Iron Deficiency Anemia among In-School Adolescent Girls in Rural Area of Bahir Dar City Administration, North West Ethiopia

Background Anemia is a major public health problem worldwide. Adolescent girls are the most vulnerable group of population due to different reasons. The aim of this study was to assess the prevalence of anemia and associated factors among school adolescent girls in rural towns of Bahir Dar City Administration, North West Ethiopia. Methods A cross-sectional study was conducted from March 5 to April 15, 2017, on 443 randomly selected school adolescent girls. Data were collected using pretested structured questionnaire and anthropometric measurements. Blood sample was also collected to assess the hemoglobin (Hgb) value of study participants. SPSS version 20 was used to analyze data. Descriptive statistics were used to describe data. Bivariate and multivariable logistic regression models were used to identify the associated factors with the outcome variable. Crude and adjusted odds ratios with 95% confidence interval (CI) were calculated to identify the variables significantly associated with the outcome variable. Result The prevalence of anemia was 11.1%. Household family size [AOR=3.2, 95%CI (1.29-7.89)], average household monthly income <500 ETB [AOR=10; 95%CI (2.49-41.26)], 501-1000 ETB [AOR=6, 95%CI (2.54-14.33)], history of intestinal parasitic infection [AOR=2.7; 95% CI (1.19-6.21)], duration of menstruation flow [AOR=2.4; 95%CI (1.08- 5.44)], and BMI for age [AOR-3.2; 95% CI (1.43-7.05)] were the predictors of anemia. Conclusion and Recommendation Anemia was a mild public health problem among school adolescent girls in the study area. Household monthly income, family size, intestinal parasite infections, duration of menstruation, and BMI for age are predictors of anemia. Thus, intervention strategies should focus on prevention and early treatment of intestinal parasite, nutritional education, screening, and iron supplementation programs to prevent anemia among school adolescent girls.


Introduction
Anemia is defined as a condition in which the number of red blood cells (RBCs) and their oxygen-carrying capacity is insufficient to meet the body's physiologic needs. It is a condition when the normal number of RBCs (<4.2 million/ l) or hemoglobin (Hb) level <12 g/dl) in women and < 13 in men [1]. Globally, anemia is the most common and inflexible nutritional problem affecting around 2 billion of the world's population having major impact on human health and social and economic development; and more than 89% of this burden occurred in developing countries [2,3].
Accounting half of all cases, iron deficiency anemia is the most common cause of anemia. However, other conditions like nutritional deficiencies, acute and chronic inflammation, parasitic infections, growth spurt, increase in iron requirements, increased iron loss from the body during the menstruation, inherited or acquired disorders of hemoglobin synthesis, RBC production, or survival are also considered cause of anemia [1].

Anemia
Even though iron deficiency anemia can possibly occur at all stages of the life, it is more prevalent among pregnant women, young children, and adolescents. Since the overall iron requirement increases two-to threefolds during adolescence due to high growth spurt and the loss of 12.5-15 mg iron each month, adolescent girls are vulnerable to anemia. Anemia during adolescence is nutritional problem and it has irreversible negative effects on growth and cognitive, work performance and serious impact throughout the reproductive years of life and beyond. Occurrence of pregnancy during adolescence with anemia increases not only the maternal morbidity and mortality but also the incidence of poor maternal birth outcomes such as still birth, low birth weight, and prematurity and also has negative impact on infant iron status [2,[4][5][6].
The impact of anemia among adolescent girls is still public health problem globally although there are specific actions like encouraging consumption of iron-rich foods through dietary change, nutritional education, treatment and prevention of parasitic infections, weekly iron supplementation to prevent iron-deficiency anemia, and improving iron status among adolescent girls [2,5].
Different researchers have conducted studies on anemia among adolescent girls from different part of the world. However, the age range which these scholars considered as adolescent differs among the studies and they were not the standard age category between 10 and 19 years. Since using the finding of studies that use different age ranges can negatively affect the impact of interventions, we argue that the studies should be conducted by selecting the appropriate age group [7][8][9][10][11].
Indeed, the government of Ethiopia had implemented the National Nutrition Program II focusing on reducing prevalence of stunting, wasting, and chronic undernutrition among women of childbearing age. However, intermittent weekly oral iron supplementation for children which is recommended by the WHO was not practically implemented yet to prevent the risk of iron deficiency anemia during childhood [2,12]. Additionally, studies conducted on anemia among the adolescent girls in the country are not only few in number but also did not address these adolescents' living conditions and their knowledge on anemia prevention and food rich of iron and the effect that these variables have on anemia. In the current study, these factors were considered [11,[13][14][15].
Furthermore, determining the prevalence of iron deficiency anemia and those factors associated with it among adolescent girls is crucial for initiation of effective intervention that improve their nutritional status to prevent occurrence of different risks during their adolescence, pregnancy, child birth, and beyond. Therefore, the aim of this study is to assess the prevalence of anemia and associated factors among school adolescent girls in rural areas of Bahir Dar City Administration, North West Ethiopia.

