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Year : 2017  |  Volume : 6  |  Issue : 2  |  Page : 69-74

Intervention for improvement of knowledge on anemia prevention: A school-based study in a rural area of West Bengal

Department of Preventive and Social Medicine, All Institute of Hygiene and Public Health, Kolkata, West Bengal, India

Date of Web Publication18-May-2017

Correspondence Address:
Bobby Paul
P-19, Jadavpur University Employees' Housing Co-operative Society Ltd., P.O. Panchasayar, Kolkata - 700 094, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijhas.IJHAS_94_16

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CONTEXT: Adolescents are at a high risk of iron deficiency and anemia due to accelerated increase in the requirements for iron, coupled with poor dietary intake, high rate of infection, and worm infestation.
AIMS: This study aimed to assess the effectiveness of health education intervention on baseline knowledge of anemia prevention among schoolgoing adolescents.
MATERIALS AND METHODS: This was a quasi-experimental interventional study with before and after comparison group, conducted in one secondary school of Singur Block of Hooghly district, West Bengal, in September–October 2015. The study was conducted among 181 schoolchildren of standard VIII and IX by administering a predesigned self-administered questionnaire based on the following five domains – knowledge of anemia, role of diet, use of slipper, handwashing, health-seeking behavior, and management of anemia.
STATISTICAL ANALYSIS USED: Data entry and analysis was done using SPSS software version 20, and both parametric (paired t- test) and nonparametric (McNemar-matched Chi-square test) test were applied for pre- and post-test comparison. To elicit the effect size, Cohen's d was calculated.
RESULTS: Out of the 181 students, 84 (46.4%) studied in Class VIII and rest in Class IX. About 86 (47.5%) students were boys and 95 (52.5%) were girls; with 70.2% in 14–16 years' age group. Postinterventional score on the five domains significantly improved (P < 0.001), and father's education was a significant predictor in preinterventional score. After health education intervention, knowledge score increased with a medium effect size.
CONCLUSION: Health education will play an effective role in improving health of adolescents by increasing knowledge and changing their attitude.

Keywords: Anemia prevention, effectiveness, intervention, knowledge

How to cite this article:
Bandyopadhyay L, Maiti M, Dasgupta A, Paul B. Intervention for improvement of knowledge on anemia prevention: A school-based study in a rural area of West Bengal. Int J Health Allied Sci 2017;6:69-74

How to cite this URL:
Bandyopadhyay L, Maiti M, Dasgupta A, Paul B. Intervention for improvement of knowledge on anemia prevention: A school-based study in a rural area of West Bengal. Int J Health Allied Sci [serial online] 2017 [cited 2024 Feb 25];6:69-74. Available from: https://www.ijhas.in/text.asp?2017/6/2/69/206429

  Introduction Top

Anemia is currently one of the most common and intractable nutritional problems globally that affects both developing and developed countries with major consequences on human health as well as social and economic development. The World Health Organization estimates the number of anemic people worldwide to be a staggering 2 billion, with approximately 50% of all anemia attributable to iron deficiency.[1]

Adolescents (10–19 years) are at a high risk of iron deficiency anemia due to accelerated increase in requirement, poor dietary intake, high rate of infection, and worm infestation as well as the consequence of social norm of early marriage and adolescent pregnancy.[2] Iron requirement peaks during adolescence due to rapid pubertal growth with sharp increase in lean body mass, blood volume, and red cell mass, resulting in an increased need of iron for myoglobin in muscles and hemoglobin in the blood. During adolescence, the continuous increase in median requirement for absorbed iron peaks between the ages of 14–15 years for girls and 1 to 2 years later for boys.[3]

Anemia can have profound negative impact on psychological and physical development, healing capacity, work performance, and reproductive health of an individual. Indian statistics, according to the National Family Health Survey 3 (2005–2006), data revealed that approximately 56% of adolescent girls and 30% of boys were anemic.[4] Iron deficiency anemia has been identified among the ten most serious risks in countries with a high infant mortality coupled with a high adult mortality as per the World Health Report (2002), and measures to reduce the burden of this disease are among the most cost-effective public health interventions.[5] Among the various strategies to reduce this public health problem on the part of the Government of India, “Weekly Iron and Folic Acid Supplementation Program” is one of the successful initiatives going on in every school of India. However, it is widely felt that the ongoing program would have made a more powerful impact in reducing the disease burden, if these adolescent children could be empowered with the knowledge regarding strategies to prevent anemia. Hence, this study was undertaken to educate the students on the impact of anemia on health and the primary preventive strategies through a planned teaching program.

