ANAEMIA_REPORT

A Baseline Study
on
Nutritional Anaemia Among Non-school-going
Adolescent Girls in Shivpuri District of M.P.
Final Report
Submitted to
Department of Women and Child Development
District Shivpuri
Government of Madhya Pradesh
With Support From
United Nations Children's Fund (UNICEF)
Bhopal, M.P.
BY
Indian Institute of Health Management Research
Regional Office, Bhopal, Madhya Pradesh

Project Team:
Dr. P. C. Dash, Ph.D.
Project Coordinator
Asst. Professor and Regional Office Incharge
IIHMR- Bhopal
Dr. Jai. Ghanekar, Ph.D.
Consultant
Mr. Hemant Kumar Mishra, M.Phil
Research Officer
IIHMR, Bhopal
Mr. Javed Shaikh, M.S.W.
Field Officer
IIHMR, Bhopal
Advisor:
Dr. S. D. Gupta, M.D. Ph.D.
Director
IIHMR, Jaipur
Address for communication:
The Project coordinator
Indian Institute of Health Management
Research, Regional office, E2/145 Arera
Colony ,Bhopal-462016
E-mail: iihmrbhopal@mantrafreenet.com
The Director,
Indian Institute of Health Management
Research
(Who Collaborating Center on District Health
Systems)
1, Prabhu Dayal Marg, Sanganer Airport,
Jaipur – 302 011
Tel: (0141)-791431-34 Fax: 0141-792138
E-mail: iihmr@iihmr.org
A Baseline study on Nutritional
Anaemia among non-school-going
Adolescent Girls in Shivpuri
District, Madhya Pradesh
(Supported by UNICEF, M.P.)
November 2002

A C K N O W L E D G E M E N T
We express out sincere thanks to the Collector Mr. V. L. Kanta Rao, CEO Mr. A. Srivastava,
Mrs. Seema Sharma, DPO, Department of Women and Child Development, Dr. A. K.
Shrivastava, CMHO, Shivpuri District for their support, encouragement and cooperation for the
successful completion of the study.
We are extremely thankful to Dr. Vandana Agarwal, APO, Food and Nutrition Department,
UNICEF, Bhopal for her constant support, guidance and encouragement for maintaining quality
during data collection and analysis. In addition we are extremely grateful for her comments on
the draft report of the study and her valuable suggestions for the further improvement of the
report in the final version.
Our special thanks are to Prof. S. Shesadri, Dr. Kavita Sharma and Dr. Arun Maity for their
valuable inputs during the preparation of this report.
We are extremely thankful to Miss. Dimple Save for her continuous involvement and interest
shown from the beginning to end of the project. We are also thankful to Dr. Jai Ghanekar,
External Consultant of the project, for her constant support for preparing this draft report.
We are thankful to all the CDPOs, ICDS supervisors and Anganwadi Workers, of Shivpuri
District for their participation and support, which has made this document possible. We specially
want to thank all the field investigators who helped us in the data collection process for the study.
Last but not the least, the cooperation and efforts made by Dr. Arun Maity and his team in
Bhopal Path. Lab. for Haemoglobin estimation is duly acknowledged.

TABLE OF CONTENTS
CONTENTS PAGE
EXECUTIVE SUMMARY
I. INTRODUCTION
1.1 Iron Deficiency Anemia………………………………………………………………...
1.1.1 Prevalence of Anemia Among Different Physiological Groups, and its
Causes……………………………………………………………………………….
1.2 Anemia and the Adolescent girl………………………………………………………...
1.2.1 Vulnerability of Adolescent Girls to Anemia………………………………...
1.2.2 Consequences of Anemia in Adolescent Girls……………………………….
1.3 Interventions for Controlling Iron Deficiency Anemia…………………………………
1.3.1 Iron Supplementation for Combating Anemia Among Adolescent Girls……
1.4 The Scenario in India…………………………………………………………………...
1.5 Anemia Among Adolescent Girls: the Madhya Pradesh Situation……………………..
1.6 The Adolescent Girls Anemia Reduction Program in Madhya Pradesh………………..
II. THE BASELINE
SURVEY………………………………………………………………...
2.1 Major Objectives of the Survey………………………………………………………...
2.2 Methodology……………………………………………………………………………
2.2.1 Research Setting ……………………………………………………………...
2.2.2 Sample Selection……………………………………………………………..
2.2.3 Tools Used for Data Collection………………………………………………
2.2.4 Data Collection in Selected Field Areas……………………………………..
2.2.5 Ethical Consideration and Informed Consent……………………………….
2.2.6 Laboratory Estimation and Quality Control…………………………………
2.2.7 Data Management and Analysis…………………………………………….
III. RESULTS AND
DISCUSSION…………………………………………………………….
3.1 Socioeconomic Profile of the Adolescent Girls………………………………………..
3.2 Utilization of Health Service Facilities by the Adolescent Girls………………………
3.3 Information Related to Menarche……………………………………………………...
3.4 Perceptions of the Girls About Their Health…………………………………………..
3.5 Food Frequency………………………………………………………………………...
3.5.1 Consumption of Iron and Vitamin C Rich Foods…………………………….
3.5.2 Tea Consumption……………………………………………………………..
3.6 Perceptions of the Girls Related to Anemia……………………………………………
3.6.1 Awareness of the Girls Regarding Anemia or “khoon ki kami”………………
3.6.2 Causes and Consequences of Anemia……………………………………….
1-6
7-12
7
8
9
9
9
10
10
11
11
12
13-19
13
13
13
14
16
17
18
18
19
20-51
20
24
24
25
26
26
28
28
28
29
31
33

3.6.3 Treatment of Anemia………………………………………………………...
3.6.4 Perceptions of the Girls Regarding Anemia Through Focus Groups……….
3.7 Prevalence of Anemia Among the Adolescent Girls…………………………………..
3.7.1 Regional Differences in Anemia Prevalence…………………………………
3.7.2 Block wise Anemia Prevalence………………………………………………
3.7.3 Age wise Prevalence of Anemia……………………………………………..
3.7.4 Severity of Anemia…………………………………………………………
3.7.5 Distribution of Hemoglobin Levels of the Girls by Different Characteristics.
3.8 Nutritional Status of the Adolescent Girls……………………………………………..
3.8.1 Mean Weight-for-Age Values of the Adolescent Girls……………………..
3.8.2 Mean Height-for-Age Values of the Adolescent Girls………………………
3.8.3 Body Mass Index Values of the Adolescent Girls…………………………..
3.8.4 Summary of the Prevalence of Under nutrition Among the Girls…………...
3.9 Willingness of the Girls to Consume Iron Tablets……………………………………..
IV DETERMINANTS OF BODY MASS INDEX AND HAEMOGLOBIN LEVEL: ANALYSIS
THROUGH MULTIPLE REGRESSIONS ………………………………………………………
V CONCLUSION AND RECOMMENDATIONS………………………………………………
VI REFERENCES………………………………………………………………………….
VII APPENDICES…………………………………………………………………………
34
35
35
36
38
41
41
41
44
47
48
50
52-62
63-64
65-67
Appendix
Page 1-25

EXECUTIVE SUMMARY
Background
Adolescence is characterized by a swift growth spurt and the attainment of adult phenotypes and
biologic rhythms. This period marks an increased requirement of iron as a result of expansion in
the blood volume, increase in lean body mass and onset of menarche in young adolescent girls.
The available data on iron intakes of adolescent girls indicate the unlikelihood of acquiring
sufficient iron by them through their diets, leading to low iron stores. This makes them
susceptible to anemia and is reflected through high prevalence of anemia among this group.
Recognizing the consequences of anemia among adolescent girls, and following the
recommendation given in the State Nutrition Policy of Madhya Pradesh, the Department of
Women and Child Development, Ministry of Health and Family Welfare, Government of
Madhya Pradesh has initiated the Kishori Shakti project for reduction of nutritional anemia
among adolescent girls in Guna and Shivpuri districts of Madhya Pradesh with the financial and
technical assistance of UNICEF, Madhya Pradesh. Under this program, all the school going and
out-of-school adolescent girls (10-19 years) of Guna and Shivpuri were proposed to be given
iron tablets containing 100 mg of elemental iron and 0.5 mg of folic acid, once a week under
supervision.
As a part of the Kishori Shakti project, it was decided to undertake a baseline survey to assess the
prevalence of anemia among out-of-school adolescent girls (10-18 years) of Shivpuri district,
which would later on be useful for evaluating the effectiveness of the program.
Major Objectives
• To obtain a socio-economic profile of out-of-school adolescent girls (10-18 years) of
Shivpuri district
• To assess the perceptions and awareness of the girls with respect to nutritional anemia, its
causes, consequences and treatment
• To assess prevalence and severity of anemia among these girls using the cyanmethemoglobin
method

• To study the nutritional status of the girls using anthropometric measurements (weight and
height)
Methodology
All Gram Panchayats under the 8 blocks of Shivpuri, with a population above 5000 were
selected for the study. All villages under these Gram Panchayats and with population above
1500 were listed down. Out of these villages, six or nine villages were purposively selected
depending on the availability of out-of-school adolescent girls. In each of the selected villages,
the ICDS Anganwadi Workers were contacted who provided a list of all school going and out-of-
school girls 10-18 year old girls. Those out-of-school girls who were willing to participate in the
study were selected. Similar procedure was used to select the tribal sample.
As regards the urban sample, one town from each block was purposively selected and those out-
of-school girls who were ready to participate in the survey were chosen. As the number of out-
of-school girls was very less in the urban areas, the total urban sample was much smaller as
compared to the rural sample.
In all 1568 adolescent girls participated in the survey. The rural girls formed 74.5% of the total
sample, whereas 22.8% of the total sample resided in the urban areas, and 2.7% of the sample
was selected from tribal areas.
Data on Socio-economic profile of the adolescent girls, utilization of health services by them
and their perceptions regarding anemia, its symptoms, causes and adverse consequences were
collected using a semi-structured questionnaire and through focus group discussions.
Hemoglobin estimation was done using the cyanmethemoglobin method. Data on their
anthropometric measurements and frequency of consumption of iron and vitamin C rich foods
were also collected.
Highlights of the Results
a. Socioeconomic profile of the adolescent girls
All the girls belonged to the low socioeconomic group. A majority of the girls (92-95%) from the
rural, tribal and urban areas were Hindus and only 3-5% of the total girls were Muslims. More
than 80% of the girls were unmarried and all of them were not currently studying. Above 50% of

