29

CHAPTER III

REVIEW OF LITERATURE

3.1 PREVALENCE OF ANEMIA IN CHILDREN

The exact prevalence figures vary from study to study, there is no doubt that

anemia is an extremely serious public health problem in India.

3.1.1 Prevalence of anemia in pre school children

Giebel HN et al (1998) [28] conducted a study to examine prevalence

and correlates of anemia in 433Young Children (1 to 4 years old) of the

Muynak District of Karakalpakistan, Uzbekistan. The results showed that the

mean hemoglobin level was 9.78 (SD = 1.80) g/dL. 72.5% of the children had

anemia (26.3% mild, 38.8% moderate and 7.4% severe). The prevalence of

anemia rates were 89%, 79%, 66% and 48% for 1,2,3 and 4 years old children

respectively. Only age, history of pica, and primary household water source

were significantly associated with anemia status (P < .05).

Cornet M et al (1998) [29] conducted a longitudinal survey in

Ebolowa in southern Cameroon, to identify the prevalence and the main risk

factors for anemia in young children. Authors enrolled children in two cohorts

and follow up done for a three years period. The first cohort was composed of

122 children from 0 to 36 months of age and the second cohort was composed

of 84 children from 24 to 60 months of age. The children were grouped into

six-month age groups. Weekly for symptomatic malaria, monthly for both

symptomatic and asymptomatic malaria, and every six months for

hematologic data were determined for two cohort’s children. The result shows

that the prevalence of anemia was the highest in the six month old age group

(47%) and 42% of the children less than three years of age were anemic,

30

while 21% of the children between three and five years of age were anemic.

The lowest hemoglobin mean (10.7 ± 2.1 g/dl) was observed in the six-

month-old children and a regular improvement in the hemoglobin level

occurred from six months to three years of age. Hookworm infection was

diagnosed in two children in the study population. Results of a multivariate

analysis of the study showed that placental malaria infection was the strongest

risk factor for anemia in the six-month-old children and was independent of

the frequency of parasitemia. In the one-year-old age group, microcytosis was

a significant factor related to anemia, pointing out the role of iron deficiency

at this age. Parasitemia at the time of Hb measurement was significantly

associated with anemia in all age groups (except in 54- and 60-month-old

groups).

A.A. Adish et al (1999) [30] the result revealed that 42% of preschool

children in northern Ethiopia had anemia. In a sub-sample of 230 anemic

children, 56% had a low red blood cell (RBC) count, and 43% had a serum

ferritin of less than 12 mg l-1 indicating that the anemia was largely due to

iron deficiency. Unlike other regions in developing countries, hookworm

(0.4%) and malaria (0.0%) were rare and contributed little to the anemia.

Even though their diet lacked variety, the amount of iron consumed through

cereal-based staple foods was adequate. However, the iron in these foods was

not readily available and their diets were probably high in iron absorption

inhibitors and low in enhancers. Dietary factors associated with anemia

included frequent consumption of inhibitors, such as fenugreek and coffee,

and poor health in the child such as diarrhea and stunting.

S.Jain et al (2000) [31] in their study found that the prevalence of

anemia was 59.9 % in 137 children of age 1-2 years in urban slums of Meerut.

Of these anemic children, 24.3% had severe anemia (Hb less than 7 g %),

49.8% children had moderate anemia ( Hb between 7-9.9 g %) and 26.8% had

31

mild anemia (Hb between 10-11g%). The study also indicated that

socioeconomic status, mother's educational status, birth weight, sibling order,

sex and type of weaning food did not show any significant relationship with

the prevalence of anemia in these children (p > 0.05 by X 2 test). Prevalence

of anemia was also found to be significantly higher in children having low

nutritional status (84.3%) as compared to children of borderline (51.4%) or

normal nutritional status (52.9%). A highly significant impact, of early iron

supplementation was also found on prevalence of anemia (p < 0.001) being

23.8% among the children who were on regular iron supplementation from

age of 6 months and 68.4% among the children who were on either occasional

or irregular iron supplementation or no iron supplementation as elicited by

history.

K.A. George et al (2000) [32] conducted a study to analyze the

anemia and Nutritional status of pre-school children in Kerala. 3633 children

were participated in this study (1873 male children and 1760 female children).

Capillary blood was collected from each child and hemoglobin was estimated

by cyanomethemoglobin method. Weight and height of children were

measured for assessing their nutritional status. The results showed that

overall prevalence of anemia was found to be 11.4%. The percentage of

anemic children among male and female children was 10.25 and 12.55

respectively. Most of the children belong to the low-income group. Dietary

survey revealed that majority of children was non-vegetarians (74.5%).

Statistical analysis (Chi square) showed that there is an association between

anemia and dietary habits (p value 0.021). Among 927 vegetarians, 86

(9.27%) were anemic and among 2706 non-vegetarian, 328(12.1%) were

anemic. Even though larger percentage of anemic cases were reported in the

non-vegetarians group, the difference is not that statistically significant.

Nutritional status of children showed 46.8% children as nutritionally normal.

Among the undernourished, 43.7% were in Gomez grade I and 9.6% in

32

Gomez grade II. There were no cases in Gomez grade III. This study observed

that there is a significant relationship between hemoglobin and nutritional

status (Chi square, p value 0.006).

Osorio M M et al (2001) [33] carried out a study to determine the

prevalence of anemia in 777 children in the age group of 6–59 months old in

Pernambuco, a state in northeastern Brazil. Blood was collected by

venipuncture, and hemoglobin was measured with a portable

hemoglobinometer. The result reveled that the prevalence of anemia among

children 6–59 months old was 40.9% for the state as a whole. Prevalence in

the metropolitan region of Recife was 39.6%, and it was 35.9% in the urban

interior. The rural interior had the highest prevalence, 51.4%. Prevalence was

twice as high in children aged 6–23 months as among those 24–59 months

old, 61.8% vs. 31.0% (_2 = 77.9, P < 0.001). The mean hemoglobin

concentrations in the younger and older age groups were 10.4 g/dl (standard

deviation (SD) = 1.5) and 11.4 g/dl (SD = 1.4), respectively. There was no

statistically significant difference between the sexes in terms of prevalence.

Brunken GS et al (2002) [34] studied the prevalence of anemia in

children aged less than 36 months in public day care centers in the city of

Cuiaba, state of Mato Grosso, Brazil. Among 271 children, 63% were anemic.

The finding of this study also revealed that the prevalence of malnutrition was

0.8% according to the weight/height ratio, 5.0% according to weight/age

deficit, and showed an inadequacy of 10.3% as to the height/age ratio. Thus,

the percentage of anemic children was six times higher than the height deficit

and twelve times higher than the weight deficit. Malnutrition was not in fact

associated with anemia, but at extreme anthropometric cut-off points of height

and weight for age (< -2 z score), there is an association between these

conditions.

