Iron folic acid consumption and anemia prevalence among female adolescents in rural areas: an observational study

Introduction

The World Health Organization (WHO) reports that over half a billion women of childbearing age (15-49 years) have anemia.¹ Therefore, the United Nations decided to include the prevalence of anemia among pregnant and non-pregnant women as a significant indicator in the 2020 Sustainable Development Goals (SDGs).² By 2025, the World Health Assembly requested that the prevalence of anemia among women of reproductive age (15-49 years) decrease by 50%; however, this deadline could be extended to 2030.³

The prevalence of anemia in the world increased from 24.8% in 1993 to 25.4% in 2010, with adolescents as the most significant proportion.⁴ Anemia prevalence in women of childbearing age worldwide increased in 2015 from 28.5% to 29.9% in 2019.⁵ An increase in cases of anemia also occurred in female adolescents in Indonesia, from 18.4% in 2013 to 27.2% in 2018.⁶ A persistent discrepancy between a person’s dietary iron intake and their body’s physiological needs results in iron deficiency anemia.⁷ Female adolescent anemia is a nutritional issue that can seriously affect growth, cognition, work performance, and other areas throughout the reproductive years of life and beyond.⁸ Pregnancy during adolescence with anemia raises maternal morbidity and mortality rates and the likelihood of unfavorable pregnancy outcomes like stillbirth, low birth weight, and premature birth. It also has a detrimental effect on the infant’s iron status.⁸ The maternal deaths in Bogor District Regency were caused mainly by bleeding and eclampsia.⁹ Previous studies explained that female adolescent anemia prevalence can cause maternal death due to bleeding and eclampsia and also low birth weight.^10,11

The factors that influence the incidence of anemia include the level of education, sex, region, breakfast habits, health status, and state of body mass index (BMI) which is included in the underweight category.¹² The study results showed that food intake, age, place of residence, and activity type affect hemoglobin levels in a female adolescent who takes iron folic acid supplements.¹³ Previous studies examined the causes of anemia in female adolescents, consisting of nutritional status, menstrual cycle and length, lack of iron-folate intake, and vitamin B12 as direct factors for anemia in female adolescents.^14,15 Other studies have tried to examine indirect causes of anemia such as socio-demography (age, education, economic status).¹⁶ In addition, the influence of behavioral factors such as the application of personal hygiene and environmental sanitation and adherence to consuming iron folic acid tablets was also investigated with the incidence of anemia in adolescent girls.^17,18

Heavy monthly flow puts female adolescents at risk for iron deficiency anemia, with an incidence of about 9%, and another 15% to 20% of them have iron insufficiency without anemia.¹⁹ Adolescent girls who have experienced menstruation are at risk of suffering from anemia due to bleeding during menstruation. This is exacerbated if the dietary intake pattern of iron food sources is significantly less than the recommended adequacy rate. Apriningsih et al.’s 2021 research reported a relationship between the intake of food sources of iron and Hb levels in adolescent girls.²⁰ Intake patterns are influenced by several related factors including socioeconomic status, education, gender, and place of residence.²¹

WHO and the Indonesian Ministry of Health launched weekly iron folic acid supplementation (WIFAS) program as an effort to prevent and treat anemia in female adolescents.^22,23

Most of the WIFAS programs are carried out in schools. However, this program was hampered due to the coronavirus pandemic. There have been several adaptations and innovations that program managers have made to respond to the Ministry of Health’s policies in dealing with pandemics, such as implementing health protocols, using social media and applications for education and monitoring compliance with IFAS consumption.²⁴ An example is the Ministry of Health of the Republic of Indonesia launching the Ceria application for the prevention of anemia in young women and implementing it in several regions.²⁵ However, this requires facilities and infrastructure such as gadgets and internet networks, and not everyone in rural areas have these, both in developed and developing countries.^26,27

A previous study discussed factors related to anemia in general, without focusing on rural areas particularly in Indonesia. According to national health research 2018 data, the proportion of people with anemia is higher in rural areas (25.0%) than in urban areas (22.7%).²⁸ Therefore, this study aims to examine the factors related to anemia in female adolescents in rural areas particularly related to an iron folic acid supplement program.

Methods

Data and instruments

Data was collected by interviewing respondents face to face using questionnaires. Examination of hemoglobin levels and interviews were conducted at the village hall of Sirnagalih, Jonggol, Bogor, West Java.

The independent variables used were the menstrual cycle, duration of menstruation, and consumption of blood-added tablets. The dependent variable (outcome) used was the incidence of anemia in adolescent girls. Confounding variables suspected in this study were age and education level.

The topics in the questionnaire are menstrual cycle, duration of menstruation, nutrition status, education level and consumption of iron tablets. The researchers created the questionnaire in accordance with the research objectives. Therefore, validity and reliability tests were carried out before being used in the research sample as pilot study. The menstrual cycle is the distance between the start of the last menstrual period and the next menstruation. Menstrual cycle variables were measured using 4 multiple choice questions. Menstrual cycles are categorized into two, standard 21-35 days and abnormal if the menstrual cycle is more than 35 days. Menstruation duration is the duration (day) experienced by a woman during the menstrual process. The menstrual duration variable was measured using 6 multiple choice questions and 1 free text question for confirmation Menstruation duration is categorized into two categories, namely normal (3-8 days) and abnormal (<3 days or >8 days). The variable iron folic acid consumption was measured using 5 multiple choice questions and 1 free text question as supporting information. Respondents are said to be taking Fe tablets if they consume iron tablets regularly every week (according to the program).

