SOCIO-DEMOGRAPHIC DETERMINANTS ASSOCIATED WITH IRON DEFICIENCY ANEMIA IN MENSTRUATING ADOLESCENTS IN RURAL POPULATION

1. Prof and Principal, P D Bharatesh College of Nursing, Halaga, Belgaum, Karnataka, India. 2. Former Prof and Head of the department of MPH, KLE University, Belgaum, Karnataka, India. 3. Prof and Head of the department of Epidemiology and Statistics, KLE University, Belgaum, Karnataka, India. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History

588 from parents and assent from menstruating adolescent girls. Adolescent girls were evaluated for various socioeconomic and demographic determinants as a cause of IDA.
Data collection instrument was developed to collect information regarding age, educational status of parents of adolescent girls, type of diet and family, religion, height and weight. CE certified digital adult weighing machine with the accuracy of 100gms was used to record the weight of adolescent girls. A static height scale marked on the wall was used to measure height of the adolescent girls after standardization.To detect type of anaemia at baseline, Standard method of two glass slides was used.Haemoglobin was estimated by cyanmethaemoglobin method at baseline. Data was analyzed by SPSS 16.0 version. The results were expressed as mean ± standard deviation. P value <0.5 was taken as statistically significant.   Educational status:-222(37.8%) of mothers of adolescent girls had primary education, 186(31.6%) were illiterate, 120(20.4%) had secondary education and 60(10.2%) had higher secondary education.One hundred and ninety eight (33.7%) of fathers of adolescent girls had secondary education, 190(32.3%) had primary education, 160(27.2%) had higher secondary education, 38(6.5%) were illiterate and only 2(0.3%) were graduates.  Mean weight of the adolescent girls at different age groups reveals that, maximum weight gain has been between the age group of 13-14 years, mean weight of the girls at 14 years was 40.48 kg whereas mean weight of the girls at 13 years was 32.78kg. Mean weight gain from 13-14 years was 7.7 kg. There has been gradual increase in the mean weight from 13-16 years.  There is an increase in the mean height of adolescent girls as the age advanced minimum being 130cms for 12 years and maximum152cms for 16 years. When these figures were compared with WHO child growth standards,our subjects were much more stunted in height at all the age groups.In comparison with WHO child growth standard our subjects mean BMI was slightly less for 12 and 13 years but almost same for14, 15 and 16 years. In this study, maximum number of adolescent girls 458(77.89%) had moderate anaemia, followed by 71(12.07%) severe and 59(10.03%) had mild degree of anaemia.  Maximum number of girls 56 (78.9%) with Hb <8 gm/dl and 369 (80.6%) with Hb 8-10.9 gm/dl were having 3-4 days of bleeding. Proportion of girls having <3 days bleeding was highest in mild anaemic girls whose Hb was between 11-11.9 gm/dl. The difference observed was statistically significant.Morenumber of girls with severe and moderate degree of anaemia were bleeding for 3-4 days and more than 5days compared to those with mild anaemia where the proportion of girls bleeding for less than three days was highest. A total of 466(79.3%) of the adolescent girls were bleeding for 3-4 days.Majority of the girls in each age group had 3-4 days bleeding. Although proportion of girls with less than 3 days bleeding was similar at all the ages, it was highest i.e. 31 (18.3%) for the age of 14 years, lowest being 27(14.5%) for the girls at the age of 13 years. The difference observed was statistically not significant.  Out of total 588 adolescent girls, 427(72.6%) were having heavy and regular bleeding whereas 134(22.8%) were having heavy and irregular bleeding. Thus majority of the girls 561(95.4%) had heavy and regular or irregular bleeding. Only 22 girls (3.7%) had normal bleeding. In all the age groups more than 70% had heavy and regular bleeding. Proportion of girls having heavy and irregular bleeding has been highest i.e. 52(28.0%) at the age of 13 years, followed by 38(22.5%) at the age of 14 years. Least being 14(18.2%) at the age of 12 years. Comparatively proportion of girls with normal bleeding was slightly higher after the age of 14 years i.e. 10 (5.9%), 8(6.4%), 2(6.5%) for 14, 15, and 16 years adolescent girls respectively. None of the girls of 13 years had normal bleeding. The difference observed was statistically significant. In the present study, amongst 264 adolescent girls who were underweight, majority 190(72.0%) had heavy and regular bleeding. Similarly maximum number of adolescent girls with BMI 18.5 to 24.9 and above 25 had heavy and regular bleeding. Sixty five (24.6%) of the girls with BMI less than 18.5 had heavy and irregular bleeding. The difference observed in these three categories of BMI was statistically not significant. were severely anaemic had heavy and regular bleeding. The difference observed between the groups was statistically not significant.