33

Table: 3.2 Prevalence of Anemia among Infants and Toddlers in India

Study region Study done by Age Anemia

prevalence %

North India

Delhi Dhar et al, 1969 6m -3y 60

Varanasi Singla et al, 1982 6m-5y

urban 56

Delhi Gomber et al, 1998 3m -3y 76

Ludhiana

Kapur et al, 2002 9-36m 64

South India Hyderabad

ICMR – 1977 1-3 y 54.3

West India Bombay

ICMR – 1977 1-3 y 70.6

East India Kolkatta

ICMR – 1977 1-3 y 38.9

Source adopted from Deeksha.K et al 2002 [35].

Review of literature clearly shows that in the last five decades,

prevalence of anemia was severe public health problem (more than 40%) [6]

in various state of India.

Karimi et al (2004) [36] reported that the prevalence of Iron

deficiency and iron deficiency anemia was higher in children 6 – 23 months

old and the prevalence rate is decreased as age increased. The prevalence of

34

anemia, iron deficiency, and IDA in 997 rural children (6-60 month old) in the

Yazd province of Iran was 24.9%, 8.5%, and 4% respectively. The study also

found iron deficiency and IDA, without a relation, were higher among boys

than in girls. There was no relationship between iron deficiency or IDA and

some variables such as birth rate, number of family members, and mother’s

education. Prevalence of iron deficiency in our study was higher in children

with weight to height (W/H) under the fifth percentile. The majority of

anemia cases in this study were normocytic anemia

.

National family health survey – 2 (NFHS -2 (2000) [37] of India,

about 74% children between the ages of 6 to 35 months were anemic.

According to the NFHS -3 [38] the prevalence of Anemia in India between

2000 and 2005 is increased from 74% to 79% in children aged 6 to 36

months. As per NFHS-3 (2005) report,[39] of Tamil nadu children aged 6-35

months had 72.7 % of anemia.

A research by Anna Christofides et al (2005) [40] on the prevalence

of anemia and to identify its associated risk factors among 115 young children

(4 to 18 months) in Aboriginal communities in northern Ontario and Nunavut.

The mean hemoglobin concentration of the study population was 114.8 ± 12.2

g/L (n=115). The overall prevalence of anemia was 36% (41/115), with the

highest prevalence in the Inuit community (48%, 24/50) as compared to the

First Nations communities (26%, 17/65), however the difference was not

significant. The prevalence of ID was similar between Inuit and First Nations

communities, 25.5% and 27.7% respectively. Depleted iron stores were

present in 53.3% (56/105) of the study population. This study also revealed

that infection with H. pylori, prolonged consumption of breast milk and

cow’s/evaporated milks were significant risk factors associated with anemia.

The study concluded that both dietary factors and evidence of H. pylori

infection were identified as associated risk factors for anemia in young

35

children in northern Ontario and Nunavut. The researcher stress the

importance of feeding iron-rich complementary foods in addition to breast

milk or use of iron-fortified formula to replace evaporated or cow’s milk in

young children should be revitalized.

Schneider JM et al (2005) [41] did a cross-sectional study to identify the

prevalence of anemia, low iron stores, iron deficiency, and iron deficiency

anemia in children 12 to 36 months old participating in the Special

Supplemental Nutrition Program for Women, Infants and Children (WIC)

population in California. Hemoglobin, serum ferritin (immunoradiometric

assay), serum transferrin receptor (human transferrin receptor immunoassay

kit), serum transferring (nephelometric assay), serum iron (atomic absorption

spectrophotometry), and serum CRP (radial immunodiffusion) Transferrin

saturation and Total iron binding capacity (TIBC) was analyzed for 425

children. The results revealed that the prevalence of anemia was 11.1%.

Research used two cut off values for each iron measures as follows: serum

ferritin <8.7 or, <10.0µg/L, serum transferrin receptor >8.4 or >10.0 µg/mL

and transferrin saturation <13.2% or <10.0%.

The prevalence of low iron stores (low ferritin) on the basis of study and

literature determined cutoffs were 24.8% and 29.0%, of ID were 16.2% and

8.8%, and of IDA (ID with low hemoglobin) were 3.4% and 3.2%.,

respectively.

Siegel EH et al (2006) [42] described the distribution of hemoglobin

and prevalence of anemia in 569 Nepali children 4 to 17 month’s old living in

the Terai region. The results found that 58% of the children were anemic and

having mean hemoglobin value of 105g/L. Bivariate analyses revealed age,

caste, socio-economic status (SES), dietary diversity, stunting, and

underweight were associated with hemoglobin concentration and/or anemia.

36

In multivariate models with and without EP, age and caste were found to be

strong predictors of both hemoglobin concentration and anemia.

Lozoff B et al (2007) [43] find out the impact of iron deficiency

anemia on children’s social looking toward adults, affect, and wary or hesitant

behavior in response to novel situation. Play observations, social looking

toward adults and wariness or inhibition in reaction to novelty was observed

for 74 iron deficiency anemic and 164 non anemic preschool aged Indian

children. Results were compared between the non anemic group and the IDA

group. Mean hemoglobin concentration of anemic and non anemic children

was 94.0 (±1.4), 119.0 ± (0.6) g / L respectively. Pre school children with

IDA displayed less social looking toward their mothers, moved close to their

mothers more quickly, and were slower to display positive affect and touch

novel toys for the first time. These results indicate that IDA in the preschool

period has affective and behavioral effects.

Sharda Sidhu et al (2007) [44] done a study on the prevalence of

anemia among the Bazigar preschool children age between 1 and 5 years old

of Amritsar, Ludhiana, Moga and Patiala districts of Punjab. The results

showed that only 9.50% were normal and 90.50% were affected with various

grades of anemic conditions, 6.33% had mild anemia and 75.75% moderate

anemia while 8.42% suffered form severe anemia. A higher proportion of

children were severely anemic in age groups 1+ (15.00%) and 2+ (13.64%) as

compared to the older age groups. It became evident that the frequency of

severe anemia decreases as the age increases, but the frequency of mild

anemia increases as the age increases.

Hanumante and colleagues (2008) [45] conducted a pilot study to

assess the iron status and dietary intake of 1-3 year old apparently healthy

toddlers of the lower socio-economic class, and the effect of eight weeks

37

intervention with liquid oral iron in an urban slum in Pune, India.

Anthropometry, Food Frequency Questionnaire, a hemogram and ferritin

were measured for 50 toddlers (Male 25 and female 25). Twenty mg of

elemental iron was given to all toddlers. After 8 weeks clinical examination,

anthropometry, hemoglobin (Hb) and Ferritin were measured. Prevalence of

anemia was 66% (Hb <11gm %) and ferritin (iron stores) were low (< 12

μgm/L) in 45 (90%). The prevalence of anemia significantly ((p<0.001).)

decreased from 66 to 30% after treatment with liquid iron. The authors

therefore concluded that there was a significant difference in the HGB and

ferritin levels of children after eight weeks of therapy.