Qualitative data is collected to add supporting information to the quantitative data. There is one open question that collects qualitative data combined alongside the quantitative questions. The answers given by the respondents were written in the form of a questionnaire.

Anemia status variables were measured using 4 multiple choice questions and measurement of Hb levels to validate respondents’ answers. Meanwhile, the cyanmethemoglobin method is categorized as anemia (<12 g/dl) and not anemia (≥12 g/dl). The anemia threshold for women aged 11 years and above is if the concentration or level of hemoglobin in the blood is less than 12 g/dl.³¹

Independent variable (age) is categorized based on median value, education level grouping is based on up to junior high school and senior high school or above, nutrition status grouping is based on ideal (Z score -2SD until +1SD) and unideal, menstruation pattern grouping is based on normal and abnormal, and whether or not participants were consuming iron folic acid.

Health workers carried out data collection via hemoglobin examination to measure respondents’ Hb levels (Figure 1). This was done by taking a blood sample at the fingertips using an EasyTouch GcHb tool. The quantitative data were analyzed univariately to display the distribution and frequency of the existing variables. We used the chi-square test to examine the association between the variables. Crude OR was obtained in bivariate analysis with α=0.05 and 95% confidence interval (95% CI). All statistical analysis was performed using SPSS Software (25th version, International Business Machines Corp., New York). The multivariate test was not carried out because only one variable met the entry requirements for the multivariate test model. Thus, no interaction test between variables was carried out. There is no missing data in this study.

Figure 1. Flowchart of data collection.

The risk of bias that may occur includes selection bias caused by the selection of samples that are not random so that they are not representative. The bias can interfere with the external validity. Another possibility of bias is that there are several other variables that may be associated factors for anemia but were not measured in this study.

Results

Discussion

In this study, the prevalence of anemia among female adolescents in Sirnagalih village was 10.3%. This figure is lower than the national figure (27.2%) and the findings of Sari et al. (2022) in Soreang, West Java (14.3%).^28,32 However, it is similar to the prevalence of anemia among adolescents in rural areas in western China (11.7%)³³

Early marriage or marriage before the age of 18 is common in developing nations and is related to a number of social, physical, and health issues.³⁴ Women who marry young typically have a low level of education. Because they have to start caring for a child, they neglect their health. Additionally, early-married women are far more likely to experience domestic abuse.³⁵ The limited availability of nutritious foods, lower socioeconomic status, and lack of access to hygienic sanitation facilities are associated with elevated rates of disease which in turn may be associated with increased risk of anemia in rural areas. Research in Albania shows that the women who lived in rural regions were more vulnerable to being anemic than the women who lived in urban areas.³⁶

Most anemic female adolescents in this study had a senior high school level of education. This finding is in line with a study by Bellizzi et al. (2020) in India, who found that many adolescent girls suffer from anemia with higher education than primary school.³⁷ This is different from the study of Ma et al. (2017) in China, which found that most anemia sufferers in non-pregnant reproductive women had junior high school education.³⁸ This difference is assumed to be because those with junior high school education still get iron-folic acid supplements from their schools. In contrast, those with senior high school education and above do not get them.

In contrast to the findings from this study, a person’s nutritional condition affects the incidence of anemia.³⁹ A person’s nutritional status (malnutrition) is one of the affectional factors for anemia. The cause of that problem is that young women often eat unhealthy foods like fast food because they ignore their health.³¹

They also drink tea or coffee less than an hour after meals, which might interfere with iron absorption.⁴⁰ Moreover, they often undergo unhealthy diets without an instructor, such as a doctor or nutritionist, affecting their growth and nutritional needs.⁴¹

The menstrual pattern has no significant association with female adolescent anemia. This differs from the meta-analysis study that Endale et al. (2022) conducted. Those studies identified factors associated with female adolescent anemia, such as low dietary diversity (OR: 1.56; 95% CI: 1.05, 2.32), illiterate mothers (OR: 1.45; 95% CI: 1.13, 1.86), households with more than five people (OR: 1.65; 95% CI: 1.14, 2.38), food insecurity in the home (OR: 1.48; 95% CI: 1.21, 1.82), and menstrual blood flow lasting longer than five days (OR: 6.21; 95% CI: 1.67).¹⁴

This study found that a factor significantly related to anemia in young women in rural areas was the consumption of iron folic acid supplements. These results align with the study on Ghana (2021) and Bhutan.^42,43 This result reinforces the need for an iron-folic acid supplement program to prevent and treat anemia in female adolescents.

The supplementation iron-folate program guide by WHO and Ministry of Health of the Republic of Indonesia should be sustainable and monitored for its effectiveness.^1,23,44 Its effectiveness includes the issue of adherence to drinking iron folic acid for female adolescents and the level of school readiness as the spearhead of the program’s success. The pandemic period that has hampered health programs, including the WIFAS school-based program, should give rise to innovations such as using internet-based social media for education and promoting adolescent health, including anemia. However, internet-based social media is very limited in its application in rural areas, where internet facilities are still limited.

This study has limitations in the number of samples, types of causative factors, and study design by using a cross-sectional design. A cross-sectional design was appropriate in this study because it was effective in observing the phenomenon and causes at the same time. Therefore, it is recommended for further research to increase the number of samples, add causal factors, and use a more robust study design such as a cohort or experiment.

Conclusions

Iron folic acid supplement consumption factor is associated with anemia in female adolescents in rural areas. Therefore, it is necessary to organize an iron folate supplementation program in school-based to reach female adolescents who do not attend school in rural areas.