the girls from all areas were illiterate. Of those girls who were working, 22-35% worked as farm
laborers.
Above 85% of all the mothers were illiterates and above 50% of the rural and urban fathers were
illiterates. The major income source of the main earner in the family was farm labor for the rural
girls (60 %). For the tribal and urban girls it was labor for 43% and 38% respectively. More than
half of the girls (52-62%) lived in kutcha houses and the hygiene and sanitation of the overall
household environment of the girls was quite poor.
b. Attainment of menarche
About 52% of the rural girls, 78% of the tribal girls, and 47% of the urban girls had attained
menarche. The mean age at menarche for the rural and urban girls was 13.5 years, whereas it was
12.6 years for the tribal girls.
c. Food frequency
More than 50% of the rural girls and 61% of the urban girls consumed green leafy vegetables
(GLVs) 2-4 times a week whereas nearly 60% of the tribal girls reported to consume GLVs 5-7
times a week. Pulses and legumes were consumed either 5-7 times or 2-4 times a week.
Consumption of sprouts was showed a lot of variation with about 40% of the tribal girls
consuming it once a week. Fruits were consumed 2-4 times or once a week by about 16% of the
girls. The frequency of consumption of flesh foods by the girls was quite low at about once a
month or rarely.
d. Perceptions of the girls regarding anemia
Only about 13% (rural) to 18% (urban) girls had heard about ‘khoon ki kami’. In case of the
tribal girls, only one had heard of anemia. The major signs and symptoms mentioned by the girls
included breathlessness, frequent illness, tiredness and paleness.
The major causes mentioned included worm infestation, poor food intake, low consumption of
green leafy vegetables, frequent illnesses and overwork. Many of the girls (79% rural, 97% tribal
and 44% urban) did not know about the treatment taken for anemia.

e. Prevalence and severity of anemia among the girls
This survey revealed an extremely high prevalence of anemia (87.75%) among the out-of-school
adolescent girls of Shivpuri district. The highest prevalence was found among the urban girls
(92.87%), followed by the rural girls (87.41%). Girls from the tribal area had a lower prevalence
of about 55% as compared to their urban and rural counterparts. The mean hemoglobin levels of
these girls ranged from 9.7 to 10.3 g/dl.
About 53% of the girls had hemoglobin levels between 10 to 12 g/dl and nearly 35% of the girls
had hemoglobin levels below 10 g/dl. The prevalence of severe anemia (Hb < 7 g/dl), moderate
anemia (Hb: 7-9.99 g/dl), and mild anemia (Hb: 10-11.99 g/dl) was 1.47%, 33.35% and 52.93%
respectively among the girls.
f. Nutritional status of the girls
Along with anemia, the overall nutritional status of the adolescent girls surveyed as measured
through anthropometric measurements was found to be quite unsatisfactory, with 32% girls
having below normal height-for-age, 59% girls having below normal weight-for-age, and 32%
girls having below normal BMI values.
g. Willingness of the girls to consume iron tablets
Over 90% of the rural and urban girls stated that they were willing to consume iron tablets if
given to them once a week. However, only 64% of the tribal girls showed a willingness, and as
many as 28% were undecided. This indicates the significance of creating awareness regarding
the importance of controlling anemia among the girls, especially for those hailing from tribal
areas.
Conclusion and Recommendations
The alarmingly high prevalence of anemia (87.75%) among the adolescent girls of Shivpuri
district calls for immediate attention. The Kishori Shakti project, which has been initiated by the
Department of Women and Child Development, Ministry of Health and Family Welfare,
Government of Madhya Pradesh with the financial and technical assistance of UNICEF, Madhya
Pradesh is a laudable step in this direction.

Targeting adolescents through the school system is a key solution to this problem. However, low
school attendance, especially of girls belonging to economically deprived communities in
Madhya Pradesh poses a threat of not reaching the out-of-school girls. Therefore, efforts should
be made to reach the unreached girls with the help of the grassroots level health functionaries
like the ICDS Anganwadi Workers. Along with iron supplementation, efforts should be directed
to other interventions to combat anemia such as the food based approaches and food fortification
with a built-in component of an effective communication strategy. Building linkages with other
health and nutrition programs would unquestionably support in effectively integrating
components of the anemia control program with the other programs.

I. INTRODUCTION
Iron deficiency and its anemia is the most common nutritional deficiency in the developing
world (1), stealing vigor from the young and the old, and impairing cognitive development
among children. Iron deficiency has a massive, but until recently almost totally unrecognized,
economic cost. It adds to the burden on health systems, affects learning and school performance,
and reduces adult productivity (2).
Iron deficiency is truly a global epidemic as over 50 per cent of the world’s population suffers
from its consequences (2). Iron deficiency in humans has wide-ranging negative consequences,
including impaired physical growth, compromised cognitive development, short attention span
and impaired learning capacity, reduced muscle function and energy utilization, decreased
physical activity and lower work productivity, lowered immunity, increased infectious disease
risk, and poor pregnancy outcomes (3).
1.1 IRON DEFICIENCY ANEMIA
Anemia is defined as a low hemoglobin (Hb) concentration in blood, or less often, as a low
hematocrit, the percentage of blood volume that consists of red blood cells. Anemia is usually
caused by lack of iron, the most common nutrient deficiency. Iron deficiency anemia (IDA) is
typically diagnosed by low Hb, accompanied by biochemical evidence of iron deficiency, such
as low serum ferritin concentration. Hb response to iron supplementation can also be used to
confirm that the anemia was caused by iron deficiency (4). Women and children have a higher
prevalence of nutritional anemias than men. Even in developed countries, about 20 to 30% of
women of reproductive age have little or no stored iron. Malaria and hookworm, the major non-
nutrient risk factors for anemia, affect both men and women (4).
As shown in Table 1, the prevalence of anemia, defined by low hemoglobin or hematocrit, is
commonly used to assess the severity of iron deficiency anemia in a population.

Table 1. Hemoglobin and hematocrit cutoffs used to define anemia in people living at sea
level
Age or sex group Hemoglobin below:
g/dL
Hematocrit below:
%
Children 6 months to 5 years 11.0 33
Children 5-11 years 11.5 34
Children 12-13 years 12.0 36
Nonpregnant women 12.0 36
Pregnant women 11.0 33
Men 13.0 39
Source : Ref. No. 5
1.1.1 Prevalence of Anemia Among Different Physiological Groups, and its Causes
The World Health Organization (WHO) estimated that about 40% of the world’s population
(more than 2 billion individuals) suffers from anemia. The groups with the highest prevalence
are: pregnant women and the elderly, about 50%; infants and children of 1-2 years, 48%; school
children, 40%; nonpregnant women, 35%; adolescents, 30-55%; and preschool children, 25%
(6).
The prevalence of anemia in developing countries is about four times that of developed
countries. Current estimates for anemia in developing countries respectively are: for pregnant
women, 56 and 18%; school children, 53 and 9%; preschool children, 42 and 17%; and men, 33
and 5% (6).
Asia has the highest prevalence of anemia in the world. About half of all anemic women live in
the Indian subcontinent where 88% of them develop anemia during pregnancy. Vast number of
infants and children are also affected (7).
Low intakes of absorbable iron, malaria and hookworm are the main causes of anemia.
Intervention trials have demonstrated the benefits from improving iron status and reducing
anemia. The greatest benefits are to be anticipated in the most severely anemic individuals (8).
1.2 ANEMIA AND THE ADOLESCENT GIRL

Adolescence is a period of great transition in human life. Of the total 1.1 billion adolescents (10-
19 years) in the world, 84% live in developing countries, of whom, 190 million live in India
alone (9, 10). During this period, iron requirements increase dramatically in both boys and girls
as a result of the expansion of the total blood volume, the increase in the lean body mass and the
onset of menses in young girls. The overall iron requirements increase from a preadolescent level
of ~ 0.7-0.9 mg Fe/day to as much as 2.2 mg Fe/day or perhaps more in heavily menstruating
young women.(11).
1.2.1 Vulnerability of Adolescent Girls to Anemia
As mentioned earlier, the iron needs of the body increase during periods of rapid growth among
both boys and girls, reaching a peak during puberty. Loss of iron through menstruation further
increases the iron needs of adolescent girls. These increased requirements are associated with the
timing and size of the growth spurt as well as sexual maturation and the onset of menses (11).
Low dietary iron intakes, low bioavailability of iron along with increased requirement of iron
during adolescence makes this group extremely vulnerable to anemia. These factors along with
cereal-based diets and poor food consumption providing very low amounts of dietary iron
precipitate iron deficiency and anemia among girls as compared to boys of the same age group
(8). Also the high rate of parasitic infestations like hookworm and malaria further increases the
probability of the Indian adolescent girl to be anemic.
1.2.2 Consequences of Anemia in Adolescent Girls
The major consequences of anemia observed among adolescent girls are: reduced work capacity
and productivity, delayed and impaired growth, poor cognitive functions leading to low attention
span and poor performance in school, and increased vulnerability to infections (8, 12). If these
young women become pregnant, they are exposed to additional risks. Anemia due to iron
deficiency is associated with several functional impairments in pregnant women. These include
higher rates of perinatal morbidity and mortality, intrauterine growth retardation, preterm
delivery, and low birth weight babies (13).
1.3 INTERVENTIONS FOR CONTROLLING IRON DEFICIENCY ANEMIA
A wide-ranging assortment of interventions are designed to prevent and correct iron deficiency
anemia. These include dietary improvement, fortification of foods with iron, iron

supplementation, and other public health measures, such as helminth control. The appropriate
use of iron supplements will be an important part of anemia control programs in all contexts, but
supplements should be viewed as one of several tools in the battle against iron deficiency anemia
(14).
1.3.1 Iron Supplementation for Combating Anemia Among Adolescent Girls
The fact that anemia remains a problem suggests the need to expend the iron strategies of
countries beyond addressing the iron needs only of pregnant women, and adding new actions to
current interventions. Importantly, targeting adolescent girls for reduction of iron deficiency
anemia before childbearing serves to complement ongoing efforts to address the problem during
pregnancy (15).
A substantial amount of evidence confirms that iron supplementation of anemic children
improves their school performance, verbal and other skills. Also, as it has become increasingly
apparent that it is difficult, if not impossible, to correct anemia fully by iron treatment during
pregnancy alone, more attention is being paid to provide adolescent girls with either daily, or
weekly, low dose iron supplements. This strategy may prevent them from being anemic and iron
deficient when they become pregnant, as long as the supplements are given for long enough and
close enough to conception; however, where the usual intake of dietary iron is low, as in India,
supplementation will still need to be continued till pregnancy. It has also been proven that
supplementation with iron to adolescent girls improves their growth, as low iron intakes limit the
growth spurt (4).
The new rationale for considering prechildbearing adolescent years as a time to reduce iron
deficiency anemia is based on three considerations. First, many girls are often already anemic by
the time they become pregnant. Second, pregnancy is too short a period in which to reduce
preexisting anemia, particularly when many women do not seek prenatal care until their second
or third trimester. Third, intervention channels already exist through which to target adolescents
with iron supplements (15).
Reducing the prevalence of anemia among adolescent girls, and improving their iron status can
lead to improvements in functional outcomes, including pregnancy and birth, physical growth,