Psirropoulou TE et al (2008) [46] estimated the prevalence of iron

deficiency anemia in children 12-24 months old in a specific area of Thessalia

, located in the central part of Greece, and also identified the environmental

risk factors associated with anemia. Hemoglobin, hematocrit, mean

corpuscular volume, mean corpuscular hemoglobin, mean corpuscular

hemoglobin concentration, zinc protoporphyrin, serum iron, serum ferritin,

transferring saturation, total iron binding capacity and Hb electrophoresis

were analyzed for 938 children. Seventy-five children (7.99%) out of 938

children participated in the study had iron deficiency anemia and 20 children

(2.13%) were carriers of b-thalassaemia. Concerning the anthropometric

indices, the highest statistical difference between the two groups was

observed with respect to the weight of the children with p value <0.001. The

height also differentiates the two groups in a statistically significant way (p <

0.003). Significant differences were recorded (p<0.001) in all hematological

and anthropometric parameters except for head circumference. Regarding

environmental factors, significant differences were found in the following

parameters: ratio rooms/number of family members (p=0.01), number of

family members (p=0.01), number of children in the family (p<0.001), birth

rate (p<0.001), education and profession of the parents (p<0.001), source of

38

drinking water and sewage system (p<0.001), duration of breast feeding

(p<0.001), milk consumption by the child during the period of the reported

research (p<0.001), child’s health status according to the mother (p<0.001),

and frequency of seeking pediatric care (p=0.02).

Kikafunda JK et al (2009) [47] carried out a study to determine the

prevalence of anemia and associated factors among under-five year old

children and their mothers in a rural area of Bushenyi district, Western

Uganda. The results revealed that the overall prevalence of iron deficiency

anemia among children and their mothers was 26.2% and 17.9%, respectively.

There was a significant correlation (r=50.5, P=0.008) between the

hemoglobin levels of the mothers and their children. Place of birth, age of the

child, factors related to complementary foods, and formal education and

nutrition knowledge of the mother were major factors that were significantly

associated (r=50.05, P=50.05) with low hemoglobin levels among the

children. This study concluded that iron deficiency anemia was found to be a

major problem of these children and their mothers. Dietary factors and socio

demographic factors were the major factors associated with high levels of

anemia among the children and their mothers. This study recommended that

rural mothers should be sensitized on best practices for prevention of anemia

among both women and children.

Uddin MK et al (2010) [48] determined the prevalence of anemia in

767 children of 6 to 59 months old in Narayanganj, Bangladesh. The results

reveled that the prevalence of anemia among the children of 5-59 months old

was 40.9% for the district as a whole. Prevalence in the municipal region of

Narayanganj was 40.9%. The rural areas had the highest prevalence of 66.9%.

Prevalence was almost two times higher in children of 6-23 months in

comparison to children of 24-59 months i.e. 61.8% and 31.0% respectively.

The mean haemoglobin concentrations in the younger and older age groups

39

were 10.4 (±1.5) g/ dl and 11.4 (±1.4) g/dl respectively. There was no

difference find between the sexes.

Ainur Baizhumanova et al (2010) [49] conducted a study in children

and women to evaluate the prevalence of anemia, iron deficiency and IDA

before and after the campaign in Kyzyl-Orda region, Kazakhstan. The results

revealed that after communication campaign the prevalence of anemia had

significantly decreased among rural women (from 65.9% to 48.0%, p < 0.05)

and among urban children (from 63.1% to 11.5%, p < 0.001). The prevalence

of iron deficiency was significantly reduced among the children (from 51.1%

to 24.8%, p < 0.001). IDA prevalence was meaningfully decreased among

women in urban and combined areas (from 37.5% to 15.0% and 40.5 to

14.8%, respectively, p < 0.001) and among urban children (from 7.1% to

2.1%, p < 0.05). The study concluded that the communication campaign was

effectively carried out in Kazakhstan before implementation of the wheat

fortified flour program, giving a biological impact on hematological indices.

Carvalho AGC et al (2010) [50] did a study to diagnosis iron

deficiency anemia in 301 children aged six to thirty months attending public

daycare centers in the city of Recife, Northeast Brazil. 92.4% of the children

had anemia (Hb <110 g/L) and 28.9% had moderate/severe anemia (Hb <90

g/L). 58.1% had anemia with iron deficiency, 34.2% had anemia without iron

deficiency and 2.3% had iron deficiency without anemia. About 51% of

subjects had an inflammation. Only ferritin was significantly associated with

CRP. High ferritin levels were significantly associated with high CRP levels.

The mean ferritin concentration was significantly higher in subjects with

inflammation when compared with those with normal CRP (22.1 vs. 14.8

μg/L, p = 0.01).

40

Heckman J et al (2010) [51] did a study to find out the prevalence of

anemia and to investigate possible etiologies’ including malnutrition,

intestinal helminthes infection and Helicobacter pylori infection in 52

children aged under 5 presenting for well-child examinations at a community

health centre in Thohoyandou, Limpopo Province. The result found that 75%

of the children had anemia and girls were significantly more anemic then

boys. The median hemoglobin concentration was 9.65±2.6 g/dl. Anemic

children were significantly less likely to be underweight compared with their

peers (32/38 v. 5/12 respectively; p=0.007). There was no significant

association between anemia and infection with Helicobacter pylori (p=0.729),

intestinal helminthes (p=1.000) or food insecurity (p=0.515).

Health and Science Bulletin (2010) [52] reported that the prevalence

of anemia in children (>2 years) in rural Bangladesh was 60% (755/1,237)

when a single parameter hemoglobin level <11.0 g/d was used. However

considering other parameters of low iron status such as ferritin (<12 μg/L) and

C-reactive protein (<5 mg) along with low hemoglobin level, only 25%

children had iron deficiency anemia. When low hemoglobin and high serum

transferrin receptor (>5 mg/L) was considered as an indicator of iron

deficiency, 30% of anemic children had iron deficiency anemia. The study

team compared the 225 iron deficient anemic children with 209 non-anemic

children matched for age, sex and village. Diagnosed iron deficient anemic

children received 30 mg ferrous sulphate syrup daily for 6 months. All the

enrolled children were reassessed for their iron status 6 months later. All the

iron deficient anemic children responded adequately to 6 months of iron

treatment. Mothers of anemic children scored low in an intelligence test and

provided less care to their children compared to mothers of non-anemic

children. They were also from poorer economic conditions, Children with iron

deficiency anemia were more likely to be stunted compared with non-anemic

41

children; a higher percentage of anemic children were severely stunted

children.

Santos RF et al (2011) [53] conducted a study among 595 children (6

to 59 months old) in a children's hospital in Recife, Brazil with the objectives

of identifying the prevalence of anemia and their associated factors. Anemia

was reported among 56.6 % of children. Only 34.1% anemic students were

aware of being anemic. Anemia was significantly correlated with low weight

young age and a diagnosis of acute lower respiratory disease.

Muoneke VU et al (2011) [54] determined the prevalence, etiology

and outcome of severe anemia in children aged 6 months to 5 years in

Abakaliki South Eastern Nigeria. Out of 1450 children under the age of 5

years 140 had severe anemia. The finding of this study shows that the

prevalence rate of severe anemia was 9.7%. Malaria was the commonest

cause of severe anemia 64.3%. Other common causes included sickle cell

anemia 9.3%, Septicemia 13.6 %, and malnutrition 7.1%. One hundred and

seventeen (83.6%) patients recovered

The results shown by Onyemaobi and Onimawo etal (2011) [55] was

that 70.5% of under five children aged 6 to 60 months were anemic in Imo

state of Nigeria, and 48.1% were iron deficient. The results also showed that

the overall mean haemoglobin of the subjects investigated (n=400) aged 12-

60 months were 10.478g/dl. The most affected age group was 12-23 months

(84.8%). Anemia was much more prevalent in rural (78.7%) than urban

(61.3%) areas. The prevalence of anaemia decreased with age group i.e.