Study Design and Period.
A cross-sectional study was conducted from March 5 to April 15, 2017, to assess the prevalence of anemia and associated factors among school adolescent girls.

Study Area and Population.
The study was conducted at rural towns of Bahir Dar city administration. Bahir Dar city is located in Amhara region North West Ethiopia which is 565 KMs from Addis Ababa, capital city of Ethiopia. Meshenti, Tiss Abay, Zegie, and Zenzelema are the four rural towns in Bahir Dar city administration. In these rural towns, there are 4 elementary and 3 secondary schools. School girls aged between 10 and 19 years in rural towns of Bahir Dar city administration were the study population. Adolescent girls who were critically ill at the time of data collection and pregnant were excluded from the study.

Sample Size and Sampling
Procedure. The sample size was calculated using Epi info version 7 open software by considering variables that determine anemia in previous study [11]. The final adequate sample size (443 adolescent girls) was obtained using the following parameters: odds ratio of consumption of fruit (5.1), 95% CI, and power 85%. Sampling frame was prepared using the school roster sheets. Proportion to size allocation was made to determine the required sample size from each school. Simple random sampling technique was used to select study participants from the registration roster sheet.

Data Collection Tools and Procedures.
Data were collected using pretested structured questionnaire. The questionnaire had sociodemographic characteristics, knowledge questions, dietary practice, health, and nutritional status. The English version questionnaire was translated in to national language (Amharic) and then back to English to check its consistency. Those school adolescent girls who were absent at the time of data collection were followed and recontacted for the next additional 1 to 2 days to include in this study. Three diploma nurses and one diploma laboratory technician were recruited and trained for data collection. One-degree holder nurse was recruited as supervisor during data collection.

Measurements. Outcome Variables.
Anemia was the outcome variable of the study. If the level Hb is <12 g/dl in adolescent girls, it indicates the presence of anemia. Hb level between 11 to 11.9 g/dl and 8 to 10.9 g/dl indicates mild and moderate anemia, respectively, while Hb level of <8.0 g/dl is indication of severe anemia in adolescent girls [16].
Independent Variables. These are sociodemographic characteristics, knowledge on anemia, dietary practice, health, and nutrition condition. Sociodemographic characteristics include adolescent's age, education level, place of residence, and occupation of her parents/guardian. Knowledge on anemia was measured using ten items by summing the statement related to anemia, its common cause, sign and symptoms of anemia, consequences, treatment, and prevention after reversely scoring the incorrect statements. Dietary diversity practice was measured using the number of different food groups irrespective of the amount consumed over the past 24hour period.

Anemia 3
Health and nutrition condition include menstrual status, history of parasitic and malaria infection, and iron supplementation.
Body mass index (BMI) was calculated as weight for height (BMI for age) using WHO anthroplus software. The weight was measured by wearing light clothing to the nearest 0.1 kg by standing in the center of the platform of the scale and remaining motionless until the measurement can be obtained. The height was measured using a wooden height measuring board with a sliding head bar to the nearest 0.1 cm on standing Frankfurt position without shoes. Finally, BMI for age of ≥-2SD and <-2SD were considered normal and underweight or thinness, respectively.
Dietary Diversity Score (DDS). The DDS was calculated by summing the number of different food groups irrespective of the amount consumed over the past 24-hour period. It was classified as poor, medium, and high DDS if the participants consume 3, 4 -6, and > 6 food items in the last 24 hours, respectively.

Data Quality Assurance.
Training was given to the data collectors and supervisors on the data collection procedures and techniques. Before actual data collection, the questionnaire was pretested in school which is outside of study area and modification on some questions was made to increase the clarity of questions. The filled questionnaire was reviewed and checked on a daily basis for completeness and consistency by the supervisors and the principal investigator.

