Self assessed symptoms and risk
factors of anemia in urban school going adolescent girls
Kulkarni S.P.1
1Dr. Suhas P. Kulkarni, Department of Pediatrics, Dr. D. Y. Patil
Medical College, Kolhapur, Maharashtra, India
Address for
Correspondence: Dr. Suhas P. Kulkarni, 240, Ruikar
colony, City: Kolhapur, Maharashtra, India. Email: drspk_2000@yahoo.com
Abstract
Introduction:
Anemia prevalence is very high in adolescent girls. Anemia detection is
not done adequately due to non specific symptoms. Risk factors for
anemia have been identified and taken care of but still the prevalence
rate remains same. Methods:
A questionnaire based study was conducted at urban school in Kolhapur
city in adolescent girls. The questionnaire was filled by the students
themselves to find out the symptoms suggestive of anemia. Hemoglobin
estimation was done by finger prick method. Results: 81 girls
gave consent to the study. The anemia was present in 70.3% girls, 23%
of the girls had severe anemia. There was no association between
symptoms (breathlessness, anorexia, and weakness, lack of
concentration, palpitation, giddiness, nails, and edema) and anemia.
There was no association between risk factors (worm infestations,
education of mother and education of father, menstrual problems) and
anemia. In severe anemia cases also there was no association between
self assessed symptoms and risk factors and anemia. Conclusion:
Prevalence of anemia in adolescent girls remains high. In adolescent
girls perception of symptoms of anemia is very poor. Hence there is
need to examine hemoglobin concentration actively every year. Education
regarding iron rich food should be given. The hemoglobin level of each
and every adolescent should be recorded in progress report so as to
make students, parents and teachers aware. A hemoglobin day should be
observed in the whole country like pulse polio to increase awareness in
the community at large.
Key words:
Adolescent, Anemia, Risk factors, Symptoms
Manuscript received: 15th
March 2017, Reviewed:
24th March 2017
Author Corrected: 30th
March 2017, Accepted for
Publication: 6th April 2017
Introduction
Anemia is a condition in which number of red blood cells and their
oxygen carrying capacity is insufficient to meet body’s
physiological needs [1]. There are many studies regarding anemia in
children below 5 years and in pregnant women. There are many programmes
for these groups [2]. Surprisingly there are few studies about
association of clinical symptoms and signs of anemia in adolescent
girls which remain undetected. The prevalence of anemia in adolescent
girls varies from 21% to 69% in various studies [3, 4].
Nutritional needs increase during adolescence in girls which are not
taken care of. This leads to various consequences such as stunting.
Anemia remains one of the major consequence due to neglect of nutrition
in adolescent girls [4].
WHO identifies adolescent from age 10—19 years. The period of
adolescence is a period of preparation for adulthood [5].The anemia
affects growth of the adolescent girl. It causes decrease in school
performance and memory. If the anemia remains untreated later on in
pregnancy it can causes fetal mortality, morbidity and increased
incidence of low birth weight babies [6]. In India District Kolhapur is
having one of the best per capita incomes. Most of the health
indicators have improved [7]. Hence there is needed to focus on others
parameters such as anemia in adolescent girls.
The symptoms and signs of anemia described in the standard textbook are
tiredness, lassitude, easy fatiguability, generalized muscular weakness
as the earliest symptoms of anemia. Patient can present as poor
feeding, irritability and inadequate school performance. The most
characteristic sign of anemia is pallor. Dyspnea on exertion,
palpitation is common symptoms [8].
The symptoms of anemia develop on two main factors, the rate of
development of anemia and state of cardiovascular system of the
patient. Symptoms do not usually occur if the development of anemia is
slow. Hence to address this issue of whether the anemia in adolescent
girls is developing without symptoms or the symptoms are present but
are neglected by the adolescents and parents this study was carried
out. There are studies on symptoms and causes of anemia. But there are
few studies about self assessed symptoms of anemia and prevalence of
anemia highlighting the importance that anemia can be present without
symptoms [8].
Aims
and Objectives
To determine association of self assessed symptoms and risk factors
with anemia in adolescent girls.
Materials
and Methods
Study design: Cross
sectional study
Setting:
This study was carried out by conducting a camp about anemia in an
urban school in city of Kolhapur.
Inclusion criteria: Adolescent
girls whose parents gave written consent for the study and which are
studying in urban school in Kolhapur city.
Exclusion criteria:
Adolescent girls who were not willing to participate in the study.
Participants:
Girls studying in urban school of Kolhapur city.
Variables:
Variables were hemoglobin in gms, symptoms of anemia, and risk factors
of anemia
Data source:
Questionnaires filled by the adolescent girls studying in urban school
and hemoglobin done by finger prick method.
Bias: Since
this was a self assessed questionnaire based study and finger prick
method was used for hemoglobin estimation bias in detection of cases
can be there.
Study size:
With the prevalence of anemia around 50% and considering the alpha =
0.05 and beta =0.80 the sample size is around is around 384 .Hence 350
girls were approached but 81 consented for the study.