Discussion:-
Although there was an increase in the number of girls as the age advanced, definite pattern was not observed. Out of the total 588 adolescent girls, slightly less than one third girls were of 13 years, the least being at the age of 16 years. This could be perhaps due to the fact that in rural areas the parents do not encourage their daughters to go for higher education after seventh standard. The majority 556(94.6%) of adolescent girls were Hindus. Slightly less than 70% mothers and 93.5% fathers of adolescent girls were literate. When compared with Government of Karnataka figures, the female literacy is similar whereas literacy rates for males has been much higher in our study (Karnataka figure 82.47%) 6 . As against this the literacy rates for females and males at the national level have been lower i.e.59.4% and 82% respectively 7 . Slightly less than three fourths of the adolescent girls belonged to joint family.
Our study revealed that slightly less than two thirds of the girls were consuming mixed diet. As against this other Indian studies revealed that the girls consuming vegetarian diet and having nutritional inadequacy are more likely to be anaemic 8, 9 . Another Indian study has shown that prevalence of anaemia was less in vegetarians consuming green leafy vegetables 10 . This could be because in our study the adolescent girls consuming non vegetarian diet have not been regular in taking non vegetarian food in adequate quantity.
Because of the gender bias, the adolescent girls always get the last chance to eat non vegetarian food in the family. Although the mean height of our adolescent girls has increased with increase in age, it has been less when compared with WHO standards. When the mean increase in height was compared with WHO child growth standards, our girls were much more stunted in height at all the ages, the difference being in the range of 10-25cms indicating that all our adolescent girls are malnourished. As against this, the study conducted in Karad, Maharashtra revealed that the mean height of the adolescent girls was higher at 13 and 14yrs and was almost equal to NCHS values 11 . Although there was gradual increase in mean weight from 12 to 16 years, the increase has been comparatively less between the ages of 15 to 16 years. Several studies conducted at West Bengal and Tamilnadu have also observed the similar results 8, 12 .
In our study, mean BMI for the 12 and 13 years has been less than 18(underweight) whereas the mean BMI of the girls at 14, 15 and 16 years have been within normal range (18.5-24.9). In the nationwide study conducted in the year 2011, mean BMI was higher than the present study and their values were even higher when compared with the WHO reference 13,14 . When these figures are compared with WHO child growth standard our subjects mean BMI was slightly less for 12 and 13 years but almost same for 14, 15 and 16 years 15 .

Prevalence of anaemia in adolescent girls:-
Out of the total 624 adolescent girls of eight Handignur schools, 588(94.6%) adolescent girls were anaemic. Several studies conducted in India have also shown more than 90% of prevalence in adolescent menstruating school girls 16,17,18 . However in some studies, the prevalence has been as low as 10% to 40% 19,20,21,22,23,24 .
In our study, maximum number of adolescent girls 458(77.89%) had moderate anaemia, followed by 71(12.07%) severe and 59(10.03%) mild anaemia ( Table 4). As against this, more than 50% of the girls in rural area of Raigad district, Maharashtra had mild anaemia and none of the subjects were severely anaemic 25 . In developing countries like Pakistan and India, prevalence of severe anaemia varied in different studies 22% in Hyderabad (Pakistan) and 2.1% in rural Tamilnadu (India) 26, 27. Comparatively high proportion of girls with moderate and severe anaemia in our study could be because of heavy bleeding coupled with intake of diet poor in iron and unhealthy practices. Many of these adolescent girls with moderate anaemia are likely to become severely anaemic. Unless these girls are treated with iron supplementation chances of them having maternal complications like preterm delivery and low birth weight babies are high if these girls get married and become pregnant 28,29 .
More than 80% of the girls in our study had normocytic normochromic anaemia, followed by 59(10.03%) microcytic hypochromic, 39(6.63%) normocytic hypochromic and 7(1.19%) dimorphic anaemia. (Table 3). In our girls it is mainly the nutritional deficiency that has led to anaemia. Whereas in a study conducted in rural area of Maharashtra, the pattern of peripheral smear was different where more than 50% of the girls had normocytic normochromic and 13.11% had dimorphic anaemia 25 .

Conclusion:-
In India iron deficiency anaemia is most common in the adolescent menstruating girls. In our study majority of the girls are moderately anaemic. Unhealthy practices like open air defecation and barefoot walking are highly prevalent. Majority of the girls are consuming diet deficient in iron. In order to prevent the complications of anaemia during pregnancy and child birth and also the maternal deaths, all the adolescent girls' anaemia needs to be corrected before they get married.