Prevalence and risk factors of anemia among adolescent females in Beni-Suef governorate, Upper Egypt

Background

Anemia is recognized as a global public health issue, particularly in low- and middle-income countries [1]. Adolescents are recognized as a vulnerable population regarding anemia. This age group’s vulnerability is often attributed to the increased physiological demands for micronutrients (such as iron and folic acid) that accompany rapid physical growth, as well as to the micronutrient losses that may be caused by intestinal parasitic infestations, especially in developing countries [2]. Moreover, anemia is usually the result of malnutrition. Adolescent females, women of childbearing age, pregnant women, and children in developed and developing countries are more vulnerable to anemia [3].

The World Health Organization (WHO) defines adolescents as those aged 10–19 [4]. Adolescent females are more likely to suffer from anemia due to monthly blood loss and, in the event of a teenage pregnancy, which is still prevalent in certain underdeveloped nations. In contrast, males tend to recover their nutritional reserves by the end of adolescence [5].

Impaired development, decreased physical fitness, and an increased risk of infection are all possible outcomes of anemia in teenagers. A child’s cognitive development, school attendance, and performance may all be negatively impacted by anemia, which hinders their academic accomplishment and future labor productivity [6]. This is in addition to the detrimental effects on physical growth and health status [7]. The risk of maternal and neonatal mortality [8], 9], low birth weight child delivery [10], and birth difficulties [11] may be increased in pregnant adolescents with anemia. Thus, anemia is a problem for developing communities, not only for today’s teenagers [11].

Worldwide, 15 % of adolescents suffer from anemia. However, this number drops dramatically to 6 % in industrialized nations, but can be as high as 47 % in less privileged countries. Anemia affects anywhere from 14 % to 42 % of children and adolescents in the Middle Eastern area [12]. The substantial disruptions in health and food systems in low-income nations and humanitarian circumstances may worsen anemia’s burden [13].

Anemia is a significant health concern in Egypt, affecting many children, adolescents, and women. Studies examining the prevalence of anemia among different age groups or cohorts in Egypt have reported inconsistent results. However, most of these studies indicate that Egyptian children and females are more likely to suffer from anemia. A national survey conducted in the year 2000 revealed that 46.6 % of Egyptian adolescent females were anemic [14]. Another study conducted in the northern Delta region of Egypt in 2007 showed that iron deficiency anemia is prevalent among 47 % of women in the reproductive age group 15–49 years and 54 % of adolescent females aged 10–19 years [15].

The National Nutrition Institute in Egypt (NNI) conducted a baseline survey on IDA among several country regions in 2010. It concluded that 35 % of the school children are anemic, as well as 35.7 % of the adolescents. The incidence was highest among school children in Lower Egypt (55.7 %) and among adolescents in Greater Cairo (52 %). The study could not find a difference between the incidence in rural and urban regions [16]. A recent study of the Egyptian Family Health Survey conducted by CAPMAS reported that 43 % of Egyptian children aged 6 months to 6 years suffer from anemia. The World Bank estimated that 28.5 % of Egyptian women in the reproductive age of 15–49 years were anemic in the year 2016 [17].

The current research is a collaboration project between the Egyptian Family Health Society (EFHS) in the Beni-Suef governorate and the Embassy of the Netherlands. The project aims to promote rural adolescent females’ health, well-being, and social status in the governorate. Anemia has been pointed out to be a significant health concern among these adolescent females. EFHS felt a great need to address the issue of combating anemia among the females in the Beni-Suef governorate. The Society implemented a program to provide comprehensive services to these females and help promote their general and reproductive health. The objectives of the current research were estimating the prevalence of anemia among adolescent females in Beni-Suef Governorate, and exploring the risk factors associated with iron deficiency anemia among the studied participants, The study aimed also at assessing awareness about anemia and its negative consequences among participants in Beni-Suef Governorate through focus group discussions and treating 1000 adolescent females from the governorate who might be suffering from anemia.

Subjects and methods

Results

The study enrolled 1000 adolescent females from the seven Beni-Suef districts. These females were tested for anemia by conducting a complete blood count. The prevalence of anemia among participants was 35.8 %. The most frequently reported symptoms were dizziness (51.1 %), headache (50.6 %), lack of concentration (45.3 %), and dyspnea (34.2 %), Table 3.

The study participants were asked about their previous history of anemia. More than half of them (505 out of 1000) reported that they had earlier been told to be anemic (50.5 %). 366 of them (72.5 %) said they were told so by physicians and 48.5 % had been tested earlier for anemia. These previous blood tests had been requested by physicians in the case of 86.9 % of the studied females. However, only 16.2 % of the females who had been previously tested for anemia remembered their test results and said that they were only told to be anemic.