It is well known that investing in adolescent health yields large benefits for the generations to come, as well as it is the period when they are highly receptive to acquisition of new knowledge.[6] With this backdrop, the objectives of the present study were to determine the level of knowledge of adolescent schoolchildren in a rural area of West Bengal regarding anemia and its prevention as measured by structured knowledge questionnaire, to impart health education through modular teaching, prepared after gap analysis of their existing knowledge, and to evaluate the effectiveness of the intervention in terms of gain in their knowledge score.

  Materials and Methods Top

This was a quasi-experimental interventional study with before and after comparison group and was conducted in one co-educational secondary school selected purposively from Singur Block of Hooghly district, West Bengal, during the months of September 2015–October 2015. One school was selected purposively for logistic reasons. Mid adolescence, that is, students of Class VIII and Class IX was preferred since it is the period when they are highly receptive to acquisition of new knowledge.[6] Therefore, complete enumeration method was followed, i.e., all 210 students of Class VIII and class IX present on the day of data collection were all included in the study. Prior administrative permission and consent were obtained from the school authority to carry out the study by focusing the nature and purpose of the study. Although educational intervention was imparted to all those present on the day of intervention, postinterventional knowledge was assessed among only those students whose preinterventional knowledge score was available. Hence, out of the total student strength of 210 belonging to the age group of 12–16 years, analysis of questionnaires of 190 students was considered, i.e., the students who were present on all the 3 days, i.e., preinterventional assessment, educational intervention, and postinterventional assessment which was done after 2 weeks. Final analysis was done on 181 students as nine questionnaires were incomplete and had to be discarded. Before commencement of the study, all the participants were elaborately explained about the purpose, importance, and procedure of the study, and assent was obtained from them after assuring anonymity and confidentiality.

Preinterventional evaluation

The knowledge regarding anemia prevention based on five domains including knowledge of anemia, role of diet, use of slipper, handwashing, health-seeking behavior, and management was assessed by a self-administered questionnaire method.

The questionnaire was constructed in local language with a mixture of multiple choice questions and open-ended questions and validated by a group of experts of the concerned department. To assess the preliminary knowledge level, the students were asked to fill the questionnaire independently.

Educational intervention

A teaching module was developed based on gap analysis of knowledge. Two weeks later, intervention was imparted by three lecture sessions of 30 min duration each, poster display, distribution of booklets, and interactive sessions.

Postinterventional evaluation

Improvement if any regarding the knowledge of anemia prevention was reassessed by the same questionnaire after a gap of 2 weeks. Comparison was made between the result of pre- and post-test to evaluate the improvement of educational awareness score. For knowledge assessment from 24 items pre- and post-test questionnaire, scoring was done, and for each correct answer “1” was ascribed and for each wrong or incorrect answer “0” score was ascribed. Maximum attainable score was 24 and minimum possible score was 0.

Statistical analysis

Data were analyzed using SPSS (version 20.0, Statistical Package for the Social Sciences Inc, Chicago, IL, USA) software. Paired t-test and McNemar-matched Chi-square test were applied for pre- and post-test comparison. Binary logistic regression was performed to determine the predictors for preinterventional score. Cohen's d was calculated to estimate the effect size. School authority consent was obtained prior to the conduction of the study, and informed consent was also obtained from the participants focusing the nature and purpose of the study.

  Results Top

Out of the 181 students, 84 (46.4%) studied in Class VIII and rest in Class IX. About 86 (47.5%) were boys and 95 (52.5%) were girls; with 70.2% in 14–16 years' age group. Approximately 40.3% and 33.1% of fathers and mothers of the students were educated up to primary level, respectively. There was no sanitary latrine facility in the houses of 19 (10.5%) students. Only 9 (5%) students resided in mud-thatched houses, whereas 99 (54.7%) students lived in pucca houses. Fathers of most of the students (33.7%) were skilled laborers followed by farmers (32%), while mothers of all students were homemakers.

Proportion of respondents giving correct answers in all the five domains during postinterventional evaluation were more in comparison to their preinterventional knowledge and these differences were statistically significant by McNemar's-matched Chi-square test (P < 0.05) [Table 1].
Table 1: Impact of educational intervention on knowledge of respondents (n=181)

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Average difference of post- and pre-interventional knowledge score on anemia was 2.18 (P = 0.000). Mean improvement of knowledge score on diet was 2.46 (P = 0.000), regarding use of slipper was 1.34 (P = 0.000), and handwashing and health-seeking behavior were 1.96 and 1.01, respectively (P = 0.000). Total mean knowledge score was significantly improved by 9.11 points (P = 0.000). All domains had medium effect size except handwashing and total knowledge score which had a large effect size [Table 2].
Table 2: Comparison between preinterventional knowledge score of participants with postinterventional knowledge score by paired samples t-test (n<181)