84.8%, 78.4%, 69.7% and 65.9% for 12-23, 24-35, 36-47, and 48-60 months

age groups, respectively. There was no difference in anemia among the boys

and girls in Imo State.

42

N. Arlappa et al. (2012) [56] conducted a community based cross-

sectional study on Prevalence of anemia among rural pre-school children of

Maharashtra, India. It was found that the mean hemoglobin level among the

children of 1-5 years was 10.4 g/dL (CI: 10.2-10.6), with 9.6 g/dL (9.3-9.9) in

1-3 year and 10.6 g/dL (10.4-10.8) in 4-5 year-age group. The mean

hemoglobin values are significantly (p<0.01) different between different age

groups. The results showed that the overall prevalence of anemia among the

rural pre-school children of Maharashtra was 59.2%, and the prevalence was

significantly (p<0.001) higher (76.5% with CI: 68.1-84.9) among 1-3-year

children as compared to 53.6% in 4-5-year- children. a higher (63%)

proportion of girls were anemic compared to boys (57%). The prevalence of

anemia was decreased with increase in age where significantly (p<0.01) a

higher proportion (90.9%) of 1+ year- children were anemic compared to the

children of 4+ years (48.1%).

Souganidis ES et al (2012) [57] examined the relationship between a

mother’s knowledge of anemia with the prevalence of anemia in mothers and

their children from rural areas and urban slums in Indonesia. The mothers and

children from rural areas and mothers and children from urban slum areas of

Indonesia were participated in the study. The finding of this study revealed

that in urban slums, 28.7% of mothers and 62.3% of children were anemic

whereas in rural areas, 25.1% of mothers and 55.2% of children were anemic.

Maternal knowledge of anemia was associated with child anemia in urban and

rural areas, respectively (odds ratio [OR] 0.90, 95% confidence interval [CI]

0.79, 1.02, P = 0.10; OR 0.93, 95% CI 0.87, 0.98, P = 0.01) in multivariate

logistic regression models adjusting for potential confounders

Rocha DS et al (2012) [58] evaluated the prevalence and risk factors

of anemia in 312 children aged 7 to 59 months old attending daycare centers

in the city of Belo Horizonte. He diagnosed anemia in children by

43

determining hemoglobin concentration, using the Hemocue portable photometer,

considering hemoglobin levels below 11.0 g/dL. Weight and height

measurement were done to evaluate the nutritional status of children. The

result shows that the prevalence of anemia in children aged 7 to 59 months

old attending daycare centers was 30.8%, with a higher prevalence in children

≤ 24 months of age (71.1%). Risk factors for anemia were nutritional status

and age and these two were the only variables associated with anemia of this

study population.

Table: 3.1 Prevalence of anemia between 1995 and 2011 in abroad

Children aged < 5 years

1995 2011

Mean

Hb g/L

Anemia

%

Severe

Anemia

Mean

Hb g/L

Anemia

%

Severe

Anemia

High income regions 123 11 0.3 123 11 0.1

Central & eastern Europe

116 29 1.4 117 26 .2

East and southeast Asia

118 29 0.9 118 25 0.2

Oceania 111 42 2.0 112 43 0.5

South Asia 100 70 5.9 106 58 2.1

Central Asia, Middle East, and north Africa

111 43 1.5 114 38 0.4

Central and west Africa

95 80 9.7 100 71 4.9

East Africa 96 74 10.2 107 55 2.5

Southern Africa 116 30 1.1 110 46 0.9

Andean and central Latin America and Caribbean

113 38 1.4 116 33 0.4

44

Southern and tropical Latin America

117 28 1.3 119 23 0.2

Globe 109 47 3.7 111 43 1.5

Source adopted from Stevens GA et al. (2013)

Stevens GA et al. (2013) [59] indicated in their study that the Global,

regional, and national trends in hemoglobin concentration and prevalence of

total and severe anemia in children improved slightly for children aged 6–59

months, between 1995 and 2011.

Gao W et al (2013) [60] described the severity of anemia and explored

its determinants among children under 36 months old in rural western China.

From 9 province-level regions, 6711 children were selected and their

hemoglobin was measured. The prevalence of anemia among children

younger than 36 months in rural western China was 52.5% (95%CI 51.3%–

53.7%), of which mild anemia covered 27.4%, moderate anemia 21.9% and

severe anemia 3.2%. Among the 9 province-level regions, Qinghai had the

highest prevalence (72.75%) of anemia and Inner Mongolia the lowest

(41.73%). The analysis of the severity of childhood anemia shows that the

prevalence of moderate and severe anemia was the highest but that of mild

anemia the lowest in Qinghai, that of mild anemia the highest in Guizhou, and

that of moderate and severe anemia the lowest in Sichuan.

3.1.2 Prevalence of anemia in school children

Rajaratnam J et al (2000) [61] carried out a study to estimate the

prevalence of anemia among adolescent girls of rural tamil nadu. The age of

the girls ranged from 13-19 years Blood was drawn from 141 and 147 girls

from K.V. Kuppam block and Gudiyatham block of Vellore District,

45

respectively. The hemoglobin concentration was assessed by using the

cyanmethemoglobin method. The result shows that 44.8% of the adolescent

girls were anemic with severe anemia being 2.1%, moderate 6.3% and mild

anemia 36.5%. The prevalence of anemia was 40.7% in premenarcheal girls

as compared to 45.2% in post menarcheal girls. There was reduction in the

mean hemoglobin as the age increased. A similar decreasing trend was

observed with increasing age at menarche of the girls and also earlier the age

at menarche, the higher was mean hemoglobin. The mean hemoglobin of

premenarcheal girls was 11.63 g/dl (SD ±1.5) and that of post menarcheal

girls was 11.52 g/dl (SD ±1.54). Girl’s education, mother’s education and the

family type were identified as independent predictors for hemoglobin

concentration.

D. Shojaeizadeh (2001 ) [62] conducted a study to find out the factors

affecting Knowledge, Attitude and Practice among 218 secondary school girls

in Qazvin, Tehran, Iran, on iron deficiency anemia. The data revealed that

57.3% had poor knowledge, 54.1% Unfavorable attitude towards iron

deficiency anemia and 44.5% did not perform appropriate behavior (poor

practice) to prevent anemia. The knowledge was better among science

students than non-science students. The relation was significant. It was also

significantly better among those girls, whose mothers were employed. There

was significant relationship between knowledge and attitude and also

knowledge with practice.