Blood testing of the studied females showed their mean Hemoglobin (HB) content was 12.2 g/dl, with a standard deviation of 1.02, and values ranging from 7.7 to 15.5. Their Hematocrit (HCT) value showed a mean of 36.2 %, a standard deviation of 2.60, and a range from 25.8 to 47.6 %. The red blood cell (RBC) count had a mean of 4.66 million cells/mcl, a standard deviation of 0.45, and a range from 3.09 to 8.96 million cells/mcl. The mean corpuscular volume (MCV) was 77.8 fl, with a standard deviation of 6.5 and a range from 44.9 to 91.5 fl. The mean corpuscular hemoglobin (MCH) was 26.4 pg, with a standard deviation of 2.91 and a range of 15.4–38.3 pg. The mean corpuscular hemoglobin concentration (MCHC) showed a mean of 33.8 g/dL, a standard deviation of 1.73, and a range from 23.1 to 45.8 g/dL. Red cell distribution width (RDW) had a mean of 13.6 %, with a standard deviation of 1.62, and a range from 10.1 to 32.9 %.

Based on the blood hemoglobin level, participants were divided into two groups: anemic (HB) and non-anemic (HB) (according to the WHO definition of anemia, be less than 12 g/dl). This was utilized to assess the risk factors associated with anemia. Age (p=0.014), residence (p<0.001), participant education (p=0.039), mother education (p=0.033), and daily number of pads (p=0.010) were found to be significantly different among anemic and non-anemic females, Tables 1 and 2.

Table 3 revealed that anemic females significantly reported general fatigability (35.8 %) more than non-anemic adolescent females (28.0 %) at p=0.011. While there was no significant difference between the two groups regarding other reported symptoms.

The binary logistic regression analysis identifies factors associated with anemia, focusing on those significant in univariate analysis. Age, education of adolescent females, and mothers’ education show no significant association with anemia (p-values >0.05). However, the rural residence has an important association (OR=0.652 and CI=0.439–0.970). The number of pads also shows a significant association with anemia (OR=1.208 and CI=1.006–1.451) as shown in Table 4.

Table 5 shows the binary logistic regression analysis results stratified by menstruation to control for potential confounders. All independent variables showed no significant association with anemia among groups with and without menstruation, except for rural residence in adolescent females with menstruation (Adjusted OR=0.606, 95 % CI: 0.408–0.900).

Discussion

The prevalence of anemia among adolescent females in the districts of the Governorate of Beni-Suef in Upper Egypt is 35.8 %. This incidence is considered a moderate public health problem according to the WHO classification of anemia as a problem of public health significance [19]. The prevalence of anemia found in this study is higher than that seen in Angola, 21.6 % [20], Turkey, 8.3 % [21], Ethiopia, 23.02 % [22], Northeastern Brazil, 9.3 % [23], Vietnam, 12.9 % [24], Cameron, 5 % [25], China, 7.4 % [26], Alexandria governorate, Egypt 28.8 % [27]. This could be due to variations in the geographical area, lifestyle, socio-economic norms, and dietary habits and practices. The study setting, sample size, and age group were also included in the study. Moreover, it is higher than the rates reported from the Egyptian Demographic and Health Survey (EDHS) 2014. The proportion of adolescent females with anemia in EDHS 2014 was 13.9 % in the 10–11 age group, 24.5 % in the 12–14 year age group, and 21 % in the 15–19 age group [28].

In contrast, the prevalence rate of anemia in the current study is lower than that found among females in a study conducted at El Minya governorate, Egypt (39.9 %) [29], and Giza governorate, Egypt (53.8 %) [30].

One possible explanation for the increased prevalence of anemia in teenage females is the natural decline in red blood cell count that occurs with menstruation and the beginning of menarche, especially among undernourished females. Furthermore, adolescents naturally experience rapid physical growth that requires more intake of hematinic nutrients like iron, folates, and other elements [22].

The current study supports the previous findings of similar studies that found that anemia was more prevalent among older adolescent females than among females in early adolescence. Anemic females in our study were older than (14.5 ± 3.1) and non-anemic females (13 ± 3.0) at p=0.014. This finding is in line with studies conducted in Bhutan, South Asia [31], in Siaya District, Kenya [32], and Wayu Tuqa District, southwest Ethiopia [33].