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Binary logistic regression was performed taking dependent variable as good and bad preinterventional score based on median value, i.e., 10. In regression analysis, it was found that, probability of scoring was higher among 12–13 years' age group, while probability of scoring was less among boys in reference to girls; probability of scoring was more among the students whose parents were educated higher secondary and above and those who used tap water in latrine. On multivariable analysis, only lower age group and higher paternal education came out to be significant covariates of preinterventional knowledge score of the students [Table 3].
Table 3: Association of covariates with the preinterventional median score

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  Discussion Top

Iron deficiency which is one of the principal causes of childhood anemia may impair physical and cognitive development that may cause weakness, inability to work, vertigo, palpitation, learning disabilities, inattentiveness, repeated illness, and as a result, reduce children's earning potential as adults.

The results of this study showed that nearly all the students (97.2%) did not know the symptoms of anemia whereas 98.3% of children had no idea about the cause of anemia. Similar observations were noticed by Maiti et al. among 827 secondary schoolchildren and by Ruzita et al. among 418 primary schoolchildren.[7],[8] On the contrary, Kapil et al. reported in their study that 90.78% of Indian adolescent girls had correct knowledge regarding the cause of iron deficiency anemia.[9]

Dietary knowledge in relation to prevention of anemia was poor among the children. More than half of the students (57.5%) did not know the vegetable source of iron whereas 91.2% respondents had no idea about the Vitamin C-rich fruits. It is a documented fact that inadequate and improper food intake adversely affects the growth of the growing students coming from the unprivileged sections of the community.[10] Few students (34.3%) mentioned correctly that Vitamin C enhances iron absorption and merely 3.3% answered that tea prevents iron absorption. Anemia is induced by lower intake of nutrients such as Vitamin A and C which is involved in iron metabolism. The presence of iron absorption inhibitors (such as phytates in bran, calcium in dairy products, polyphenols in certain vegetables, and tannins in tea) also plays a role in anemia.[11] Several studies have reported a higher intake of carbonated drinks which was associated with a higher intake of energy and carbohydrates as well as a lower intake of protein, vitamins, and minerals. It is possible that the food consumption behavior of children may lead to both iron deficiency and obesity. Specific habits, such as snacking and eating junk food, may also contribute to anemia.[12]

In the present study, almost all the respondents (98.9%) commonly used shoes/slippers when outside the house. In rural Bangladesh, most of the children had slippers, but many of them did not wear when outside the house.[13] Preinterventional knowledge of the students revealed that 84.5% of children were not aware that slipper use could prevent anemia and about all of them (97.8%) had no knowledge regarding the mechanism of anemia prevention through slipper use which however improved remarkably after intervention. During the education session, we observed that about half of the respondents did not cut their fingernails regularly. Similar reports were also found in previous studies conducted in Bangladesh and Ethiopia.[14],[15]

Considering the practices toward helminth infections, we found that only 20.4% of respondents knew the right technique of handwashing, about two-thirds practiced handwashing with soap before eating, 0.1% after defecation, and 19.9% both before eating and after defecation. Ekeh and Adeniyi and Fung and Cairncross et al. also emphasized on the importance of handwashing in their studies.[16],[17] However, in a study conducted in Zimbabwe by Midzi et al., the authors revealed that more than two-thirds of the respondents did not wash their hands with soap and water neither before eating nor after defecation.[18] On the contrary, a better situation was observed in Bangladesh where almost all the participants were found to wash their hands before eating and after defecation.[14]

Majority of the students (81.2%) considered that anemia was curable and 71.3% identified government health facility for treatment and diagnosis. Although above 80% of respondents did not know the adverse effects of iron and folic acid (IFA) tablets, 84.5% had knowledge regarding the correct prophylactic dose of IFA tablets distributed in their school and 72.9% of the children knew that tablet albendazole should be taken for de-worming. These observations are very convincing and hopeful toward the effective implementation of the existing national programs.