A study among 800 school students in Jeddah, Saudi Arabia to identify

the prevalence of anemia, their awareness about anemia and the relation of

anemia with the literacy level of mothers. The results indicated that 20.5% of

students had anemia. Only 34.1% anemic students were aware of being

anemic. Anemia was significantly more prevalent among those born to low

educated mothers ( Bahaa Abalkhail et al (2002)) . [63]

46

Al-Sharbatti et al (2003) [64] determined the prevalence of anemia in

a healthy school adolescents aged 11 to 19 years old selected from 2 distinct

socio-economic areas (SEAs) in Baghdad; and to assessed the importance of

diet and some other factors which could be relevant in the epidemiology of

anemia in adolescents. The prevalence of anemia among 487 adolescents in

high socio-economic area (HSEA) was 12.9% and the prevalence of anemia

was 17.6% in 564 adolescents in low socio-economic area in Baghdad, Iraq.

Hemoglobin concentration in males was significantly correlated with age and

dietary iron intake. In females it was correlated significantly with years of

education of father and mother, number of pads and age at menarche.

The study was conducted by Sethi V et al (2003) [65] among the

prevalence of anemia amongst children in the age group of 6-11 years in

National Capital Territory (NCT) of Delhi. A total of 393 subjects (189 boys

and 204 girls) were included in this study. Hemoglobin estimation was carried

out by indirect Cyanmethemoglobin method. The finding of this study

revealed that the overall prevalence of anemia was found to be 66.4% (Hb <

11.5 g/dL). The prevalence of mild, moderate, and severe anemia was found

to be 33.3%, 32.6%, and 0.5% respectively. The mean hemoglobin

concentration of girls and boys was 10.7 ±1.3 and 10.9 ± 1.2 g/dL

Sharda Sidhu et al (2005) [66] reported that prevalence of Anemia

among 265 adolescent girls between the age group 11 and 15years old of

scheduled caste community of Punjab was 70.57%, of which 30.57% mildly

anemic, 27.17% moderately anemic and 12.83% severely anemic. The

prevalence of anemia increases with age and becomes maximum (78.57%) in

the age group 15 years. The frequency of mild anemia was displayed to the

maximum (38.46%) by age group 11 years and the minimum (21.43%) by age

group 15years. In this study, the largest number of girls fall in the category of

moderate anemia, with maximum (35.55%) present in age group 14years as

47

compared to age group 11years where the number of lowest moderate anemia

(21.54%). Maximum level of severity of anemia was present in age group

15years (30.95%). The age group 11years had the least (4.62%) number of

severely anemic girls. This may be accounted for as repeated menstrual blood

loss with each cycle which results in drainage of iron reserves ending in

anemia.

Gur E et al (2005) [67] determined the prevalence of anemia and the

risk factors associated with anemia among primary School children in

Istanbul. 1531 students between 6 and 16 years old (52.1 % (798 students)

were male and 47.9 % (733 students) were female) from 14 primary schools

located in seven different regions of Istanbul were participated in this study.

A complete blood cell count was done by an automated cell counter to

measure the prevalence of anemia. The overall prevalence of anemia among

primary School children in Istanbul was found to be 27.6 per cent. The rates

of mild, moderate, and severe anemia were 27.1 %, 0.2 % and 0.3 %

respectively. The anemia prevalence were 27.3 and 28.0 in males and

females, respectively (p>0.05). This prevalence was 28.9 per cent for children

aged 6–10 years and 26.2 per cent for 11 to 16 years (p>0.05). The results

also revealed that the prevalence of Microcytic anemia was 15.6 % (66 cases),

normocytic anemia prevalence was 84.2 per cent (356 cases), and macrocytic

anemia prevalence was 0.2 per cent (one case). The thalassemia minor rate

was found to be 0.8 % in this study population. There was no significant

relationship between the prevalence of anemia and the students’ age, gender,

parents’ educational level and employment, and monthly family income by

logistic regression analysis. Only the number of family members and

malnutrition were risk factors for anemia.

A study by Sabita et al (2005) [68] showed that the over all

prevalence of anemia among 1120 school going adolescents (12 to 18 years)

48

of Chandigarh were 16.25% and the Hemoglobin values ranged from 6.5 g/dl

to 18.2g/dl. Mean Hemoglobin was 13.35 1.54 g/dl. Prevalence of anemia

was significantly higher amongst girls (23.9 %, 141/590) as compared to the

boys (7.7%, 41/530). Anemia was observed significantly more in rural area

(25.4%) as compared to urban area (14.2%) adolescents (P < 0.01). 14.3%

(84/590) girls and 14.2%(76/530) boys were undernourished (BMI <5th

centile). Prevalence of anemia in girls whose weight was more than 5th

centile was 21.9% as compared to 35.7% in those whose BMI was less than

5th centile (P <0.001). Similarly, in boys 6.7% were anemic in well-nourished

group as compared to 14.4% in undernourished group (P <0.05).

Keskin Y et al (2005) [69] investigated the prevalence of iron

deficiency among schoolchildren (12 to 13 years) of different socio-economic

status (SES), living in the three largest cities of Turkey. Anthropometry,

hematological and biochemical indices of iron status and consumption of food

items related to dietary iron bioavailability were analyzed for 504 males and

510 female children. The finding of study revealed that the prevalence of Iron

deficiency was 17.5% among boys and 20.8% among girls. Low SES boys

exhibited significantly higher frequency of tea consumption and lower

frequency of citrus fruit, red meat and fish consumption, compared to their

higher SES counterparts.

Karur .S et al (2006) [70] studied the epidemiological correlation of

nutritional anemia among adolescent girls (13 to 19 years) in rural Wardha.

The prevalence of anemia was found to be 59.8%. In univariate analysis, low

socioeconomic status, low iron intake, vegetarian diet, history of worm

infestation and history of excessive menstrual bleeding showed significant

association with anemia. While Multivariate logistic regression analysis

suggested that strongest predictor of anemia was vegetarian diet followed by

history of excessive menstrual bleeding, iron intake <14mg followed by 14-

49

20mg and history of worm infestation. However age, education,

socioeconomic status, BMI and status of menarche did not contribute

significantly.

R.Gawarika, et al (2006) [71] conducted a study to find out the

prevalence of anemia in adolescent girls, aged 10.5 to 18 years in Ujjain city,

in western Madhya Pradesh, belonging to different economic groups. The

results revealed that the overall prevalence of anemia was 96.5%. The

prevalence of severe anemia was 11.0% in weaker income group and 2.63%

among middle income group. The prevalence of severe anemia was high in

girls above 14 years of age than girls below 14 years of age. The severe

anemia was high (13.49%) among girls above 14 years of age in weaker

economic group but it was 4.23% among below 14 years of age. The

association was significant between the age of the adolescent girls and the

prevalence of anemia.

Bulliyy et al (2007) [72] found in their study in three districts of

Orissa that out of 296 adolescent girls, 96.5% among non school going

adolescent girls were found to be anemic. Of which 45.2%, 46.9% and 4.4%

had mild, moderate and severe anemia respectively. They also found that

significant association between hemoglobin concentration and the educational

level of girls, their parent’s family income and body mass index.