Statistical Methods:
For the purpose of statistical analysis, those with hemoglobin <
12 g/dl were categorized as anemia. Association was found out by
calculating odds ratio and relative risk was estimated. P value
<0.05 was taken as statistically significant.
WHO cut off values of assessing anemia in adolescent girls.
NORMAL: >12gm/dl
Mild Anemia: 11gm to 11.9gm/dl
Moderate Anemia: > 8 gm to <10.9 gm
Severe Anemia: <8gm/dl [1]
This study was carried out by a questionnaire in Marathi Language. The
questionnaire was given a day prior to obtain consent of parents. It
was filled by the students. Verbal assent of the student was taken. The
study was approved by the ethical committee.
Haemoglobin concentration was done by finger prick method under aseptic
precautions. Data compiled and analyzed after collection of data. It
was coded and entered into Microsoft excel. Association between
categorical variables was tested chi-square test and P value <
0.5 was taken as significant.
Results
A cross sectional study was conducted to find out prevalence of anemia,
clinical symptoms and associated risk factors among adolescent girls.
Total 81 girls took part in study. The percentage of anemia was 70.37
%. Out of 81 girls, 19 girls had severe anemia 23%
Self assessed symptoms (breathlessness ,anemia ,weakness ,lack of
concentration ,palpitation ,giddiness, nails , edema) did not show any
significant association with anemia (table 1).Risk factors worm
infestations ,education of mother, education of father ,menstrual
problems did not show any significant association with anemia (Table2).
Table-1: Association of
symptoms with anemia
Serial
Number
|
character
|
Odds
ratio
|
RR
|
P
value*
|
1
|
Breathlessness
|
1.19
|
1.158
|
P =1.0
|
2
|
Anorexia
|
1.41
|
1.26
|
P=0.61
|
3
|
weakness
|
1.754
|
1.516
|
P=0.42
|
4
|
Lack of concentration
|
1.5
|
1.26
|
P=0.46
|
5
|
palpitation
|
0.98
|
0.98
|
P=1.0
|
6
|
Giddiness
|
0.42
|
0.56
|
P=0.41
|
7
|
Nails
|
1.30
|
00
|
P=1.00
|
8
|
Edema
|
1.30
|
00
|
P=1.00
|
*p value <0.05 significant
Table-2: Association of
risk factors with anemia
Serial
Number
|
Character
|
Odds
ratio
|
RR
|
P
value*
|
1
|
Menstrual problems
|
1.736
|
1.684
|
P=1.00
|
2
|
Education(father)
|
-
|
-
|
P=0.33
|
3
|
Worm infestation
|
2.21
|
2.10
|
P=0.66
|
4
|
Education(Mother)
|
-
|
-
|
P=0.30
|
*P value<0.05 significant
Table-3: Association of
self assessed symptoms and severe anemia
Serial
Number
|
Character
|
Odds
ratio
|
RR
|
P
value*
|
1.
|
breathlessness
|
-
|
0.50
|
P=0.50
|
2.
|
anorexia
|
0.271
|
0.39
|
P=0.057
|
3.
|
weakness
|
0.60
|
0.68
|
P=0.56
|
4.
|
Lack of concentration
|
0.88
|
0.03
|
P=1.0
|
5.
|
Palpitation
|
1.47
|
1.39
|
P=0.69
|
6.
|
Giddiness
|
1.34
|
1.30
|
P=0.66
|
7.
|
Edema
|
1.05
|
-
|
P=1.00
|
*P value < 0.05 significant
Table-4: Association of
risk factors with severe anemia
Serial
Number
|
Risk
factor
|
Odds
ratio
|
Relative
risk
|
P
value*
|
1.
|
Worm infestation
|
1.70
|
1.30
|
P=0.66
|
2.
|
Education (father)
|
|
|
P=0.24
|
3.
|
Education(Mother)
|
|
|
P=0.28
|
4.
|
Menstrual problem
|
2.31
|
|
P=0.33
|
*P value < 0.05 significant
When self assessed symptoms (breathlessness ,anorexia ,weakness ,lack
of concentration ,palpitation ,giddiness, nails, edema) were assessed
in severe anemia ,still they did not show any association (Table 3).
Risk factors like worm infestations ,education of mother ,education of
father ,menstrual problems did not show any significant association
with severe anemia(table 4).
Discussion
Anemia remains a public health concern in developing countries .In our
study the percentage of anemia in adolescent girls as found to be 70.37
% which is very high.
Dutta et al 2009 found prevalence of anemia among adolescent girls in
rural areas to be 61 %. The associated factors were excessive
menstruation, worm infestation, history of malaria, vegetarian diet
[9]. Sudhagandhi et al observed 52.88 % anemia in adolescents. Mild
Anemia, 30.4 %, Moderate Anaemia-37.33 %, no severe Anemia was
detected. Anemia in girls was 67.77% which was similar to our study
[10].