cognitive function and school performance, work productivity, physical activity and overall
quality of life (11, 16, 17, 18).
1.4 THE SCENARIO IN INDIA
According to the National Family Health Survey (NFHS II), more than half (56%) of the ever-
married adolescent girls (15-19 years) in India were found to be anemic (19). Research carried
out on adolescent girls in the Department of Foods and Nutrition, M. S. University of Baroda,
Baroda, has highlighted the high prevalence of anemia in the low income group (LIG) and
unfortunately even in the high income group (HIG) adolescent girls in Baroda, Gujarat. In a
compilation of 14 studies carried out from 1985-1997, the prevalence of anemia (Hemoglobin <
12 g/dL) in urban adolescent girls ranged from 65-88% in the LIG, and 51-74% for HIG (20).
Data available on rural adolescent girls of Gujarat report the prevalence of anemia at 59.7% (21).
In a more recent study carried out in the Baroda district of Gujarat has reported a prevalence of
anemia among adolescent girls at 74.7% (rural: 74.5%, tribal: 73.7%, urban: 75.8%) (22).
1.5 ANEMIA AMONG ADOLESCENT GIRLS : THE MADHYA PRADESH SITUATION
Scarcely any data are available regarding the prevalence of nutritional anemia among the
adolescent age group in Madhya Pradesh. The National Family Health Survey (NFHS II) data for
Madhya Pradesh gives prevalence figures of 54.9% for anemia among 15-19 year old ever-
married girls (23).
The results of a single study carried out in the Guna district of Madhya Pradesh give the anemia
prevalence figures among school going adolescent girls. This survey of 1495 adolescent girls
(10-19 years) revealed a 50% prevalence of nutritional anemia among them. Other than these,
data on prevalence on anemia among adolescent girls of Madhya Pradesh practically do not
exist.
1.6 THE ADOLESCENT GIRLS ANEMIA REDUCTION PROGRAM IN MADHYA PRADESH
Madhya Pradesh is one of the largest states in India, with a health delivery structure comprising
community health centers at the district level serving as the first referral unit to a sizeable
number of primary health centers at block levels, and sub centers and Anganwadis at the village
level. All nutrition programs in Madhya Pradesh primarily function through this health system.

Reduction of anemia among adolescent girls through weekly iron supplementation has been
found to be an effective approach by several researchers, especially due to its near-total absence
of side effects as compared to the daily supplementation regime (24, 25, 26). Reduction of
anemia among adolescent girls has also been endorsed in the Madhya Pradesh State Nutrition
Policy (27).
With this background, the Department of Women and Child Development, Ministry of Health
and Family Welfare, Government of Madhya Pradesh launched the Kishori Shakti project for
reduction of nutritional anemia among adolescent girls in Guna district in September 2001, with
the financial and technical assistance of UNICEF, Madhya Pradesh. Under this program, all the
school going and out-of-school adolescent girls of Guna were proposed to be given iron tablets
containing 100 mg of elemental iron and 0.5 mg of folic acid, once a week under supervision.
The total number of targeted population adolescent girls was 1,32.940 out of which 22,311 were
enrolled in schools. The Kishori Shakti project was launched in Shivpuri district in July 2002.
As a part of the project, it was determined to undertake a baseline survey to assess the prevalence
of anemia among out-of-school adolescent girls (10-18 years) of Shivpuri district. The data of
this survey would also be useful in the program evaluation.
II. THE BASELINE SURVEY
2.1 MAJOR OBJECTIVES OF THE SURVEY
• To obtain a socio-economic profile of out-of-school adolescent girls (10-18 years) of
Shivpuri district
• To assess the perceptions and awareness of the girls with respect to nutritional anemia, its
causes, consequences and treatment

• To assess prevalence and severity of anemia among these girls using the cyanmethemoglobin
method
• To study the nutritional status of the girls using anthropometric measurements (weight and
height)
2.2 METHODOLOGY
This survey was a stratified, cross sectional prevalence study for out-of-school adolescent girls
(10-18 years) of Shivpuri district.
2.2.1 Research Setting
Shivpuri district is located in the southern part of Madhya Pradesh (See Maps 1 and 2). It is
surrounded by four districts of Madhya Pradesh – Morena on its north and west, Gwalior on its
north, Guna on its south, and Datia on its north-east. Shivpuri is on the state border and it has the
State of Uttar Pradesh on the eastern side, and Rajasthan on its western side. The total
geographic area of Shivpuri is 10,278 sq.km.
The district consists of eight blocks namely Shivpuri, Kolaras, Karera, Narwar, Khaniyadana,
Badarwas, Pohri, and Pichhore. Of these eight blocks, seven are economically developed except
Khaniyadana. There are seven tehsils or talukas in Shivpuri. The total number of Gram
Panchayats in Shivpuri is 603 and there are a total of 1291 villages. The block wise number of
Gram Panchayats ranges from 64 to 92.
According to the 2001 Census survey, The total population of Shivpuri district is 14,40,666,
which is about 2.4% of the total population of Madhya Pradesh. Out of the total population,
2,39,672 lives in the urban areas, and a vast majority of 12,00,994 (approximately 84%) resides
in the rural region. Of the eight blocks of Shivpuri, only the Pohri block does not have any urban
area. With regard to the gender wise distribution of the population in Shivpuri, 53.8% are males
and 46.2% are females. The total number of adolescent girls (10-19 years) in Shivpuri is
estimated to be 1,00,846.
The average population density (number of persons/sq. km) of Shivpuri is 140 as compared to
196 of the State of Madhya Pradesh. The average population density in the Shivpuri district
ranges from 85 (Kolaras block) to 150 (Karera block).

The sex ratio (number of females per 1000 males) for Shivpuri is 858, which is much lower than
that of Madhya Pradesh (920). The overall literacy rate of the district is 59.55. The male literacy
rate (74.78) is much higher than the female literacy rate (41.54).
2.2.2 Sample Selection
As mentioned earlier, Shivpuri district has a total of eight blocks with 603 Gram Panchayats. All
Gram Panchayats with a population above 5000 were selected for the study. All villages under
these Gram Panchayats and with population above 1500 were listed down. Out of these villages,
six to nine villages were purposively selected depending on the availability of out-of-school
adolescent girls. In each of the selected villages, the ICDS Anganwadi Workers were contacted
who provided a list of all school going and out-of-school girls 10-18 year old girls. Those out-of-
school girls who were willing to participate in the study were selected as shown in Table 2.
Similar procedure was used to select the tribal sample.
As regards the urban sample, one town from each block was purposively selected and those out-
of-school girls who were ready to participate in the survey were chosen. As the number of out-
of-school girls was very less in the urban areas, the total urban sample was much smaller as
compared to the rural sample.
Table 2: Sampling of the Survey Carried out in Shivpuri District, M. P.
Name of the
block
(Population)
Rural/Urban
(In lakhs)
Number of
villages/towns
selected for the
survey
(Population)
(In lakhs)
Number of
girls
selected
(Rural)
Number of
girls
selected
(Tribal)
Number of
girls
selected
(Urban)
Shivpuri
(12.0/2.3)
7 / 1
( 0.17/NA)
171 - 76
Kolaras
(2.5/0.26)
6 / 1
(0.14/NA)
142 - 26
Karera
(1.7/0.23)
8 / 1
(0.27/NA)
147 - 56
Narwar
(1.4/0.15)
7 / 1
(0.20/NA)
109 - 36
Khaniyadana
(1.7/0.12)
9 / 1
(0.26/NA)
158 - 60
Badarwas* 6 / 1
(0.19/NA)
96 19 45

Pohri
(1.6/0)
9 / 0
(0.24/NA)
201 23 -
Pichhore
(1.4/0.14)
7/1
(0.22/ NA)
144 - 59
Total number of
girls selected :
1168 42 358
* The rural population of the Badarwas block was not available in census records.
Total Sample Selected (Rural+Tribal+Urban) = 1568
The figures in the parentheses show the population of the blocks in lakhs.
NA: Not available
In all 1568 adolescent girls participated in the survey. The rural girls formed 74.5% of the total
sample, whereas 22.8% of the total sample resided in the urban areas, and 2.7% of the sample
was selected from tribal areas.
Table 3 displays the age (10-18 years) and area wise (rural/tribal/urban) distribution of the
adolescent girls selected for the survey, whereas Table 4 gives the block wise and age group wise
(10-12 y, 13-15 y and 16-18 y) distribution of the adolescent girls. Appendix 1 gives the block
wise list of all villages and towns where the data collection was carried out.
Table 3: Age wise and Area Wise Distribution of Adolescent Girls Surveyed
Age
Number of girls surveyed
Rural % Tribal % Urban % Total %
10 41 3.51 - - 21 5.86 62 3.95
11 175 14.9 1 2.38 58 16.20 234 14.92
12 216 18.49 6 14.28 71 19.83 293 18.69
13 142 12.16 9 21.42 43 12.01 194 12.37
14 151 12.93 6 14.28 26 7.26 183 11.67
15 158 13.53 8 19.05 40 11.17 206 13.14
16 116 9.93 7 16.67 38 10.61 161 10.27
17 88 7.53 4 9.52 28 7.82 120 7.6
18 81 6.93 1 2.38 33 9.22 115 7.3
Total 1168 100 42 100 358 100 1568 100
Table 4: Block wise Distribution of Adolescent Girls Surveyed
District Name of
the
Age Group (years)
Total %10-12 13-15 16-18