Brouwer TLH et al (2007) [73] studied an association between

anemia and intestinal parasite infection in 400 primary school children in

rural Vietnam. Hemoglobin (Hb), serum ferritin (SF), serum transferrin

receptor (TfR), serum C-reactive protein (CRP) total immunoglobulin E

(IgE) were analyzed for iron deficiency anemia. Stools samples were

examined for hookworm, Trichuris, and Ascaris infection (parasite infection).

The prevalence of anemia (Hb<115g/L) was 25%. Iron deficiency (TfR

50

>8.5mg/L) occurred in 2% of the children. The prevalence of intestinal

parasites was 92% with the highest prevalence for Trichuris (76%) and

Ascaris (71%). More than 30% and 80% of the children showed an elevated

CRP (≥ 8 mg/L) and IgE (> 90 IU/mL) concentration. Anemia status was

significantly associated with SF and not associated with TfR and CRP. The

study concluded that anemia was highly prevalent among primary school

children in Vietnam but not associated with iron deficiency. Trichuris

infection is associated with a doubled risk of anemia, not mediated through

iron deficiency. Chronic infection may play a role in anemia.

Chaudhary SM et al (2008) [74] found 35.1% anemia prevalence

among 296 adolescent females (10 to 19 years old) in the urban area of

Nagpur (India), of which 69.2 % had mild anemia, 30.8% moderate anemia

and non of the girls had severe anemia. They found significant association

between anemia and the socio – economic status of girls, their parents’

literacy.

SR Tatala et al (2008) [75] identified that the prevalence of anemia

among 845 school children age 7-14 years were 79.6%. Micronutrient

deficiencies were highly prevalent. Iron deficiency (SF <20 μg/dl) was 33%,

vitamin A deficiency (SR < 20 μg/dL) 31.9% and 25% of the children had

mild iodine deficiency (UIE < 20 μg/L). Intestinal helminths were also highly

prevalent; 68% of children had hookworm and 54% had urinary

schistosomiasis. Inadequate diet was a feature in >50% of children. About

10% of households had no latrines and multiple infection rank score was high

especially in older age children. The risk of having anemia was two times

higher in children with iron deficiency (RR=2.1) and 49% higher in those

with vitamin A deficiency. These deficiencies correlated significantly with the

anemia (P<0.05). Vitamin A deficiency and infections with hookworm and

schistosomiasis were the most significant factors predicting for anemia

51

(r=0.318 and r2=0.101). This study concluded that high prevalence of

infections and nutritional deficiencies were important risk factors for anemia

of this community. The high attributable fraction for hookworm,

schistosomiasis, iron deficiency and vitamin A confirms that these were

significant risk factors for anemia.

S.C. Jai prabhakar et al (2009) [76] study indicated that 77.7 % of

175 Jenukuruba Primitive Tribal Children (6 to 10 years) of Mysore District,

Karnataka were suffering from anemia. The study revealed that, 36.57% of

children were moderately anemic, 26.29 per cent were mildly anemic and

14.86 percent severely anemic. Their study indicates that prevalence of

anemia was significantly higher in girls when compared to boys, (Girls

83.33% and Boys 70.89%).

Gupta N et al (2009) [77] assessed the Pervasiveness of anemia in

adolescent girls of low socio-economic group of the district of

Kurukshetra (Haryana) India. 110 girl students (13-16 years) who were

studying in VIII, IX, X, XI class of Kurukshetra of Haryana were participated

in this study. It was found that out of one hundred ten girls, only 20 (18.19 %)

subjects were non anemic and remaining 90 (81.81 %) subjects were suffering

from various degree of anemia and their hemoglobin level ranges between 6.6

g/dl to 11.0 g/dl, among the anemic subjects, 20 % had mild, 73.33 % had

moderate and 6.67 % of subjects had severe degree of anemia. Prevalence of

anemia was found lower in nuclear families than joint families. Further, size

of family also affect, higher the number of members in the family, higher the

prevalence of anemia. As both quality and quantity of food consumption get

affected by number of members in family especially with limited income

sources.

52

In the study by Dharmistha Jadeja and Gayatree Jadeja a

supplementation of iron rich Date ball to the 70 anemic (Iron deficiency

anemia) girls for 21 days increases the hemoglobin concentration and

decreases the urinary calcium and creatinine of anemic girls. The findings of

this study also indicating that 76% girls were anemic due to iron deficiency.

(Jadeja D et al (2010). [78]

Gupta VK et al (2011) [79] observed in their study ‘a high prevalence

of anemia in both males and females in the rural population in Punjab’. The

prevalence of anemia was 95.2% among younger females of the age group of

5-9 years (n-807), 87% in the age group of 10-19 years. The prevalence of

anemia in males in both the age groups of 5 to 9 years (n-822) and 10-20

years (n- 399) was almost similar, that is 90.5% and 88.7% respectively.

N. Arlappa et al. (2011) [80] carried out a community-based cross-

sectional study on 3490 children of 6–12 years in West Bengal, India.

Prevalence of vitamin A deficiency (VAD), anemia and Iodine deficiency

disorders (IDD) were assessed. The results showed that the overall prevalence

of vitamin A deficiency in pre-school children was 0.6%. The overall

prevalence of anemia was 81.2% with a significantly ( p < 0.01) higher

(91.0%) proportion of 1–3 year children being anemic as against 74.6% in 3–

5 year age group. The prevalence of anemia was decreased with increased age

and ranged from a high (94.8%) in 1+ year to a low (71.9%) in 4+ year

children. However, no gender differentials were reported in the prevalence of

anemia in 1–5 year old children (p > 0.05). The overall prevalence of goiter in

6–12 year old children was 9%. The author therefore concluded that

micronutrient deficiencies were found to be of public health significance

among rural children of West Bengal. Therefore, there is a need to initiate

sustainable long term interventions for prevention and control of

micronutrient deficiencies in children.

53

T. Jain et al. (2011) [81] premeditated that Overall 43% of the boys

(10 to 19 years) were found to be anemic with 23% having moderate to severe

anemia in urban Meerut, India. Prevalence of anemia was significantly higher

among children who took 2 meals per day (49%) compared to those who took

3 meals per day (39%). This study also revealed that majority of upper lower

class students (55.6%) were anemic and the prevalence of anemia decreased

with increase in socio-economic status but the difference was not statistically

significant. Prevalence of anemia was higher among boys who had illiterate

mothers (47.4%) and just literate mothers (50.0%) and minimum in boys with

graduate mothers (36.9%) but the difference was not statistically significant.

Prevalence of severe anemia was, however, found to be significantly higher

among upper lower and lower middle class (p<0.05). Thirty-nine percent of

the students were underweight, and only 4.5% were overweight or obese.

Even among the overweight and obese students, the prevalence of anemia was

high at 50%.

Ahmed S. Selmi et al (2011) [82] determined the prevalence of

anemia (35.3%) among children aged 6-11 years old in Gaza Strip, Palestine.

The mean level of hemoglobin was 12 mg/dl; standard deviation was 0.915

while the hemoglobin values ranged between8.9 g/dl and 15.2 g/dl. This study

also indicates that anemia was slightly higher in girls (36.3%) than boys

(34%), but no significant difference was found.

