Introduction:
Nutritional anemia has been found associated with impaired mental, physical, and cognitive performance in children and is a significant risk factor for maternal mortality. The prevalence of nutritional anemia among adolescent girls was found high (47.6% to 90%) in different parts of in North India.[1] Since there are limited studies on nutritional anemia at sub-district levels in Southern part of India,[2,3] there is a need to know the extent of the problem among adolescent girls to plan for context specific interventions. Hence, a present study was undertaken to find out the prevalence of nutritional anemia among adolescent girls and explore their perceptions of the causes and effect of nutritional anemia.
Materials and Methods
The study was undertaken in two wards of Kallitheerthalkuppam village, where our medical college is located. It also comes under field practice area of the Department of Community Medicine, SMVMCH, Pondicherry. Since, it was a study done by a second year female medical undergraduate, the feasibility and time constraints in the ongoing educational program was considered while selecting the study area and the study sample.
It was a mixed-methods design where quantitative (survey) and qualitative (cause-effect diagram) methods were used. The study period was two months between August 2013 and September 2013. The study subjects were adolescent girls from age 12-19 years. A female medical social worker paid house-to-house visit in the selected wards and prepared a sampling frame. Out of total 384 listed girls, 100 girls were selected by a simple random sampling. This sample size of 100 was adequate at p=50% (taking prevalence of anemia among adolescents on an average), power 80%, design effect -1 (since the design effect for simple random sampling is one) and alpha error-5% (Calculated using Epi_Info software package version 3.4.3). A team of female medical undergraduate student, female medical social worker and female faculty in the Department of Community Medicine paid house-to-house visit and interviewed the selected adolescent girls by using a structured questionnaire. Informed consent was obtained before the interview. A free-flowing blood drop was obtained from each subject by the finger prick method using a sterile disposable lancet. The hemoglobin level was assessed by using the approved test strips (Hemoglobin Colour Scale 4) in daylight by a trained lab technician. Hemoglobin Colour Scale is a simple, reliable, valid and inexpensive tool developed by World Health Organization to screen for anemia among women and children where appropriate prevention and treatment strategies are most beneficial, especially in rural areas.[4] World Health Organization guidelines were followed for defining anaemia as (Hb < 12g/dl), mild anemia (11-11.9g/dl), moderate anemia (8-10.9g/dl) and severe anemia (<8g/dl).[5] Anemic girls were referred for medical treatment. Data was analyzed using Epi_info ( version 3.4.3) software package.
After the survey, two cause and effect diagrams were facilitated. A trained female medical social worker contacted 10-15 adolescent girls one day prior to the meeting and decided a convenient day and place for the meeting. On the scheduled day, adolescent girls gathered in an open place on a village street for the exploration of their perceived cause and effect diagram. We followed guidelines by PRAXIS, Patna for this exercise.[6] The exercise was facilitated by the female medical student and supervised by a female faculty in Community Medicine, who had received training in qualitative research methods. Adolescent girls were explained the purpose of the exercise and given adequate time to discuss among them before drawing their perceived cause and effect diagram. They chose a volunteer among themselves to draw the diagram on the street. The girls were asked to enlist the causes of anemia and its effect. Later, they were asked to link these causes and effects as per their perceptions and knowledge. The participants were given refreshments at the end of the exercise. The discussion and diagram were noted down. A manual content analysis of the discussion was done.
Adolescent girls, who was found to have nutritional anemia were referred for its medical treatment. We obtained ethical clearance from the Research Committee and Ethics Committee of our Medical College. Informed consent was obtained from the respondents.
Results
The sociodemographic characteristics of the study population are shown in Table 1. A total of 100 adolescent girls (12-19 years) were included in the study and the response rate was 100%. The mean age of the respondent was 15.63 ± 2.0 years (range 12 to 19 years). Among them, 19% were early adolescents (<13years), 46% belonged to a mid adolescent age group of 13-16 years and 35% were late adolescents (17-19 years). Regarding the educational status of the respondents, the majority of them (40%) studied up to higher secondary. Of them, 84% were going to school, 6% were working and 9% not working. Classification of socioeconomic status based on the colour of the ration card showed that 68% belonged to BPL families (Below Poverty Line). The majority of the participants (46%) belonged to the backward caste category.
Table 1: Socio Demographic Characteristics of the Study Population, n=100. |
| S.no |
Variable |
Number % |
1. |
Age in years |
|
<13 |
19 |
13-16 |
46 |
17-19 |
35 |
2. |
Education in years |
|
Middle school |
17 |
High school |
29 |
Higher secondary |
40 |
Graduation |
14 |
3. |
Occupation |
|
Student |
84 |
Company labourer |
2 |
Job |
4 |
Not working |
10 |
4. |
SES (acc to colour of ration card) |
|
BPL |
68 |
APL |
29 |
Do not know |
3 |
5. |
Caste |
|
BC |
16 |
MBC |
46 |
SC |
37 |
ST |
1 |
The prevalence of anemia (Hb < 12g/dl) among the study population was 58 percent. The overall mean ±SD distribution of Hb level was 11.2 ±1.39 (g/dl). The grade of anemia was assessed using WHO cutoff levels. Regarding severity, among the anemic children, 23% had mild anemia (11-11.9g/dl), 35% had moderate anemia (8-10.9g/dl) and none had severe anemia (Table 2).