Data Processing and Analysis.
Data was checked, cleaned, coded, and entered using Epi info version 7 and then exported to SPSS version 20 statistical software for analysis. Descriptive statistics such as frequencies, proportions, and standard deviation were done to describe data. Bivariate logistic regression analysis was done to check association between each independent variable with the outcome variable (anemia). All variables with p-value < 0.2 in the bivariate analysis were entered into the multivariable logistic regression analysis. Adjusted odds ratio (AOR) with 95% confidence interval (CI) was used to identify the independent predictors of anemia. A p-value <0.05 was set as cut-off value for statistical significance.

Sociodemographic Characteristics of Study Participants.
A total of 423 school adolescent girls participated in this study, making response rate 95.5%. The mean (±SD) age of study participants was 14.5 (±2.28) years. Above ninety percent of the study participants (94.3%) were Orthodox Christianity followers. Three hundred and two (71.4%) and 267(63.1%) of the study participants' fathers and mother's occupation were farmers and house wives, respectively. Regarding the educational status, 228 (53.9%) and 156 (36.9%) of mothers/guardians and fathers/guardians were unable to read and write, respectively. Around one-third (30.3%) of study participants had an estimated average monthly household income of less than 1000 Ethiopian birr. Almost all 416 (98.3%) of study participants lived with their parents, of which 392 (92.7%) of adolescent girls lived with both father and mother (Table 1).

Knowledge of Study Participants about Anemia.
More than three-fourths, 332 (78.5%), of the participants had not heard about anemia. Majority 240 (56.7%) of participants had poor knowledge on anemia. Around 43.3% adolescent girls had good knowledge about anemia. Of all study participants, only 162 (38.3%) had good knowledge on the causes of anemia, 178 (42%) on signs and symptoms of anemia, 196 (46.3%) on consequences of anemia, and 183 (38.5%) on prevention of anemia ( Table 2).

Dietary Diversity Score (DDS) and
Practice. Less than half (46.1%) of study participants had a medium DDS. Majority, 349 (82.5%), of adolescent girls were reported that they consume bread and rice, pasta, biscuits, or any other foods made from cereals followed by consumption of fats and oils 331(78.3%) and roots and tubers 285 (67.4%). Majority (85.2%) of the respondents had meal frequency of three or more times per day. More than half 226 (53.4%) of the respondents said they drink tea immediately after meal within 30 minutes. Only 32 (9.2%) of the respondents ate fruits three or more times per week. Only few (0.7%) of the study participants reported that there are foods that are restricted for adolescent girls within the community. Almost all 419 (99%) of them did not have a history of iron supplementation (Table 3).

Prevalence of Anemia, Health, and Nutritional Status.
The prevalence of anemia was found to be 47 (11.1%) of which 46 (97.8%) of them had mild anemia. Above half (54.8 %) of study participants were thin. Nine in ten (91.7%) and eight in ten (80.9%) of the study participants have no history of malaria and intestinal parasite infection in the last one month, respectively. More than two-thirds (67.7%) of adolescent girls had already menstruated. Around 44 % of adolescent girls had duration of menstrual flow ≥ 5 days during each cycle (Table 4).

Factors Associated with Anemia among Adolescent Girls.
In the bivariate analysis variables like age, average household monthly income, household family size, post meal consumption of tea, history of intestinal parasite infection, duration of menses, and BMI status of adolescent girls were significantly associated with anemia (p-value <0.2) and were entered to multivariable analysis.
In multivariable logistic regression analysis, average household monthly income, household family size, duration of menstrual flow per each cycle, history of intestinal parasite infection, and BMI for age were significantly associated with anemia. Adolescent girls who had household family size of > 5 were 3.2 times more likely to be anemic, compared with those who had household family size of ≤5 [AOR =3.2, 95% CI (1.29, 7.89)]. Adolescent girls whose family average monthly income is <500 were 10 and 6 times more likely to be anemic as compared to those whom family average monthly income 4 Anemia  (1.43, 7.05) more likely to be anemic compared with those BMI for age ≥ -2 SD. (Table 5).