Mikki N et al (2011) [83] investigated the prevalence of anemia and

associated factors among Palestinian school adolescents (aged 13–15 years) in

Ramallah and Hebron governorates. Students from Ramallah area were

grouped as one group and the students from Hebron area were grouped as

other group. The prevalence of anemia in boys was significantly higher in

Hebron than Ramallah (22.5% versus 6.0% respectively) (P < 0.0001), while

54

the rates for girls were similar in the 2 areas (9.3% and 9.2% respectively).

No cases of severe anemia were detected and most of the cases of anemia

(90.8%) were mild. Mean hemoglobin level was 14.4 g/dl in Ramallah and

13.3 g/dl in Hebron. For girls, similar mean hemoglobin levels in both areas

(13.9 g/dl in Ramallah and 13.7 g/dl in Hebron).

Jain N et al (2012) [84] conducted a research to assess the prevalence

of anemia in school children within the ages of 5 to 16 years from

Government School of Rishikesh, Uttrakhand, India. Relevant history,

complete physical examination, hemoglobin estimation and Peripheral smear

were done for two hundred school children. The results revealed that 56.5%

of the children had anemia. A significantly higher number of girls were

anemic at all age (66.6%) and more menarcheal girls were anemic (36.5%).

At almost all ages significantly more (65.2%) vegetarian children were

anemic. Hemoglobin showed a rising trend with improved socio-economic

status. Most (90.90%) of the children belonging to lower socio-economic

groups were anemic. The prevalence of anemia was high (66.89%) in the

undernourished children, 29.09% were anemic in the well nourished group.

Clinical pallor was detected in 42% of total children while 56.5% were

anemic as per hemoglobin estimation. The commonest blood picture was

microcytic hypochromic seen in 54.86% followed by normocytic

normochromic in 42.47% and dimorphic picture was seen in 2.54% only. The

most common cause could be nutritional 48.67%, followed by different worm

infestation in 17.69% only.

Balci YI et al (2012) [85] carried out a study to determine the

prevalence and risk factors of anemia among 1120 adolescents (672 girls and

448 boys), aged 12 to 16 years in Denizli ,Turkey. The results indicated that

5.6 % had anemia. 8.3% of the girls and 1.6% of the boys were anemic.

55

Thirty-seven (59%) patients were diagnosed as IDA, and 26 (41%) were

diagnosed as combined iron deficiency and vitamin B12 deficiency anemia.

None of the patients were diagnosed as having folic acid deficiency. No

parasitic infestation was detected.

Biradar SS et al (2012) [86] conducted a cross-sectional study to

assess the prevalence and the severity of anemia among adolescent girls in

rural areas (Vantamuri PHC which is situated 22 kilometers away from

Belgaum city), and to study the association of anemia with respect to the age

of the participants and their socio-economic status. Eight hundred and forty

adolescent girls (10-19 years of age) were participated in this study.

Hemoglobin estimation (by using an automated cell counter) and clinical

examination were done for the girls. The adolescent girls were divided in to

two groups, early adolescence (10-14 years) and late adolescence (15-19

years). The overall prevalence of anemia was 41.1% (345 / 840), adolescent

girls had varying severity of anemia, 34.6% were mildly anemic, 6.3% were

moderately anemic and only 0.2% (2) were severely anemic. The prevalence

of anemia among the girls who belonged to class III was 4.1%, whereas it was

43.1% in girls of class IV and 100% in girls of class V. This was found to be

statistically significant. The prevalence of anemia among the late adolescents

was 60%, whereas; it was 38.9% among the early adolescents. This was found

to be statistically significant.

Kokore BA et al (2013) [87] determined the prevalence of anemia in

a school population of 310 children (172 girls and 138 boys) aged 5 to 11

years from three municipilities of Abidjan. Hematological parameters and the

electrophoretic profile of hemoglobin were done for all the children. The

results of study revealed that 82.9 % of children have indicated that at least a

parameter of the blood count was abnormal. The prevalence of anemia

(hemoglobin < 11.5 g/dl) was 30.3 % with 33.3 % of males and 29.1 % for

56

girls. In addition, haemoglobinopathies was found in 16.1 %, including sickle

cell trait and hemoglobin C trait.

In a study of Bhise RM, et al stated that overall prevalence of anemia

among school children aged 8-16 years of the Tribal community from Tribal

Ashram Schools in Ahmadnagar district of Maharashtra was 77.10 %

(239/310). The prevalence of anemia in girls (87.8%) was higher than the

boys (65.1%) (Bhise RM, et al, 2013) [88]

A Sumbele et al (2013) [89] did a study on 351 P. falciparum infected

children (46.2% females and 53.8% males) with a mean age of 6.45 ± 7.9

years (6 months to 14 years) residing in the Mount Cameroon region were

evaluated for the prevalence and risk factors of anemia. Anemia was assessed

by Hb concentration (Hb < 11 g/dl). The results revealed that 80.3% (282) of

the children had anemia and the prevalence of mild, moderate and severe

anemia in the study population was, 22.7% (64), 65.2% (184) and 12.1% (34)

respectively. Children ≤ 5 years had a significantly (P < 0.01) higher

prevalence of anemia when compared with those greater > 5 years. Similarly

the prevalence of anemia in children with enlarged spleens was significantly

(P < 0.01) higher than those with normal spleen Children who were malaria

parasite positive showed a higher prevalence of anemia on D14 (69.2%) and

D42 (78.6%) than those negative (D14 = 37.9%, D42 = 30.2%) post

treatment.This difference in prevalence was statistically significant (D14; χ2 =

4.7, P = 0.03 and D42; χ2 = 20.2, P < 0.001). The level of education of the

guardian/caregiver was identified as a risk factor (P = 0. 04) for anemia.

Children whose caregivers were illiterate had a higher prevalence of anemia

(90%) when compared with those whose caregivers had basic education (77.

8%).

57

3.2 PREVALENCE OF VITAMIN DEFICIENCY ANEMIA

Mao X eta al (1992) [90] conducted a study on 65 children with mild

iron deficiency anemia in china, to assess the effect of vitamin C

supplementation along with iron. Children were divided into 5 groups, and

received 7.5 mg of iron and 0, 25, 50, 100 and 150 mg/day of vitamin C

respectively every day for 8 weeks. Hemoglobin, serum ferritin, free

erythrocyte and hematocrit were determined every week. The results of the

study indicate that vitamin C supplement alone could effectively control

children's IDA. The finding also revealed that 50 mg/day of vitamin C is the

most efficient dosage and 6 weeks is the shortest time for an effective therapy.

They recommended that appropriate dose of vitamin C should be

supplemented for the children having a diet predominantly comprised of plant

foods.

In Malawi, infectious diseases and vitamin B12 and folate deficiencies,

but not iron deficiency, were important factors associated with severe

childhood anemia. Malaria was associated with severe anemia in the urban

site (with seasonal transmission) but not in the rural site (where malaria was

holoendemic). Seventy-six percent of hookworm infections were found in

children under 2 years of age. (Calis JC , 2008) [91].