Surprisingly anemia was found in 43.52% girls studying in Medical and
Paramedical courses at Ahmadabad [11]. Symptoms and signs significantly
associated were palpitations, breathlessness, conjunctival pallor,
tongue pallor, nail pallor. But in this study girls were from Medical
and Paramedical colleges. In our study participants were urban school
going adolescent girls. This may be the reason of lack of association
with symptoms
In an urban cross sectional study in Mumbai Vani et al found prevalence
Anemia 78.3% among adolescent girls similar to our study [12]. Study
participants were daughters of Government Class IV employees residing
in Government Housing Colony of tertiary care hospital in Mumbai, which
indicates poor knowledge regarding anemia and Iron rich foo. According
to Teji K et al Nutritional status of the adolescent girls was
associated with anemia [13].
Angadi et al tried to find out knowledge, attitude and practice about
anemia amongst adolescent girls in urban slums, they concluded that
good knowledge but poor attitude and practice towards anemia in
adolescent girls which may be the reason for persistence of anemia in
adolescent girls in urban area [14]. In a hospital based study Thomas
et al found Iron, folate and vitamin b12 deficiency in 30.5 %, 79.5 %
and 50% of adolescent respectively. So they concluded folate, vitamin
B12 deficiency are more common in adolescent girls [15]. As this was
tertiary care hospital based study vitamin B12 deficiency may have
scored more than other deficiencies.
Government in 2012 -2013 started weekly Iron and Folic acid
supplementation programme. (WIFS) [16] to decrease the high prevalence
of anemia in girls and boys. The long term goal was to break the
intergenerational cycle of anemia. Malhotra S observed that there was a
resistance to uptake of WIFS programme in India. Due to side effects of
drugs, negative impact of mass media and failure to learn from earlier
successful Public Health Programme [17]. Hema et al found stomach pain
in 41%, nausea, vomiting in24.5%, disliking of tablets 22.3% in 9th and
10th standard students. Benefits which were observed were improvement
in symptoms like reduced fatigue, increased appetite, improved
concentration, reduced giddiness and regularization of the menstruation
after consuming IFA tablets [18].
Shah et al by a novel way with the help of peer educators at community
levels in tribal area gave Iron folic acid supplementation which
resulted in 21% decrease in anemia in adolescent girls [19]. Susheela
et al found an inverse relationship in the urine fluoride and
Haemoglobin level .The consumption of fluoride may affect adolescent
girls adversely. Withdrawal of fluoride from consumption possibly
corrected the damage caused to the gastrointestinal mucosa /microvillus
which leads to absorption of nutrients including Iron and improvement
in anemia [20].
Salam et al did a systematic review of interventions to improve anemia
with micro nutrients. Supplementation with Iron, Folic acid, vitamin
B12, vitamin A, Zinc, Calcium and Vitamin D can decrease anemia in
adolescent girls. Thus there can be risk factors other than previously
thought or there could be appearance of new risk factors yet to be
detected [21].
According to BRINDA Project (biomarkers reflecting inflammation and
nutritional determinants of anemia)although Iron deficiency is
considered to be the most common risk factor micronutrient deficiencies
,Vitamin A ,Folic acid,VitaminB12,infections,intestinal parasites,
Malaria ,HIV and Inherited RBC defect can be associated with anemia .
Serum Ferritin level has been considered as primary measure of Iron
status .Anemia can be divided into low inflammatory state and high
inflammatory state. Hence inflammatory bio-markers such as Serum
Ferritin and Serum transferrin receptors (stfr) may be measured along
with nutrient markers. Therefore region wise and country wise
programmes should be developed to treat anemia [22].
Hence we conclude that Anemia amongst urban adolescent girls in private
school remains a major health problem. Perception of symptoms of anemia
is very poor by the adolescent girls hence anemia remains undetected
and adolescent girls with anemia are not approaching health services
for the treatment. Also there may be change in risk factors causing
anemia which should be identified and treated accordingly.
Hence there is need to actively examine Haemoglobin concentration of
these girls every year .Also there is need to give education regarding
iron reach foods and it should be made part of the curriculum. We
suggest recording of haemoglobin level of each and every student every
year in the Progress Card so as to make the student, parents and
teachers aware. Similar to Pulse Polio program, ‘A
HAEMOGLOBIN DAY’ should be observed in all schools on which
haemoglobin estimation and IEC activities about anemia should be
carried out. Also further research is needed to find out precise causes
of anemia in adolescent girls and treated. Blanket treatment with iron
folic acid probably has not resulted in significant improvement in
anemia in adolescent girls. Private schools in urban area are probably
not covered by the program which should be done.
The Limitations of the study are small sample size, symptoms were not
reviewed by physicians and study sample was from single school.
Acknowledgement: We
thank Dr. Mrs. Meera Kulkarni for helping to conduct the camp and
collection of data from the students.
Funding:
Nil, Conflict of
interest: None initiated
Permission from IRB:
Yes
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How to cite this article?
Kulkarni S.P. Self assessed symptoms and risk factors of anemia in
urban school going adolescent girls. J
PediatrRes.2017;4(04):249-254.doi:10. 17511/ijpr.2017.04.01.