Discussion
In the present study, the prevalence of anemia was found to be 11.1%; out of this (95.8%) and (2.2%) had mild and moderate anemia, respectively. The finding of this study is comparable with a study conducted in Kebena district (12%) [15]. But it was lower than those similar studies reported from different Anemia 5  [11,13]. The possible reasons for this variation might be due to low socioeconomic status, small meal frequency, and hunger at those other study areas. The finding of this study was also lower than similar studies conducted in Yala division, Siaya district of Kenya (26.5%), and western Kenya 19.8%, respectively [9,10]. The possible reason for this variation might be due to high malaria and intestinal parasite infection, excessive heavy, and irregular menstruation at those study settings. Similarly, it was also lower than those studies reported from Karad district Satara of Maharashtra (45.3%), Lucknow district, Ultarpradesh of India (88.3%) and Anganwadi, Hassan district (45.2%), and Central Kerala of India (21%), respectively [16][17][18][19]. This may be due to irregular, prolonged and heavy amount of menstruation, high intestinal parasite infections and undernutrition, poor knowledge on nutrition and anemia, and skipping of meals.
School adolescent girls who had family size of > 5 were 3.2 times more likely to be anemic as compared to those school adolescent girls with a family size of <5. This finding was in agreement with the finding which is reported by a study done in Bonga town, southwest Ethiopia; household family size ≥5 was 2.58 times more likely to develop anemia as compared to household family size <5 [14]. It was also in line with a study conducted in Tang ail region of Bangladesh, Guntur, Andhra Pradesh of India, Khordha Rural District of Odisha in India, and Chennai, Tamil Nadu of India [8,[20][21][22]. This might be due to the reason that the large size of the family can be related to low care for each family member and low family income to obtain variety of foods rich in iron and other micronutrients in those study areas.
Adolescent girls whose average household income is less than 500 ETB were 10 times more likely to develop anemia and those adolescent girls with 501-1000 ETB were 6 times more likely to develop anemia. This was consistent with the finding reported in Berahle district of Afar region that low socioeconomic status was 2.8 times more likely to develop anemia compared to medium ones [11]. This finding was also comparable with studies conducted in Tang ail region of Bangladesh, Guntur, Andhra Pradesh of India, Khordha rural district, Odisha of India, and Hassan District of south India [8,20,21,23]. This might be due to low family income to obtain variety of foods rich in iron and there should be a means in which iron supplementation started for adolescent girls.
Adolescent girls who had history of intestinal parasite were 2.7 times more likely to be anemic compared to those who did not. It was in agreement with a study done in Yala division, Siaya District of Kenya, in which respondents who tested positive for ova of Ascaris were 8 times more likely to develop anemia compared to those who tested negative [9]. This finding was consistent with a previous similar study conducted in Bonga Town, southwest Ethiopia; adolescents who had intestinal parasitic infection were 5.37 times more likely to develop anemia compared to those who did not [14]. Although we were not sure which specific intestinal parasite infection the girls had, intestinal parasites have their own contribution to blood loss which further lead to anemia.
Adolescent girls who had menstrual flow for ≥ 5 days were 2.4 times more likely to be anemic as compared to those adolescent girls with menstrual flow < 5 days per each cycle. This finding was in agreement with similar findings reported in Tang ail region of Bangladesh, Guntur, Andhra Pradesh of India, Khordha rural district, Odisha of India, and Western Kenya [8,10,20,21]. This may due to the fact of blood loss during the menstruation.
Anemia is significantly associated with low BMI for age. Adolescent girls who had a low BMI for age were 3.2 times more likely to be anemic as compared to those who have a BMI for age. Similar findings were also reported in Bonga Town; those with low BMI for age were 2.54 times more likely 6 Anemia to develop anemia compared to those with high BMI for age [14]. It was also parallel with the finding in Tangail region of Bangladesh and Chennai, Tamil Nadu of India [20,22]. Since this study used cross-sectional design the cause-effect relationship was not addressed. Additionally, the study period which is fasting time might have affected the real dietary diversity practice of school adolescent girls.

Conclusions
Anemia was found to be a mild public health problem in the study area. Household monthly income, family size, intestinal parasite infections, duration of menstrual flow per each cycle, and BMI for age were the main predictors of anemia. Thus, school-based Iron folic acid supplementation and regular Anemia 7

Data Availability
The data used to support the findings of this study are available from the corresponding author upon request.

Conflicts of Interest
The authors declare that they have no conflicts of interest.