schools, and the media in informing communities about public health issues in general and anemia in particular. The media and social networks can be effective relays for disseminating relevant messages within the community.

In our series, 66.5% of mothers were able to define anemia, whereas in the series by Koffi et al. only 44% of mothers were able to provide a correct definition of anemia [12] . This difference could be explained by the fact that, in the present study, all participants had attended school, and 95% of them had a secondary education or higher, whereas in the study carried out in Togo, 36% of mothers had a primary education or were illiterate. Kamo et al. in Cameroon in 2020 found that 57% of mothers provided a correct definition of anemia [13] .

Iron deficiency (67.9%), malnutrition (67.4%), abnormal bleeding (65.7%) and malaria (62.5%) were cited by the majority of mothers as causes of anemia. Koffi et al. found malaria (24%) and malnutrition (19%) to be the leading causes, while Djadou found malaria (60.5%) and Kamo found witchcraft (12.5%) in addition to malaria (53.3%). This could be explained either by the mothers’ knowledge of anemia or by personal experience with their child or other children around them (prescription of iron to treat anemia, blood transfusion to treat severe anemia in the case of severe malaria) [12] - [14] .

The signs of anemia most frequently cited by mothers were general fatigue (73.1%), dizziness (71.6%), and paleness of the eyes, hands, and feet (71.4%). Koffi and Djadou found pallor less often (32%), which could be explained by the mothers’ low level of knowledge in their series [12] [14] .

We found that 59.3% of mothers had never heard of anemia prevention. In the series by Koffi et al., 90% of participants had never received an anemia prevention message [12] . This low level of knowledge about prevention suggests that particular emphasis should be placed on communicating how to prevent anemia.

In our study, the risk incurred by an anemic child most frequently recognized by mothers was the loss of appetite (63.3%), whereas in the series by Koffi et al. in Togo in 2012, death (71%) was the risk most reported by mothers. This could be explained by the fact that, in this study, 41% of mothers had had a child who had died or suffered from anemia [12] .

Of the 405 mothers questioned, 94.4% recognized the existence of a treatment for anemia. The treatments most frequently cited by mothers were blood transfusion (62.5%) and iron supplementation (60.4%). This could be explained by the experience acquired by these mothers during pregnancy, or if they had a previous child with anemia. Indeed, iron supplementation is often prescribed as a preventive measure for pregnant women during their first prenatal consultation and after delivery. Some mothers (32.4%) cited traditional treatment. This could be explained by the fact that, in the popular imagination, the red color of blood influences the choice of foods likely to prevent or treat anemia, according to their color. Thus, products with a red color, such as tomatoes and beets, are considered, in the popular imagination, likely to prevent or treat anemia. To this end, there are mixtures commonly used by mothers as remedies. This explains the use of mixtures of grenadine soda, tomato concentrate, and raw egg (24.74%), as well as cassava leaf juice and sugar-free milk (20.61%), and beet juice and sugar-free milk (15.46%) as remedies in our study. Similar attitudes were reported by Kamo et al. in northern Cameroon [13] .

In terms of practices, mothers’ first recourse in the event of anemia in their child was the health center (83.8%). Our results are similar to those of Kamo et al., who reported that 84.8% of mothers considered the health center as their first resort in case of anemia [13] . These results differ from those of Koffi et al., where mothers’ first recourse was to the health center (65.8%) [12] . Other practices cited by mothers included the administration of iron syrup (28.2%), the use of homemade treatments (25.6%), the administration of paracetamol syrup (13.8%), and recourse to traditional healers (4.5%). Mothers recognized Iron supplementation for its preventive and curative effects, and this would have motivated some mothers to administer iron syrup to an anemic child without visiting the health center. Some mothers’ lack of knowledge about anemia may also explain their belief that home treatment and traditional healers can cure anemia.

As for the most frequently cited means of prevention, good nutrition (69.6%), adequate malaria treatment (61.7%), and iron administration (50.1%) are the most common. Kamo et al. reported that 36% of mothers mentioned vaccination as a measure to prevent anemia, and the use of an impregnated mosquito net (34%), while good nutrition accounted for only 21% of responses in this series [13] .

In the end, our study revealed that only 117/405 (28.9%) of mothers had good knowledge and 88/405 (21.7%) adequate practices, which remains relatively low. We found that the level of education and the fact of having had a child with anemia were associated with the level of knowledge, which in turn determined practices. However, factors such as financial limitations and the decision-making roles of other household members might affect the implementation of health practices by mothers.

Financial constraints represent a substantial hurdle. Even with adequate knowledge about the importance of iron-rich foods, iron supplementation, or timely medical care, a mother’s ability to act can be restricted by a lack of financial resources. Purchasing nutritious food, which is often more expensive than staple, less nutrient-dense options, may be beyond the reach of many families. Similarly, acquiring iron supplements or other prescribed medications requires disposable income. Furthermore, accessing healthcare facilities, particularly for specialized or repeated visits, incurs costs related to transportation, consultation fees, and treatment, which can be prohibitive for financially limited households.

The hierarchical structure and decision-making processes within a household also profoundly influence a mother’s autonomy and ability to implement health practices. In many cultural contexts, particularly in sub-Saharan Africa, major health decisions for children may require approval or be the sole responsibility of the father, grandparents, or other senior family members. Discrepancies in health beliefs, priorities, or knowledge between the mother and these key decision-makers can lead to delays or resistance to adopting recommended practices. For instance, a mother who understands the need for a blood transfusion for severe anemia might face opposition from a spouse who fears the procedure or adheres to traditional beliefs about blood. This “decision-making role of other household members” may affect practice implementation, highlighting the need to consider the broader family unit in health interventions [14] .

Cultural explanations for illness, including anemia, constitute another powerful influence that can impact health practices. Traditional beliefs about the etiology of anemia can lead mothers (or other family members) to prioritize or exclusively pursue conventional healing methods or administer homemade remedies, as noted in our study, even when they possess some knowledge of biomedical causes and treatments. These cultural interpretations can delay or supplant the use of evidence-based medical interventions, contributing to adverse outcomes [8] .