Block
Shivpuri
Shivpuri 106 82 59 247 15.75
Kolaras 77 61 30 168 10.71
Karera 70 80 53 203 12.95
Narwar 51 48 46 145 9.25
Khanyadana 80 86 52 218 13.90
Badarwas 59 72 29 160 10.20
Pohri 84 78 62 224 14.28
Pichhore 62 76 65 203 12.95
Total 589 583 396 1568 100
2.2.3 Tools Used for Data Collection
Table 5 gives the description of the various tools used for data collection.
Table 5 : Tools Used for Data Collection

Tool Used Informants Number Information sought
• Semi-structured
questionnaire
Out-of-school
adolescent
girls
(10-18 years)
1568  Socio-economic profile of
the adolescent girls
surveyed
 Utilization of health
services by the adolescent
girls
 Perceptions of adolescent
girls regarding anemia, its
symptoms, causes and
adverse consequences
• Hemoglobin
estimation using
cyanmethemoglobin
method
Out-of-school
adolescent
girls
(10-18 years)
1568  Estimation of hemoglobin
levels of adolescent girls
to study the prevalence of
nutritional anemia among
them
• Structured
qualitative Food
Frequency
questionnaire
Out-of-school
adolescent
girls
(10-18 years)
1568  Frequency of
consumption of locally
available iron and vitamin
C rich foods, and tea
• Anthropometric
(weight)
measurements using
Uniscales
Out-of-school
adolescent
girls
(10-18 years)
1568  Measurement of weight
of adolescent girls as an
indicator of their
nutritional status
• Anthropometric
(height)
measurements using
fiber glass tapes
Out-of-school
adolescent
girls
(10-18 years)
1568  Measurement of height of
adolescent girls as an
indicator of their
nutritional status
• Focus Group
Discussion guideline
Out-of-school
adolescent
girls
(10-18 years)
groups of
6-8 girls
each
 Perceptions of adolescent
girls regarding anemia, its
symptoms, causes and
adverse consequences
The questionnaire used for conducting semi-structured interviews and the guideline used for
focus groups are given in Appendix 2A and 2B.
2.2.4 Data Collection in Selected Field Areas
A total number of three teams carried out the data collection. Each team consisted of one
supervisor, one investigator and one technician. The supervisor did the overall supervision for
smooth running of the data collection operation and coordinated between the field area and the
Bhopal based laboratory for transporting the samples. The investigator interviewed the girls. The
technician collected the blood samples and also recorded weight and height measurements using
standardized weighing scales and measuring tapes respectively. All the field investigators and
technicians were adequately instructed and trained with respect to interviewing techniques,

recording of weight and height measurements, and collecting blood samples using finger pricks
and filter paper method (Appendix 3A, 3B) respectively. This was done before the
commencement of data collection in the selected field areas. The procedure for estimation of
hemoglobin values was standardized in the laboratory where the blood samples were read
(Appendix 3C).
The preparation for blood sample collection included keeping adequate number of micropipettes,
lancets, filter paper pieces, alcohol swabs and acetone ready on the previous day of data
collection.
The field work was carried out for days. On an average, each day, every team traveled a
distance of about 150 km.
2.2.5 Ethical Consideration and Informed Consent
The purpose of the study was clearly explained to the Anganwadi Workers who went from house
to house to call the girl at the Anganwadi Centers. They in turn explained it to the girls and their
parents. Only those girls who were willing to give their blood sample were included in the
sample.
2.2.6 Laboratory Estimation and Quality Control
All the samples were eluted and read on the fourth day after their collection in a Bhopal Based
laboratory. The samples were eluted in Ranbaxy Drabkin’s solution. Also Ranbaxy’s
hemoglobin standard was used to standardize the procedure and plot the linear curve every time
a new bottle of the Drabkin’s solution was opened. The absorbance of the samples was measured
at 540 nm using a semi-automated Biochemistry Analyzer (Biotron BTR-810). For further
quality control, every fifth sample was taken in duplicates.
2.2.7 Data Management and Analysis
Quantitative Data
The quantitative data were entered in MS-Visual FoxPro software package, verified and cleaned.
The data were analyzed using the Statistical Package for Social Sciences(SPSS), in form of

frequency distributions, percentage values, means and standard errors. The analyzed quantitative
data were displayed as tables and graphs with accompanying text containing interpretation of
data and discussion.
Qualitative Data
The raw field notes collected through the focus groups were taken down in detail in a dialogue-
script form in the local language, Hindi, by the recorder. The expansion of these notes and
subsequent translation into English was done keeping the English translation as close as possible
to the Hindi original. Significant verbatim quotes were retained in Hindi with English equivalent
given in parentheses.
The data were categorized and major responses were summarized. Some of the responses were
quantified and their frequencies and percentages were presented in a texual form.

III. RESULTS AND DISCUSSION
As mentioned earlier, UNICEF has launched its Kishori Shakti Yojana for reducing anemia
among adolescent girls in Shivpuri. Therefore, this baseline survey was undertaken to find out
the prevalence of anemia among those girls who could not be reached for intervention through
the school system. The results of this survey are presented below.
3.1 SOCIOECONOMIC PROFILE OF THE ADOLESCENT GIRLS
The socioeconomic profile of the 1568 adolescent girls enrolled in the study is shown in Table 6.
A majority of the girls (92-95%) from the rural, tribal and urban areas were Hindus and only 3-
5% of the total girls were Muslims. As regards family type, 66% of the girls from rural areas
belonged to nuclear families whereas about 23% of the girls from the tribal and urban areas were
from nuclear families. The family size of about 50% of the total girls ranged from 4-7 members.
More than 80% of the girls were unmarried and all of them were not currently studying. As
regards their education more than 50% of the girls from all areas were illiterate. Illiteracy was
highest among the tribal girls (85%). With regard to occupation, more than 50% of the girls from
the rural and urban areas, and around 40% girls from the tribal areas did not give any response.
However, of those girls who were working, 22-35% worked as farm laborers.
Above 85% of all the mothers were illiterates. With respect to the education of fathers, above
50% of the rural and urban fathers were illiterates. The rate of illiteracy was much higher among
the tribal fathers (> 80%). Overall, the level of education was better among the men as compared
to their wives.
The major income source of the main earner in the family was farm labor for the rural girls (60
%). For the tribal and urban girls it was labor for 43% and 38% respectively. The total family
income per year for many of the girls (45-57%) ranged from Rs.12,000-40,000, reflecting their
disadvantaged economic status. However, 13-17% of the total girls interviewed did not respond
to the question regarding their family’s income.

More than half of the girls (52-62%) lived in kutcha houses. The major sources of drinking
water for the rural and urban girls were either a handpump or a well, with 86% of the rural girls
and 82% of the urban girls stating these two water sources. For 66% of the tribal girls, wells
provided the major source of drinking water. As regards toilet facilities, more than 85% of all the
girls practiced open defecation. The sanitation in and around the houses was rated on a scale, as
described in Appendix 2 as Very poor, Poor, Fair, Good and Very good. The condition of 77-
88% of the households from rural and urban areas respectively was rated as “Fair” or “Poor”. For
the tribal households, 78% of them were rated from “Poor” to “Very poor”. Thus, the hygiene
and sanitation of the overall household environment of the girls was quite poor.
Table 6 : Socioeconomic Profile of the Adolescent Girls (N=1568)
Characteristic
Rural
(n=1168)
Tribal
(n=42)
Urban
(n=358 )
n % n % n %
Religion
 Hindu
 Muslim
 Jain
1115
39
14
95.46
3.34
1.20
39
2
1
92.86
4.76
2.38
333
18
7
93.01
5.03
1.95
Family Type
 Nuclear
 Joint
775
393
66.35
33.65
32
10
76.19
23.81
273
85
76.26
23.74
Family Size
 <4
 4-7
 >7
14
622
532
1.20
53.25
45.55
-
26
16
-
61.90
38.09
7
196
155
1.95
54.75
43.30
Marital Status
 Unmarried
 Married
 Married but still
staying with parents
 Separated/divorced
n
999
160
8
1
%
85.53
13.70
0.68
0.08
n
35
7
-
-
%
83.33
16.67
-
-
n
310
48
-
-
%
86.59
54.75
-
-
Education of the girl
 Illiterate
 Less than V
 V-VII
 VIII-X
 More than X
634
243
172
90
29
54.28
20.80
14.73
7.70
2.48
36
1
2
2
1
85.71
2.38
4.76
4.76
2.38
216
61
50
22
9
60.33
17.03
13.96
6.14
2.51
Occupation of the girl
 Farm laborer 411 35.19 13 30.95 80 22.34

Characteristic
Rural
(n=1168)
Tribal
(n=42)
Urban
(n=358 )
 Service
 Business
 Laborer
 Domestic servant
 Unemployed
 No Response
3
2
68
54
87
624
0.26
0.17
5.82
4.62
7.45
53.42
-
-
-
-
5
16
-
-
--
-
11.90
38.09
2
-
46
15
29
189
0.55
-
12.85
4.18
8.10
52.7
Education of Mother
 Illiterate
 Less than V
 V-VII
 VII-X
 XII
 Graduation
 Professionals
 No Response
 Do not know
1015
58
48
24
7
2
-
1
13
86.90
4.96
4.11
2.05
0.60
0.17
-
0.08
1.11
39
1
1
1
-
-
-
-
-
92.85
2.38
2.38
2.38
-
-
-
-
-
305
20
7
13
6
-
-
-
7
85.1
5.58
1.95
3.63
1.67
-
-
-
1.95
Education of Father
 Illiterate
 Less than V
 V-VII
 VII-X
 XII
 Graduation
 Professionals
 No Response
 Do not know
601
107
115
91
64
51
1
3
135
51.45
9.16
9.84
7.79
5.47
4.37
0.08
0.26
11.56
34
3
3
1
1
-
-
-
-
80.95
7.14
7.14
2.38
2.38
-
-
-
-
194
36
33
31
13
9
-
1
41
54.18
10.05
9.21
8.65
3.63
2.51
-
0.27
11.45
n % n % n %
Source of main earner's
income*
 Farm Laborer
 Service
 Business
 Laborer
 No Response
 Do not know
* Due to multiple ratio
the responses will be not
equal to N= 1568.
696
144
121
229
47
12
59.59
12.33
10.36
19.61
4.02
1.03
16
-
2
18
1
5
38.09
-
4.76
42.86
2.38
11.90
109
68
42
135
10
6
30.45
18.99
11.73
37.71
2.79
1.67
Total annual income of
the family
 Less than 6000
 6001-12,000
 12,001-25,000
 25,001-40,000
 40,001 and above
 No response
110
105
285
384
127
157
9.42
8.99
24.40
32.88
10.87
13.44
10
6
13
6
-
7
23.80
14.28
30.95
14.28
-
16.67
15
67
110
87
25
54
4.19
18.71
30.72
24.30
6.98
15.08