Our study’s univariate and binary logistic regression analysis revealed that rural residence is significantly associated with anemia, with an adjusted odds ratio (OR) of 0.652 (95 % CI=0.439–0.970), indicating that individuals in urban areas are more likely to have anemia. These findings disagree with studies conducted in Latin America and Caribbean countries [34] and Kenya [32]. In fact, the high prevalence of anemia among adolescent females residing in urban communities can be attributed to multiple factors, including nutritional, environmental, socio-economic, and biological ones. Urbanization encourages poor eating habits such as skipping meals, low intake of iron-rich foods, and reliance on junk food. These trends are exacerbated by busy lifestyles and a lack of nutritional awareness. Moreover, urban poverty and food insecurity in slum areas restrict access to nutritious food, even though urban settings may offer better market access. Financial constraints lead to the consumption of low-cost, low-nutrient foods, especially among small governorates in low-income countries. In addition, poor sanitation in urban slums raises the likelihood of intestinal parasite infections, such as hookworms, which reduce iron absorption and cause blood loss.

Urban life frequently entails high stress levels, academic demands, and decreased physical activity, all of which can worsen anemia and general health. Higher pollution levels in urban areas can worsen inflammatory diseases, disrupt nutrient metabolism, and have a negative impact on health.

The low educational status of mothers has been linked to a greater risk of anemia in adolescents in a variety of settings and studies [35], 36]. El Sahn et al. [14] stated that the risk of anemia increased significantly with a declined level of education (OR=3.5, 95 % CI: 10.90–6.32). This finding is in contrast to the univariate analysis in our study. A possible explanation for this paradoxical finding is that highly educated females have had no time for healthy food preparation and have had to offer fast food for their children. Although maternal education is considered a protective factor in the literature, it does not always result in the best nutrition and health outcomes unless combined with specialized knowledge on managing and preventing anemia. Busy schedules and scholastic stress, accompanied by higher education, may lead to skipping meals and low food diversity.

However, mothers with little formal education may be unable to read and comprehend food labels [37]. A mother’s nutritional knowledge levels are crucial since they are the primary cook in most homes, impacting food preparation, dietary choices, and family intake. Maternal education level has been demonstrated to affect children’s normal hemoglobin levels [38], so this point is crucial, and both educated and non-educated should gain our attention.

Our data revealed that heavy menstrual bleeding significantly increased the risk of anemia. Females who were anemic changed their pads more frequently (2.8 ± 1.0) than their non-anemic counterparts (2.6 ± 0.9), (Adjusted OR=1.208, 95 % CI:1.006–1.451). Previous research by Fentie et al. [39] suggests that adolescent females who bleed for more than 5 days are more likely to be anemic (Adjusted OR=2.25, 95 % CI: 1.17–4.33). Furthermore, Regasa and Haidar [33] found that menstruation is a statistically significant risk factor for anemia in adolescents. Nevertheless, Ramzi et al. [40] discovered no significant relationship between adolescent menstruation and anemia.

The current survey has many strengths, including a large number of participants, a mix of qualitative and quantitative methods, and the inclusion of anemic participants. However, because the study is cross-sectional, the data should be interpreted cautiously when examining the temporal relationship between socio-demographics, menstrual history, and anemia. We also did not collect information on other health issues, such as family history of thalassemia, malaria infection, helminth infections, etc. Further research in these areas would enhance our understanding; therefore, a detailed investigation of anemia causes is crucial to identify the most effective prevention strategies. Another limitation is that anemia was defined solely based on hemoglobin levels, which prevents differentiation between anemia types. Additionally, the study did not evaluate participants’ body mass index, physical activity, or sleep patterns.

Conclusions

Anemia among adolescent females in Upper Egypt continues to be a public health concern. Residence and the number of pads were revealed as statistically significant risk factors for anemia in adolescent females. School-based health education has the potential to help eradicate undernutrition and unawareness among adolescent females. Nutrition education should also be extended to the parents through the rural health units and mass media. Effective nutritional interventions such as food fortification and supplementation should be provided to prevent anemia and its adverse effects on adolescent females’ academic performance, productivity, and overall growth. With extensive training and efficient monitoring, micronutrient supplementation programs should be implemented in all primary schools. Healthcare providers should be trained and motivated to implement early intervention for diagnosing and managing iron deficiency anemia among children and adolescents. Integrating these interventions into the existing public health programs and evaluating their long-term outcomes is mandatory.

Limitations

This study has some limitations that must be considered when interpreting the findings. First, its cross-sectional design prevents establishing causal relationships between identified risk factors and anemia. Second, anemia was defined solely based on hemoglobin levels, without differentiation of underlying causes such as iron deficiency, hemoglobinopathies, or chronic infections.