Overall, our results indicated that the interventional program was effective among schoolchildren at postinterventional awareness. As regards to knowledge of anemia, the present study showed a significant mean difference between pre- and post-test (P < 0.001). Knowledge regarding etiology and harmful effect of anemia, vegetable and animal source of iron, Vitamin C -rich fruits, and food preventing iron absorption considerably improved in posttest. It was demonstrated that knowledge on the use of slipper was significantly better than preliminary stage (P < 0.001). Concerning the knowledge on handwashing, paired sample t-test showed a significant mean difference among the respondents after the intervention (P < 0.001). Earlier studies conducted on nutrition education revealed that nutrition education programs could significantly improve nutritional knowledge and attitude among children.[8]

The environment in which children live strongly influences their knowledge level and learning capacity.[19] Poor environmental conditions may also be the source of health problems, which may affect how they interact and learn.[20] In the present study, 5% of respondents lived in muddy thatched houses and 10.5% of students had no sanitary latrine facility in their houses. Parental literacy is also a very important issue in anemia prevention. In our study, 12.8% of mothers and 7.8% of fathers were illiterate. Father's education was the significant predictor of preinterventional knowledge score in this study in contrast to another study conducted by Choi et al. where children with more educated mothers were significantly less likely to develop iron deficiency anemia than those who were with less educated mothers; this group consumed more protein and iron from animal sources than did the children of less educated mothers.[11] Another study conducted by Premalatha et al. showed that mother's education was significantly associated with the prevalence of anemia.[21]

However, the present study was conducted in one purposively selected school, which limits the generalizability of the study results. Since the study period was only 2 months, long-term retention of knowledge acquired by the students could not be tested.

  Conclusion Top

In this study, rural schoolchildren had inadequate knowledge on anemia prevention with regard to five domains including knowledge on anemia, dietary management, handwashing, wearing slipper, and health-seeking behavior. There was an expressive improvement in the anemia prevention knowledge of the participating children after educational intervention. School settings could also be an essential, effective, and efficient place to implement a comprehensive nutrition education program to develop the knowledge of schoolgoing children with respect to anemia prevention which would further facilitate in reducing the disease burden.


We are very grateful to the school authority for providing necessary permission and also to schoolchildren for their active enthusiastic participation and involvement in the study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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WHO. Prevention of Iron Deficiency Anaemia in Adolescents: Role of Weekly Iron and Folic Acid Supplementation; SEARO. Available from: http://www.who.int/PDS_DOCS/B4770.pdf. [Last accessed on 2016 Apr 05].  Back to cited text no. 2
Beard JL. Iron requirements in adolescent females. J Nutr 2000;130 2S Suppl: 440S-2.  Back to cited text no. 3
Adolescent Anemia. Press Information Bureau, Govt. of India, Ministry of Health and Family Welfare. Available from: http://www.pib.nic.in/newsite/PrintRelease. [Last accessed on 2016 April 07].  Back to cited text no. 4
World Health Organization. The World Health Report 2002: Reducing risks, Promoting Healthy Life. Geneva: World Health Organization; 2002.  Back to cited text no. 5
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Ruzita AT Jr., Wan Azdie MA, Ismail MN. The effectiveness of nutrition education programme for primary school children. Malays J Nutr 2007;13:45-54.  Back to cited text no. 8
Kapil U, Bhasin S, Manocha S. Knowledge amongst adolescent girls about nutritive value of foods and diet during diseases, pregnancy and lactation. Indian Pediatr 1991;28:1135-9.  Back to cited text no. 9
Mishra VK, Lahiri S, Luther NY. Child Nutrition in India. National Family Health Survey Subject Reports No. 14. 1999.  Back to cited text no. 10
Choi HJ, Lee HJ, Jang HB, Park JY, Kang JH, Park KH, et al. Effects of maternal education on diet, anemia, and iron deficiency in Korean school-aged children. BMC Public Health 2011;11:870.  Back to cited text no. 11
Yamada M, Murakami K, Sasaki S, Takahashi Y, Okubo H. Soft drink intake is associated with diet quality even among young Japanese women with low soft drink intake. J Am Diet Assoc 2008;108:1997-2004.  Back to cited text no. 12
Lamerz A, Kuepper-Nybelen J, Wehle C, Bruning N, Trost-Brinkhues G, Brenner H, et al. Social class, parental education, and obesity prevalence in a study of six-year-old children in Germany. Int J Obes (Lond) 2005;29:373-80.  Back to cited text no. 13
Mascie-Taylor CG, Karim R, Karim E, Akhtar S, Ahmed T, Montanari RM. The cost-effectiveness of health education in improving knowledge and awareness about intestinal parasites in rural Bangladesh. Econ Hum Biol 2003;1:321-30.  Back to cited text no. 14
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Fung IC, Cairncross S. Ascariasis and handwashing. Trans R Soc Trop Med Hyg 2009;103:215-22.  Back to cited text no. 17
Midzi N, Mtapuri-Zinyowera S, Mapingure MP, Paul NH, Sangweme D, Hlerema G, et al. Knowledge attitudes and practices of grade three primary schoolchildren in relation to schistosomiasis, soil transmitted helminthiasis and malaria in Zimbabwe. BMC Infect Dis 2011;11:169.  Back to cited text no. 18
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  [Table 1], [Table 2], [Table 3]


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