The most common cause of anemia was found to be IDA followed by

pure and mixed vitamin B12 deficiency (28.4%), and pure and mixed folate

(14.74 %) deficiency (92).

A community-based Study was conducted by Gamble MV et al

(2004) [93] among 919 preschool children in the Republic of the Marshall

Islands. The relationship of vitamin A and iron status and markers of

inflammation, tumor necrosis factor-α, α1-acid glycoprotein, and interleukin-

58

10 to anemia were studied in a subsample of 367 children. The prevalence of

anemia was found 42.5%. The prevalence of severe vitamin A deficiency

(serum vitamin A <0.35 mmol/l) and iron deficiency (serum ferritin <12

mg/dl) were 10.9 and 51.7%, respectively. In multivariate linear regression

models that adjusted for age, sex, and inflammation, both iron deficiency and

severe vitamin A deficiency were significantly associated with anemia. The

author concluded that both iron and vitamin A deficiencies were independent

risk factors for anemia, but inflammation was not a significant risk factor for

anemia among these preschool children.

Riboflavin enhances the hematological response to iron, and its deficiency

may account for a significant proportion of anemia in many populations [94].

Children in the Republic of the Marshall Islands, ages 1 to 5 years are at high

risk of anemia, Vitamin A deficiency and ID, and one third of these children

had the co occurrence of Vitamin A and ID [95].

3.3 SOCIO ECONOMIC VARIABLES

Poor socio- economic status is defined as a situation that is comprised

of a number of factors such as low educational attainment, limited access to

gainful resource, reduced access to sufficient amount and quality food leading

to malnutrition and under nutrition.

Bhargava et al. (2006) [96] indicated in their study that the social and

economic determinants affecting the iron intake from fish, meat, and poultry

which resulting iron deficiency in women. Iron deficiency anemia influences

a number of women in South Asian countries, particularly during

reproductive period.

59

A study conducted by Siddharam et al (2011) [97] among adolescent

girls in rural area of Hassan district, Karnataka, South India. According to this

study out of 314 adolescent girls, 142 (45.2%) were found to be anemic, of

which 57 (40.14%) had mild anemia (Hb 10.9-11gm %), 78 (54.92%) had

moderate anemia (Hb 10.9-8gm% %), and 7 (4.92%) had severe anemia (Hb

< 8gm %). Higher percentages (33%) of anemic girls were found in class four

and class five (32.4%). None of the subject belongs to upper class (class I)

was present in the study. A statistically significant association of anemia was

found with iron deficiency, weight loss and presence of pallor. Other factors

like socioeconomic status, attainment of menarche, age group were not

significantly associated with anemia. Among anemic subjects correlating with

Body Mass Index (BMI) it was found that 80 (60%) were underweight, 54

(38%) were normal weight and 2 (2%) were overweight. The prevalence of

anemia was 233(71%) in postmenerchal girls as compared to 91(29%) in

premenarchal girls. In present study among anemic subjects 121(85%) were

anemic had iron deficiency, 82(57.7%) presented with pallor and 75 (52.8%)

had normal weight.

Chandra Sekhar K et al (2011) [98] carried out a cross sectional

community based study to know the prevalence of anemia among 248

adolescent girls and to find the demographic profile among the adolescent

anemic girls in urban areas of Kadapa, south India. The results shows that the

prevalence of anemia in adolescent girls was 68.95%, of which 76.4% were

from the age group of 13-15 yrs and 65.8% were from the 10-12 yrs of age.

The results also revealed that out of 171 anemic adolescents, 75.4% (95) were

from the below poverty line and 62.3% (76) individuals from the above

poverty line group. There was significant association was found between the

below poverty line individuals and anemia (P<0.01). High prevalence of

anemia was observed in parents of truck, auto and laborers families and which

60

was significant (P<0.001). Father occupation was significantly associated

with anemic condition.

Rao et al. (2007) [99] explored that poverty is a major cause for

limited access to sample quantity and quality of nutrient rich food in South

Asia.

There is another study correlates family income of the respondents, utilization

of health facilities and level of hemoglobin. According to him, women in the

lowest income group were less likely to have used health services as

compared to high income women.

Saluja N et al (2011) [100] conducted a study to find out the

prevalence of anemia and the socio-demographic factors affecting anemia in

primary school children (5-11 years) in urban Meerut. Out of 515 children

(265 boys and 250 girls), 194 children (37.7 %) were found to be anemic.

Anemia was found to be more in girls (45.2%) as compared to boys (30.6%).

The results also shows that the prevalence of anemia was maximum in

children belonging to lower social class (100.0%) followed by upper-lower

(44.8%), lower-middle (25.9%) and upper-middle (22.2%) and this difference

in prevalence of anemia in relation to social class was found to be statistically

significant (p<0.001). Anemia cases were significantly higher (41.7%) in

vegetarians as compared to non-vegetarians (32.9%). It was also observed that

anemia was significantly (p<0.001) higher (52.7%) in children belonging to

joint families as compared to those belonging to nuclear families (31.5%).

Percentage of anaemia was significantly (p<0.001) higher in children of

illiterate mothers and working mothers (p< 0.001).

Leite et al (2013) [101] assessed the prevalence of anemia and

associated factors among indigenous children (less than 5 years old) in Brazil.

A hemoglobin level was evaluated for 5,397 children in 113 villages. The

61

results revealed that the overall prevalence of anemia (Hb < 11 g/dL) was

51.2%. Boys (52.79%) in all age groups had a slightly higher prevalence of

anemia than girls (49.6%). The risk of anemia decreased with increasing age

of the child, progressively lowering with each age group. Maternal schooling

showed a similar pattern, with lower risk among children whose mothers had

ten or more years of schooling. With regard to household and environmental

variables the risk of anemia was higher in households with floors made of

wood, walls of palm thatch, and roofing of nondurable materials such as

canvas, and plastic. Higher risk of anemia was also observed among children

in households with discontinuous electricity and drinking water originating

from rivers, lakes, or open reservoirs. It was also higher in households with

the predominant defecation location being outdoors in the open and in those

with trash disposal by means of discarding in a river, lake, or ocean.

Considering the variables related to household composition, children were

more prone to have anemia.

A cross-sectional descriptive study was carried out among 847 school

going adolescent girls in urban as well as rural schools of the Lucknow

district, Uttar Pradesh, India by Sachan B et al (2012) [102] to find out the

prevalence of anemia and the various socio-demographic characteristics in

relation to anemia. Among the 847 school going adolescent girls, 477 were

found to be anemic with a prevalence of 56.3%. Overall prevalence of anemia

was found higher (64.0%) in adolescent girls who belonged to socio-

economic status

(SES)-IV and it was statistically significant (p<0.05) and significant

association of anemia was observed with religion and caste (p value<0.05).

62

Keeton et al (2007) [103] revealed that nuclear families often do

better. Members in nuclear families have easy access to two parents earning

income. Normally, they are well off economically and this directs to have a

healthy and safe environment, good schooling, good health care and nutrition.

According to above literature, there was considerably rising trend in anemia

prevalence with decreasing socioeconomic situation.