Characteristic
Rural
(n=1168)
Tribal
(n=42)
Urban
(n=358 )
Construction of the house
 Pucca house
 Semi-pucca house
 Kutcha house
295
257
616
25.26
22.00
52.74
3
15
24
7.14
35.71
57.14
78
57
223
21.79
15.92
62.29
Source of drinking water
 Individual tap
 Common tap
 Hand-pump
 Well
 Others (bore wells)
126
83
445
557
8
10.79
7.11
38.09
47.69
0.68
1
9
4
28
-
2.38
21.43
9.52
66.67
-
59
46
163
133
3
16.48
12.85
45.53
37.15
0.84
Toilet facilities
 Individual toilet
 Public toilet
 Open defecation
 Others
153
10
1003
2
13.09
0.86
85.07
0.17
3
1
38
-
7.14
2.38
90.48
-
45
4
309
-
12.57
1.12
86.31
-
Condition of the house*
 Very good
 Good
 Fair
 Poor
 Very poor
37
153
444
456
78
3.17
13.09
38.01
39.04
6.68
-
1
8
16
17
-
2.38
19.04
38.09
40.48
1
44
128
163
22
0.28
12.29
35.75
45.53
6.15
* Appendix 2A gives a description of the levels.
3. 2 UTILIZATION OF HEALTH SERVICE FACILITIES BY THE ADOLESCENT GIRLS
As seen in Table 7, 60-66% of the tribal and rural girls, and as high as 83% of the urban girls
availed of the government health facilities in case of illness. Those girls who did not go the
government health facilities, gave reasons such as long distances from home, poor quality of
services, unavailability of medical staff, shortage of medicines at the health facility and
indifferent behavior of the staff members.
Table 7 : Utilization of Health Service facilities by the Adolescent Girls

Major Responses Rural
(n= 1168)
Tribal
(n=42)
Urban
(n=358)
n % n % n %
Health facility visited during
illness:
 Government hospital
 Private hospital
 Private clinic
 Traditional Practitioners
 Others (faith healers, quacks)
 No response
768
412
16
7
8
14
65.75
35.27
1.37
0.60
0.68
1.20
25
-
-
-
1
59.52
-
-
-
2.38
298
16
8
1
-
-
83.24
4.46
2.23
0.27
-
-
Reasons for not visiting
government health facility
during illness: (n=400, 17, 60)
 Hospital is far away
 Poor quality of services
 Doctors and nurses not
available/attentive
 Unavailability of required
drugs
 Indifferent behavior of staff
 Others (Not taken to
hospitals by family member)
179
94
24
26
6
51
44.75
23.50
6.00
6.50
1.50
12.75
1
10
2
5
2
1
5.88
58.82
11.76
29.41
11.76
5.88
11
20
4
10
9
4
18.33
33.33
6.66
16.66
15.00
6.66
3.3 INFORMATION RELATED TO MENARCHE
Table 8 gives the information regarding attainment of menarche among the girls surveyed. As
indicated in the table, 52% of the rural girls, 78% of the tribal girls, and 47% of the urban girls
had attained menarche. The age at menarche for a majority of the rural and urban girls was
between 13 and 14 years, whereas the tribal girls seemed to have attained menarche at an earlier
age of 12 to 13 years. The mean age at menarche for the rural and urban girls was 13.5 years, and
it was 12.6 years for the tribal girls
Table 8 : Information Regarding Menarche (Onset and Age) Among the Adolescent
Girls (N=1568)

Major Responses
Rural
(n=1168)
Tribal
(n= 42 )
Urban
(n=358)
n % n % N %
Menarche attained
 Yes
 No
606
562
51.88
48.12
33
9
78.57
21.43
167
191
46.65
53.35
Age at onset of menarche
 11
 12
 13
 14
 15
 16
 17
8
74
235
216
53
19
1
1.32
12.21
38.78
35.64
8.74
3.13
0.16
1
19
10
1
2
-
-
3.03
57.57
30.3
3.03
6.06
-
-
3
19
54
77
12
2
-
1.80
11.37
32.33
46.11
7.18
1.19
-
Mean age at menarche
(years)
13.51 12.58 13.50
3.4 PERCEPTIONS OF THE GIRLS ABOUT THEIR HEALTH
When asked about whether they felt that they were healthy, over 72% of the girls from the rural
and tribal areas felt and responded that they were not healthy. Around 60% of the tribal girls
gave a similar response. About 3-5% of the rural and urban girls, and 31% of the tribal girls did
not respond to this question. The rest of the girls felt that they were healthy (Table 9).
The major reasons given by the girls for feeling healthy were: they did not fall sick, did not feel
weak or tired, and their body weight was appropriate for their age.
Table 9 : Perceptions of the Girls Regarding Their Health
Major Responses
Rural
(n=1168)
Tribal
(n= 42 )
Urban
(n=358)
n % n % n %
Feels that she is healthy
 Yes
 No
 No response
270
843
55
23.12
72.17
4.71
4
25
13
9.52
59.52
30.95
71
275
12
19.83
76.81
3.35
Reasons for feeling healthy
 Does not fall sick often
 Does not feel weak or tired
 Has proper weight
 Doctor says so
 Body remains warm
 Takes medicines for health
246
19
2
2
1
-
91.11
7.04
0.74
0.74
0.37
-
3
1
-
-
-
-
75
25
-
-
-
-
63
7
-
-
-
1
88.73
9.86
-
-
-
1.41
3.5 FOOD FREQUENCY

3.5.1 Consumption of Iron and Vitamin C rich Foods
Table 10 displays the data on the frequency of consumption of iron and vitamin C rich foods by
the girls. More than 50% of the rural girls and 61% of the urban girls consumed green leafy
vegetables (GLVs) 2-4 times a week whereas nearly 60% of the tribal girls reported to consume
GLVs 5-7 times a week. Pulses and legumes were consumed either 5-7 times or 2-4 times a
week. Consumption of sprouts was showed a lot of variation with about 40% of the tribal girls
consuming it once a week. Fruits were consumed 2-4 times or once a week by about 16% of the
girls.
The frequency of consumption of flesh foods was quite low as shown in the table. Around 7% of
the rural and tribal girls reported of consuming meat, fish or chicken once a month. This
proportion was double in case of the urban girls. Consumption of eggs by the girls was also
found to be low among the girls from all three areas.
Table 10 : Frequency of Consumption of Iron and Vitamin C Rich Foods by the Girls
(N=1568)
Foods
Rural
(n=1168)
Tribal
(n=42)
Urban
(n=358)
n % n % n %
Green leafy vegetables
 5-7 times a week
 Once a week
 Once a fortnight
 Once a month
 Rarely
300
589
180
30
35
27
25.68
50.42
15.41
2.56
2.99
2.31
25
4
10
1
1
-
59.52
9.52
23.80
2.38
2.38
-
70
221
51
7
2
7
19.55
61.73
14.24
1.95
0.56
1.95
Pulses and legumes
 Once a week
 Once a month
 Rarely
493
539
104
3
12
5
42.20
46.14
8.90
0.23
1.02
0.42
20
7
6
-
2
-
47.61
16.66
14.28
-
4.76
-
133
190
24
2
1
1
37.15
53.07
6.70
0.56
0.27
0.27
Sprouts
 Once a week
 Once a month
 Rarely
46
82
71
61
101
69
3.93
7.02
6.07
5.22
8.64
5.90
2
-
16
1
3
-
4.76
-
38.09
2.38
7.14
-
2
4
19
16
17
23
0.56
1.18
5.30
4.47
4.75
6.42
Fruits (guava, amla, lemon, orange)
88
200
7.53
17.12
2
7
4.76
16.66
25
60
6.98
16.76

 Once a week
 Once a month
 Rarely
196
132
141
175
16.78
11.30
12.07
14.98
8
4
4
4
19.04
9.52
9.52
9.52
49
33
50
44
13.69
9.22
13.96
12.29
Flesh foods (meat, fish, chicken)
 Once a week
 Once a month
 Rarely
2
7
10
25
86
63
0.17
0.59
0.85
2.14
7.36
5.39
-
1
1
-
3
6
-
2.38
2.38
-
7.14
14.28
-
1
6
18
53
22
-
0.27
1.68
5.03
14.80
6.14
Eggs
 Once a week
 Once a month
 Rarely
11
67
71
18
46
22
0.94
5.73
6.07
1.54
3.93
1.88
1
5
1
1
1
5
2.38
11.90
2.38
2.38
2.38
11.90
3
32
35
14
50
5
0.84
8.94
9.77
3.91
13.96
1.39
3.5.2 Tea Consumption
Since tea consumption with meals or tea taken shortly before/after meals inhibits iron absorption,
it was decided to collect data on this aspect. As presented in Table 11, 55-61% of the girls
consumed tea every day. Of the 938 girls who consumed tea every day, 18 of them took it with
their meals and 742 (79%) consumed it before meals.
Table 11 : Consumption of Tea by the Adolescent Girls
Major Responses
Rural
(n=1168)
Tribal
(n= 42 )
Urban
(n=358)
n % n % n %
Consumes tea every day
 Yes
 No
714
454
61.13
38.87
26
16
61.90
38.09
198
160
55.31
44.69
Tea consumed
 With meals
 After meals
 Before meals
 Indefinite/Irregular
11
97
564
92
1.54
13.58
78.99
12.88
2
3
20
1
7.69
11.54
76.92
3.85
5
16
158
24
2.52
8.08
79.79
12.12
3.6 PERCEPTIONS OF THE GIRLS RELATED TO ANEMIA
3.6.1 Awareness of the Girls Regarding Anemia or ‘khoon ki kami’

As seen in Table 12, only about 13% (rural) to 18% (urban) girls had heard about ‘khoon ki
kami’. In case of the tribal girls, only one had heard of anemia. Nearly 75% of the rural and
urban girls had not heard of anemia, and 67% of the tribal girls did not respond to this question.
Many girls (62% rural, 38% tribal and 44% urban) said that they had not suffered from ‘khoon ki
kami’. Only 5% of the girls interviewed said that they had met someone who was suffering from
this deficiency of blood. These data indicate a very low awareness among the girls regarding
anemia or its equivalent local term of ‘khoon ki kami’.
When asked about the appearance of a person suffering from anemia, the girls from rural and
tribal areas came up with many responses whereas most of the tribal girls did not give any
response. The major signs and symptoms mentioned by the girls included breathlessness,
frequent illness, tiredness and paleness.