Table 2: Anemia Among Adolescents, n=100. |
| Hemoglobin (g/dl) |
Number of girls % |
>=12 (no anemia) |
42 |
11-11.9 (mild anemia) |
23 |
8-10.9 (moderate anemia) |
35 |
<8 (severe anemia) |
0 |
Total |
100 |
The perceived cause and effect relationship is shown in Fig 1. The girls listed various causes for anemia (Rattha sovai – local Tamil term for anemia) – deficiency of iron, the habit of eating brick, sand, chalk and ash, not wearing footwear, reduced intake of green leafy vegetables, and worms in the intestine. The various effects enlisted were tiredness, irregular menstrual cycle, child with less weight, poor intelligence, weakness and stomach ulcers. Later, the adolescent girls linked iron deficiency as the cause for tiredness, irregular menstrual cycles and low birth weight. Interestingly, they also linked the habit of eating brick, sand, chalk, ash, raw rice to poor intelligence in childhood. Also, they linked deficiency of iron and the habit of not wearing footwear to tiredness, reduced intake of green leafy vegetables, and intestinal worm infections to giddiness and hookworm infections to peptic ulcer.
 |
Figure 1: Perceived Cause and Effect Diagram |
Discussion:
The study findings showed the prevalence of anemia among the girls to be 58%, which comes under the cutoff of severe problem of public health significance as per WHO.[5] In spite of high awareness, the study sample was found to have a high prevalence of anemia.
The major strength of the study was the use of mixed- methods design, both quantitative methods supplemented by the findings from the qualitative methods (Participatory Research appraisal technique) through cause and effect diagram, which helped to know the gap between knowledge and practice. But it was a small scale study in a limited geographical area.
The prevalence found in the present study (58%) was lower as compared to the prevalence found in the neighbouring state of TamilNadu (78.7%)[2] and it was higher as compared to another study in Vellore (29%).[3] Thus, it shows a wide variation in the prevalence figures. Compared to the present study, studies done in other states of India like Maharashtra found the same prevalence of anemia among adolescents to be 59.8%.[1] Notably the high prevalence of anemia in Tamil Nadu[2] was also supported by the finding that understanding of the perceptions and attitude towards health and anemia was present in very few (2-3%) of the adolescents. In the present study, the cause and effect diagram showed a good awareness level among the adolescent girls which was not reflected in their hemoglobin levels. This shows the existence of good health education programs in place, but a gap between knowledge and practice components.
The Government of India has initiated many programs to combat anemia, especially among adolescent girls (10-19years). The Weekly Iron Folic Acid Supplementation Programme was started to reduce the prevalence and severity of nutritional anemia among adolescents, both, school going as well as school drop outs.[7] Government of Pondicherry is currently on the mission of covering all the adolescents under the Weekly Iron Folic acid Supplementation Program through schools and Anganwadi centres to combat anemia in the near future by translating knowledge into practice. The review of the programme performance in the state is still underway.
The study found a gap between knowledge and practice reflected by the cause and effect diagram and the hemoglobin levels measured respectively. This result indicates the need to initiate an effective behavior change communication for improving the hemoglobin status of adolescent girls.
Acknowledgement: We acknowledge the scholarship for undergraduate research from the Management of Sri Manakula Vinayagar Medical College and Hospital, Pondicherry.
References:
- Kaur S, Deshmukh PR, Garg BS. Epidemiological correlates of nutritional anemia in adolescent girls of rural Wardha. Indian J Community Med. 2006;31:255–8.
- Premalatha T, Valarmathi S, Srijayanth P, Sundar JS, Kalpana S. Prevalence of Anemia and its Associated Factors among Adolescent School Girls in Chennai, Tamil Nadu, India. Epidemiol. 2012;2:118.
- Choudhary A, Moses PD, Mony P, Matha M.Prevalence of anaemia among adolescent girls in the urban slums of Vellore, south India. Trop Doct. 2006 Jul;36(3):167-9.
- Dobson M. World Health Organization Haemoglobin Colour Scale: A practical answer to a vital need. Update in Anaesthesia:51-2.
- World Health Organization. Iron deficiency anemia. Assessment, prevention, and control: a guide for programme managers. 2001:33,17. Available at: http://www.who.int/nutrition/publications/en/ida_assessment_prevention_control.pdf. Accessed on 13 September 2014.
- Training in Participation Series [PRA tips on CD-ROM]. Patna (India): Institute for Participatory Practices; 2004.
- Ministry of Health and Family Welfare, Government of India. Operational Framework: Weekly Iron Folic Acid Supplementation Programme for Adolescents 2012:1-3.
- Joshi M, Gumashta R. Weekly Iron Folate Supplementation in Adolescent Girls – An effective nutritional measure for the management of iron deficiency anaemia. Global J Health Sci. 2013;5(3):188-94.
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