Table 12 : Awareness of the Girls About Anemia
Major Responses Rural (n=1168) Tribal (n=42) Urban (n=358)
n % n % n %
Has heard about ‘khoon ki kami’ or
anemia
 Yes
 No
 No response
155
876
137
13.27
75.00
11.73
1
13
28
2.38
30.95
66.67
66
252
40
18.43
70.39
11.17
Has herself suffered from ‘khoon
ki kami’ or anemia
 Yes
 No
 No response
38
720
410
3.25
61.64
35.10
-
16
26
-
38.09
61.90
11
158
189
3.07
44.13
52.79
Has met someone suffering from
‘khoon ki kami’ or anemia
 Yes
 No
 No response
61
605
502
5.22
51.80
42.98
-
4
38
-
9.52
90.48
23
145
190
6.42
40.50
53.07
Appearance of a person suffering
from ‘khoon ki kami’ or
anemia
 Looks pale
 Has a pale face
 Has pale eyes
 Has a pale tongue
 Has pale nails
 Feels tired, after
doing little work
 Falls ill frequently
 Is irritable
 Feels breathless
 Others (has vomiting)
29
36
31
12
8
22
30
10
60
50
18.71
23.22
20.00
7.74
5.16
14.19
19.35
6.45
38.70
32.25
-
-
-
-
-
-
-
-
-
2
-
-
-
-
-
-
-
-
-
200
8
13
8
1
6
6
14
5
35
10
12.12
19.70
12.12
1.51
9.09
9.09
21.21
7.57
53.03
15.15
3.6.2 Causes and Consequences of Anemia

Table 13 displays data on causes and consequences of anemia as mentioned by the girls.
Table 13 : Causes and Adverse Consequences of Anemia Mentioned by the Girls
Major Responses Rural (n=1168) Tribal (n=42) Urban (n=358)
n % n % n %
Causes of anemia
 Worms
 Inadequate diet/inadequate
food intake
 Inadequate consumption of
green leafy vegetables
 Frequent illnesses
 High workload/hard work
 Others (lack of vitamins in diet)
 Do not know
36
53
53
56
16
21
994
3.08
4.54
4.54
4.79
1.37
1.80
85.10
-
-
-
-
-
-
42
-
-
-
-
-
-
100.00
12
33
28
29
6
-
280
3.35
9.22
7.82
8.10
1.67
-
78.21
Is aware regarding ill effects of
‘khoon ki kami’ or anemia
during pregnancy
 Yes
 No
 No response
81
477
610
6.93
40.84
52.23
-
9
33
-
21.43
78.57
21
139
198
5.87
38.83
55.31
Adverse consequences of
pregnancy anemia mentioned
 Increased illnesses (especially
malaria)
 Baby does not grow properly
 Premature delivery
 Low birth weight babies
 Maternal death in childbirth
 Others (weakness)
 No response
44
13
6
4
11
27
1087
54.32
16.05
7.41
4.94
13.58
33.33
69.32
-
-
-
-
-
-
42
-
-
-
-
-
-
100
8
7
2
5
5
3
337
38.09
33.33
9.52
23.81
23.81
14.28
94.13
Ill effects of ‘khoon ki kami’ or
anemia on children
 Low birth weight
 Growth retardation / poor
physical development
 Poor mental development
 Learning difficulty/low
attention span
 Others (death of the baby)
 Do not know
27
43
13
2
29
1073
2.31
3.68
1.11
0.17
2.48
91.87
-
-
-
-
2
-
-
-
-
-
4.76
-
14
10
3
-
9
327
3.91
2.79
0.84
-
2.51
91.34
It could be observed from the table that hardly any tribal girls responded to the questions related
to causes, and consequences of anemia for pregnant women and young children. The major
causes mentioned included worm infestation, poor food intake, low consumption of green leafy
vegetables, frequent illnesses and overwork.

Only 102 (6.5%) of the girls said that they were aware of the adverse consequences of anemia
such as frequent illnesses, stunted fetal growth, premature delivery, low birth weight, and
maternal death in childbirth, As regards consequences of anemia in young children, the girls
talked about low birth weight, poor physical growth and mental development.
3.6.3 Treatment of Anemia
Table 14 lists down the girls’ responses related to the treatment of anemia. Here again many of
the girls (79% rural, 97% tribal and 44% urban) did not know about the treatment taken for
anemia.
Table 14 : Treatment Taken for Anemia
Major Responses
Rural
(n=1168)
Tribal
(n=42)
Urban
(n=358)
n % n % n %
Treatment for anemia
 Take doctor’s advice
 Take health worker’s advice
 Take iron tablets
 Take iron syrup
 Consume green leafy
vegetables, pulses and legumes
and citrus fruits in your diet
 Others (blood transfusion)
 Do not know
179
15
29
7
51
20
927
15.32
1.28
2.48
0.59
4.37
1.71
79.37
1
-
-
-
-
-
41
2.38
-
-
-
-
-
97.62
73
6
12
6
18
3
264
20.39
1.68
3.35
1.67
5.03
0.84
43.74
Treatment taken for anemia by
self
 Yes
 No
 No response
36
430
702
3.08
36.81
60.10
-
10
32
-
23.80
76.19
12
106
240
3.35
29.61
67.03

Major Responses
Rural
(n=1168)
Tribal
(n=42)
Urban
(n=358)
n % n % n %
Type of treatment taken
 Took doctor’s advice
 Took health worker’s advice
 Took iron tablets
 Took iron syrup
 Included green leafy
vegetables, pulses and legumes
and citrus fruits in daily diet
 Others
21
4
13
5
6
9
58.33
11.11
36.11
13.89
16.67
25.00
-
-
-
-
-
-
-
-
-
-
-
-
12
-
4
1
-
-
100
-
33.33
8.33
-
-
Foods perceived to make the
blood red and healthy
 Green leafy vegetables
 Citrus fruits (amla, orange,
lemon)
 Pulses and legumes
 Sprouts
 Meat
 Fish
 Chicken
 Eggs
 Jaggery
 Others (milk and ghee)
207
142
117
20
22
22
3
13
8
42
17.72
12.16
10.02
1.71
1.88
1.88
0.26
1.11
0.68
3.59
-
1
2
-
-
-
-
-
-
-
-
2.38
4.76
-
-
-
-
-
-
-
78
53
29
9
1
3
2
3
5
8
21.79
14.80
8.10
2.51
0.28
0.84
0.56
0.84
1.40
2.23
A few of the rural and tribal girls (around 3%) mentioned that they had taken treatment for
anemia or ‘khoon ki kami’. However, 60-76% of the girls did not answer this question. As
regards type of treatment taken, the tribal girls did not give any response. Others who took the
treatment mentioned that they took the doctors’ advice and started taking iron supplements.
The key foods mentioned by the girls which they perceived to make their blood red and healthy
included green leafy vegetables, citrus fruits, pulses and legumes, sprouts, meat and fish. Here
again, there was hardly any response from the girls belonging to tribal areas.
3.6.4 Perceptions of the Girls Regarding Anemia Through Focus Groups
The girls’ perceptions regarding anemia were also gauged through eight focus group discussions
(FGDs) in urban and rural areas of five blocks in Shivpuri. See Appendix 2B for the FGD
guidelines. The data presented here gives an overall perspective of the adolescent girls’ opinion
from all 8 groups.

Girls from all the groups had heard about the term “khoon ki kami” which was a local equivalent
to anemia. Four groups put it as ‘weakness’, and one group came up with the term “matha misi”
for anemia. Most of the groups (6 out of 8) mentioned that they did not know whether they were
suffering from anemia themselves.
The knowledge of major signs and symptoms of anemia as reported by the 8 groups were as
follows: “nails become yellowish in colour”(7 out of 8 groups), “weakness and thinness along
with frequent vomiting” (6 out of 8 groups), “body turns thin and yellowish” (6 out of 8 groups),
and “increased hunger” (4 out of 8 groups). As compared to the interviews, these responses
were less in number and variety.
The chief causes of anemia mentioned by the groups were: “Non-inclusion of green leafy
vegetables in diet” (8/8), “Inadequate milk, curd and ghee intake” (5/8), “vitamins in diet” (4/8),
“deficient protein intake” (1/8), and “irregular timing of food consumption” (1/8). These
responses were similar to the ones given by girls during individual interviews.
The preventive measures suggested by the girls included: “inclusion of adequate amount of
vegetables in diet” (8/8), “consumption of adequate quantity of food” (4/8), “doctor’s advice”
(3/8), “Good food along with happiness” (2/8), and “drinking adequate amount of water” (1/8).
They did not mention iron supplements at all which was one of the responses in the interviews.
According to the groups, consumption of vegetables and fruits such as papita, gadelu ki sabzi
,jamoon,bihi, tomato, spinach, and nonia bhaji could make their blood red and healthy. Some
were of the opinion that tea drinking made their blood “burn” and make them sick.
As regards their perception of adverse effects of anemia on pregnant women, the major
responses were weakness and tiredness, inability to work (7/8), and loss of appetite (4/8). The
adverse consequences of anemia in young children stated by the girls were birth of a weak and
thin baby (8/8), increased risk of infant mortality (3/8), insufficient mental development of the
child (2/8), and fear of having a handicapped baby (1/8).
When the girls were asked about their willingness to take iron tablets once a week to prevent
anemia, some girls were not ready to do so and said that they were healthy or that they would get
stomachache if they could not digest/tolerate the tablets.

Overall, the FGDs with the girls provided useful insights such as inadequacy of the girls’
awareness of the seriousness of anemia during adolescence.( See the details of group responses
in Appendix )
3.7 PREVALENCE OF ANEMIA AMONG THE ADOLESCENT GIRLS
The WHO/UNICEF/UNU report has suggested guidelines based on population prevalence,
which help determine whether anemia is a problem of public health significance for that
particular population (28). According to the guidelines, if the prevalence is more than 40%, it
needs to be considered as a high magnitude problem. In the present survey, the prevalence
figures were found to be considerably alarming.
Figure 1 presents the prevalence figures for anemia among the adolescent girls surveyed in
Shivpuri district. The overall anemia prevalence was found to be very high at 87.75%. Girls
having hemoglobin levels less than 12 g/dl were considered anemic, whereas girls with
hemoglobin above 12 g/dl were categorized as normal. The mean hemoglobin level of the girls
was low at 10.12 g/dl.
3.7.1 Regional Differences in Anemia Prevalence
Among the rural, tribal and urban adolescents, surprisingly, the anemia prevalence was highest
amongst the urban girls (92.87%). The tribal girls had a comparatively lower prevalence of about
55%. However, the tribal sample was also very small and represented only 2.7% of the total
sample. The rural sample, which formed nearly two-thirds of the sample had a prevalence of
87.41%.

Figure 1 : Area wise prevalence of anemia
among the adolescent girls surveyed
92.73
54.76
87.4187.75
0
20
40
60
80
100
Total
(N=1568)
Rural
(n=1168)
Tribal
(n=42)
Urban
(n=358)
%prevalenceofanemia
3.7.2 Block wise Anemia Prevalence
The block wise prevalence of anemia found among the girls is represented through Figure 2. The
prevalence figures ranged from 75% in Pohri block to as high as 97.53% in Pichhore block. As
frank iron deficiency anemia is the final stage of iron deficiency, such high prevalence of anemia
among these girls is definitely a cause for concern.

Figure 2 : Block wise prevalence of anemia
97.53
75
80
89.989.692.6
82.14
93.11
87.7
0
10
20
30
40
50
60
70
80
90
100
Overall
Shivpuri
Kolaras
Karera
Narwar
Khaniyadana
Badarwas
Pohri
Pichhore
%prevalenceofanemia
3.7.3 Age wise Prevalence of Anemia
No particular trend was observed among the age wise prevalence of anemia, though there was a
slight reduction in the mean hemoglobin levels after age 15 onwards as shown in Table 15. The
prevalence of anemia was not found to be influenced by age. Similar observations were made as
regards the median hemoglobin levels of the girls.
Figure 3 displays the age wise distribution of mean hemoglobin levels of the subjects. It could be
noticed that the mean hemoglobin of the 18 year olds was slightly lower than all other age
groups.

Table 15 : Age wise Prevalence of Anemia in the Adolescent Girls Surveyed, Mean and
Median Hemoglobin Levels (g/dl)
Age in
compl
eted
years
Numb
-er of
girls
No. of
Girls with
Hb
< 12 g/dl
%
prevale-
nce of
anemia
Mean
hemoglobin
(g/dl) ± SE
Median
hemoglobin
(g/dl) ± SE
Min-Max
hemoglo-
bin levels
(g/dl) of
anemic
girls
10 62 56 90.32 10.08 ± 0.15 10.07 ± 0.15 7.75 -11.99
11 234 201 85.90 10.28 ± 0.07 10.37 ± 0.07 7.43 -11.97
12 293 265 90.44 10.26 ± 0.07 10.47 ± 0.07 6.03 - 11.98
13 194 165 85.05 10.04 ± 0.09 10.20 ± 0.09 6.42 -11.96
14 183 166 90.71 10.19 ± 0.09 10.41 ± 0.09 6.31 - 11.98
15 206 178 86.40 10.03 ± 0.09 10.13 ± 0.09 5.82 -11.96
16 161 139 86.33 10.09 ± 0.09 10.20 ± 0.09 7.05 -11.94
17 120 106 88.33 10.02 ± 0.10 10.09 ± 0.10 7.45 -11.98
18 115 100 86.96 9.72 ± 0.14 10.01 ± 0.14 4.55 - 11.79
Total 1568 1376 87.75 10.12 ±
0.03
10.3 ± 0.03 4.55 -11.99
Figure 3 : Age wise distribution of the
mean hemoglobin levels of the
adolescent girls surveyed
10.08
10.28 10.26
10.04
10.19
10.03
10.09
10.02
9.72
9
9.5
10
10.5
11
10 11 12 13 14 15 16 17 18
Age (years)
Meanhemoglobin(g/dl)
3.7.4 Severity of Anemia

Table 16 gives an overall picture regarding the severity of anemia among the adolescent girls. It
can be noticed that about 53% of the girls had hemoglobin levels between 10 to 12 g/dl and
nearly 35% of the girls had hemoglobin levels below 10 g/dl. Thus, the prevalence of severe
anemia (Hb < 7 g/dl), moderate anemia (Hb: 7-9.99 g/dl), and mild anemia (Hb: 10-11.99 g/dl)
was 1.47%, 33.35% and 52.93% respectively.
Table 16 : Anemia Prevalence Using Different Cut-offs Among the Adolescent Girls
Hemoglobin
levels (g/dl)
Number of
girls
Percentage Cumulative
Percentage
< 7 23 1.47 1.47
< 10 523 33.35 34.82
<11 471 30.34 64.86
< 11.5 211 13.46 78.32
< 12 148 9.44 87.76
≥ 12 192 12.24 100
Total 1568 100
Figure 4 gives the regional variation found in the severity of anemia. Nearly half of the anemic
girls from the rural and tribal regions were mildly anemic. The prevalence of mild anemia
among the rural girls was slightly higher at about 55%. The tribal girls mainly had mild anemia
and the overall prevalence of anemia in this group was significantly lower than the other two
groups. In the urban category, 46% of the anemic girls were moderately anemic. The prevalence
of severe anemia was less than 2% in the rural and urban girls, whereas no tribal girl was found
to be severely anemic.
Appendix 4 gives the block wise and age wise distribution of severity of anemia among the
adolescent girls.

Figure 4 : Severity of anemia among adolescent girls
from different areas
55.65
30.14
1.63 0
45.2446.65
1.12
12.58
45.23
9.52
44.97
7.26
0
10
20
30
40
50
60
Mild (Hb: 10-
11.99 g/dl)
Moderate (Hb:
7-9.99 g/dl)
Severe (Hb: < 7
g/dl)
Normal (Hb >
12 g/dl)
Severity of anemia
Percentgirls
Rural
Tribal
Urban
Tables 17A, 17B and 17C give the age group wise (10-12 years, 13-15 years and 16-18 years)
distribution of rural, tribal and urban girls according to the severity of anemia. In the rural group,
the prevalence of mild anemia was higher among the younger (10-12 years) age group as
compared to the older age groups (13-15 years and 16-18 years). The prevalence of moderate
anemia increased with an increase in the age (Table 17A). By and large, the prevalence of
anemia was similar among the three groups.
Table 17A: Age Group wise Distribution of Severity of Anemia Among the Rural
Adolescent Girls
Age
Group
(years)
Numb
er of
girls
survey
ed
Prevalence of anemia Normal
Hb ≥ 12 g/dlSevere
Hb < 7 g/dl
Moderate Hb
7-9.99 g/dl
Mild Hb 10-
11.99 g/dl
n % n % n % n %
10-12 432 6 1.39 111 25.69 257 59.49 58 13.42
13-15 451 10 2.22 139 30.82 246 54.54 56 12.42
16-18 285 3 1.16 102 35.79 147 51.58 33 11.58
Total 1168 19 1.63 352 30.14 650 55.65 147 12.58
In case of the tribal girls (Table 17B), a higher number (71.42%) of younger girls (10-12 years)
were found to be anemic as compared to the older age groups. The prevalence of anemia
decreased with increasing age. The overall prevalence of anemia was lower among the 13-15
year age group as compared to the other two groups.

Table 17B: Area Wise and Age Group wise Distribution of Severity of Anemia Among
the Tribal Adolescent Girls
Age
Group
(years)
Numb
er of
girls
survey
ed
Hb < 7 g/dl
Moderate Hb
7-9.99 g/dl
Mild Hb 10-
11.99 g/dl
n % n % n % n %
10-12 7 0 0 1 14.28 4 57.14 2 28.57
13-15 23 0 0 2 8.69 11 47.82 10 83.33
16-18 12 0 0 1 8.33 4 33.33 7 58.33
Total 42 0 0 4 9.52 19 45.23 19 45.23
In case of the urban girls, a trend similar to the rural girls was observed with a higher prevalence
of mild anemia among the younger girls and a higher prevalence of moderate anemia among the
older age groups. The younger girls had slightly higher anemia prevalence in comparison with
the older girls (Table 17C).
T
Table 17C: Area Wise and Age Group wise Distribution of Severity of Anemia Among
the Urban Adolescent Girls
Age
Group
(years)
Numb
er of
girls
survey
ed
Hb < 7 g/dl
Moderate Hb
7-9.99 g/dl
Mild Hb 10-
11.99 g/dl
n % n % n % n %
10-12 150 2 1.33 66 44.00 75 50.00 7 4.66
13-15 109 1 0.91 51 46.78 49 44.95 8 7.33
16-18 99 1 1.01 50 50.50 37 37.37 11 11.1
Total 358 4 1.11 167 46.64 161 44.97 26 7.26
3.7.5 Distribution of Hemoglobin Levels of the Girls by Different Characteristics
In this survey, an attempt was made to find out the distribution of hemoglobin levels of the rural,
tribal and urban girls by different socioeconomic characteristics such as their religion, family
type, family size, marital status, education of the girl and her parents, family income,

construction of their houses, and availability of toilet facilities. Due to lack of space, these tables
are presented in Appendix 5.
3.8 NUTRITIONAL STATUS OF THE ADOLESCENT GIRLS
As mentioned earlier, weight and height measurements of the girls were taken to get an idea
regarding their nutritional status.
3.8.1 Mean Weight-for-Age Values of the Adolescent Girls
The mean weight-for-age values of the girls as compared with the NCHS standards (29) are
presented in Tables 18, 19A, 19B and 19C. It can be seen that overall, girls from all age groups
except the 10 year olds had their mean weights below 80% of the NCHS standards (74-77% of
the standard), indicating low weight for age. Similar trend was seen among the rural and urban
girls, whereas in case of the tribal girls, the 12 and 13 year olds had normal mean weights-for-
age. Also, the 16 year olds from the tribal areas had their mean weights even below 70% of the
standards.
Table 18: Weight-for-age of the Adolescent Girls as Compared with NCHS Standards
(n=1568)
Age (years) n Weight (kg)
Mean ± SE
Median weight % NCHS std.
Mean ± SE
10 62 26.53 ± 25.68 81.63 ±
11 234 28.58 ± 28.40 77.24 ±
12 293 31.35 ± 31.15 75.55 ±
13 194 34.95 ± 35.25 75.83 ±
14 183 37.41 ± 37.00 74.37 ±
15 206 40.26 ± 40.55 74.97 ±
16 161 42.18 ± 42.55 75.46 ±
17 120 42.36 ± 41.93 74.71 ±
18 115 42.86 ± 42.25 75.73 ±
Total 1568 36.28 ± 35.90 75.80 ±

Table 19 A: Weight-for-age of the Rural Adolescent Girls as Compared with
NCHS Standards (n=1168)
Mean ± SE
Mean ± SE
10 41 26.10 25.65 80.31
11 175 28.74 28.5 77.67
12 216 31.16 31.08 75.09
13 142 34.49 34.90 74.83
14 151 37.49 37.00 74.53
15 158 40.84 40.85 76.07
16 116 42.27 42.7 75.62
17 88 42.72 42.2 75.34
18 81 43.66 43.0 77.14
Total 1168 36.39 35.95 75.90
Table 19 B: Weight-for-age of the Tribal Adolescent Girls as Compared with
NCHS Standards (n= 42)
Mean ± SE
Mean ± SE
10 0 - - -
11 1 27.50+_ 27.5 74.32
12 6 33.34 34.17 80.34
13 9 37.23 37.1 80.75
14 6 39.34 39.05 78.21
15 8 40.25 39.9 74.95
16 7 39.13 39.8 69.99
17 4 41.06 40.97 72.42
18 1 43.90 43.9 77.56
Total 42 37.72 37.9 76.41
Table 19 C: Weight-for-age of the Urban Adolescent Girls as Compared with
NCHS Standards (n=358 )

Mean ± SE
Mean ± SE
10 21 27.37 26.15 84.23
11 58 28.13 17.75 76.02
12 71 31.76 31.50 76.53
13 43 36.01 35.20 78.12
14 26 36.49 36.45 72.55
15 40 37.93 37.70 70.63
16 38 34.64 41.63 75.96
17 28 41.43 41.23 73.06
18 33 40.87 40.10 72.20
Total 358 34.96 35.55 75.41
Figures 5 and 6 graphically present a comparison of the girls mean weight-for-age with the
corresponding NCHS figures. The curves are clearly below the NCHS means.
Figure 5 : Comparison of mean weight-for-age values
of the adolescent girls with NCHS standards
0
10
20
30
40
50
60
10 11 12 13 14 15 16 17 18
Age (years)
Weight(Kg)
Current subjects
NCHS standards

Figure 6 : Comparison of mean weight-for-age values
0
10
20
30
40
50
60
10 11 12 13 14 15 16 17 18
Age (years)
Weight(Kg)
NCHS std
Rural
Tribal
Urban
3.8.2 Mean Height-for-Age Values of the Adolescent Girls
The mean height-for-age values of the adolescent girls from all age groups and areas were above
90% of the NCHS standards (91-97% of the standards), indicating normal heights among these
girls. Tables 20, 21A, 21B and 21C and figures 7 and 8 present the data on the girls’ mean
height-for-age values.
Table 20: Height-for-age of the Adolescent Girls as Compared with NCHS Standards
(n=1568)
Age (years) n Height (cm)
Mean ± SE
Median
height
% NCHS std.
Mean ± SE
10 62 134.47 134.10 97.23
11 234 137.45 137.53 94.92
12 293 141.38 142.05 93.32
13 194 146.33 146.65 93.14
14 183 147.42 147.90 91.91
15 206 149.81 149.48 92.59
16 161 149.90 150.60 92.30
17 120 150.75 150.30 92.43
18 115 151.62 151.50 92.62
Total 1568 145.46 146.10 93.21
Table 21 A: Height for age of the Rural Adolescent Girls as Compared with
NCHS Standards (n= 1168)

Mean ± SE
Median
height
% NCHS std.
Mean ± SE
10 41 133.95 134.5 96.86
11 175 137.63 137.15 95.05
12 216 141.42 142.13 93.35
13 142 146.36 146.73 93.16
14 151 147.64 148.10 92.04
15 158 150.20 149.56 92.83
16 116 149.80 151.02 92.25
17 88 151.16 150.62 92.68
18 81 152.28 152.25 93.02
Total 1168 145.60 146.43 93.28
Table 21 B: Height for age of the Tribal Adolescent Girls as Compared with
Mean ± SE
Median
height
% NCHS std.
Mean ± SE
10 0 - - -
11 1 134.00 134.00 92.54
12 6 142.16 141.25 93.84
13 9 148.15 149.00 94.31
14 6 145.30 143.60 90.60
15 8 150.44 149.80 92.98
16 7 147.07 147.30 90.56
17 4 147.87 146.15 90.66
18 1 159.00 159.00 97.13
Total 42 146.75 147.00 92.51
Table 21 C: Height for age of the Urban Adolescent Girls as Compared with
Mean ± SE
Median
height
% NCHS std.
Mean ± SE
10 21 135.47 134.75 97.96
11 58 136.97 138.35 94.59

12 71 141.18 142.20 93.19
13 43 145.84 145.45 92.83
14 26 146.66 146.85 91.43
15 40 148.11 148.80 91.53
16 38 150.68 151.05 92.78
17 28 149.86 150.05 91.88
18 33 149.77 149.00 91.49
Total 358 144.95 145.13 93.04
Figure 7 : Comparison of mean height-for-age values
0
30
60
90
120
150
180
10 11 12 13 14 15 16 17 18
Age (years)
Height(cm)
Current subjects
NCHS standards

Figure 8 : Comaparison of mean height-for-age values
0
50
100
150
200
10 11 12 13 14 15 16 17 18
Age (years)
Height(cm)
NCHS std
Rural
Tribal
Urban
3.8.3 Body Mass Index Values of the Adolescent Girls
The Body Mass Index values were computed for each girl using the weight and height values.
These were then classified into three categories : below normal, normal and above normal after
comparing them with the Must et al norms (Table 22). Further analysis was carried out to find
out the distribution of BMI values (using different cutoffs), of the rural, tribal and urban girls by
different socioeconomic characteristics such as their religion, family type, family size, marital
status, education of the girl and her parents, family income, construction of their houses, and
availability of toilet facilities. These tables are presented in Appendix 6.
Table 22 : Undernutrition in the Adolescent Girls as Reflected by Body Mass Index
BMI Values* n %
Below normal (< 5th
Percentile) 524 33.42
Normal (Between 5th
to 85th
Percentile) 1027 65.50
Above Normal (> 85th
Percentile) 17 1.08
Total 1568 100
* Must et al norms
3.8.4 Summary of the Prevalence of Undernutrition Among the Girls
Tables 23, 24A, 24B and 24C summarize the occurrence of undernutrition among the rural, tribal
and urban adolescent girls as depicted through height-for-age, weight-for-age and BMI values
which have been compared with standard values. Of the total, 32% girls had below normal

height-for-age, 59% girls had below normal weight-for-age, and 32% girls had below normal
BMI values. The undernutrition prevalence was similar among the rural girls. As high as 78% of
the tribal girls had below normal weights. The nutritional status of the urban girls was slightly
better off as compared to their rural and tribal counterparts.
Table 23: Undernutrition in the Adolescent Girls as Reflected by their Weight-for- age,
Height-for-age and Body Mass Index (BMI) values (N=1568)
Age (Years) n
Height-for-age
< 90 % of NCHS
Std.
n %
Weight-for-age <
80 % of
NCHS Std.
n %
BMI
< 5 th percentile of
Must et al norms**
n %
10 62 0 0.00 5 8.06 6 9.68
11 234 3 1.28 47 20.09 37 15.81
12 293 53 18.09 116 39.59 69 23.55
13 194 51 26.29 100 51.55 55 28.35
14 183 79 43.17 126 68.85 51 27.87
15 206 93 45.15 167 81.07 81 39.32
16 161 83 51.55 147 91.30 75 46.58
17 120 69 57.50 109 90.83 68 56.67
18 115 73 63.48 107 93.04 67 58.26
Total 1568 504 32.14 924 58.92 509 32.46
* Compared with the 50th percentile values of the NCHS (1983) standards
** Compared with the 5th percentile values of the Must et al (1991) norms
Table 24A: Undernutrition in the Adolescent Girls as Reflected by their Weight- for-
age, Height for-age and Body Mass Index (BMI) values (Rural: n=1168)
Age (Years) n
Height-for-age
< 90 % of NCHS
Std.
n %
Weight-for-age <
80 % of
NCHS Std.
n %
BMI
Must et al norms**
n %
10 41 0 0.00 4 9.76 4 9.76
11 175 2 1.14 33 18.86 28 16.00
12 216 44 20.37 91 42.13 53 24.54
13 142 37 26.06 78 54.93 49 34.51

14 151 69 45.70 104 68.87 44 29.14
15 158 75 47.47 128 81.01 60 37.97
16 116 62 53.45 106 91.38 56 48.28
17 88 54 61.36 78 88.64 48 54.55
18 81 51 62.96 76 93.83 48 59.26
Total 1168 394 33.73 698 59.76 390 33.39
Table 24B: Undernutrition in the Adolescent Girls as Reflected by their Weight-for- age,
Height for-age and Body Mass Index (BMI) values (Tribal : n =42)
Age (Years) n
Height-for-age
< 90 % of NCHS
Std.
n %
Weight-for-age <
80 % of
NCHS Std.
n %
BMI
Must et al norms**
n %
10 0 0 0.00 0 0 0 0.00
11 1 0 0.00 0 0.00 0 0.00
12 6 0 0.00 3 50.00 2 33.33
13 9 2 22.22 4 44.44 0 0.00
14 6 2 33.33 6 100.00 0 0.00
15 8 3 37.50 8 100.00 6 75.00
16 7 4 57.14 7 100.00 4 57.14
17 4 3 75.00 4 100.00 3 75.00
18 1 1 100.00 1 100.00 1 100.00
Total 42 15 35.71 33 78.57 16 38.09
Table 24 C: Undernutrition in the Urban Adolescent Girls as Reflected by their Weight-
for-age, Height-for-age and Body Mass Index (BMI) values (Urban: n=358)
Age (Years) n
Height-for-age
< 90 % of NCHS
Std.
n %
Weight-for-age <
80 % of
NCHS Std.
n %
BMI
Must et al norms**
n %
10 21 0 0.00 1 4.76 0 0.00
11 58 1 1.72 14 24.14 9 15.52
12 71 9 12.68 22 30.99 14 19.72
13 43 12 27.91 18 41.86 6 13.95
14 26 8 30.77 16 61.54 7 26.92
15 40 15 37.50 31 77.50 15 37.50
16 38 17 44.74 34 89.47 15 39.47

17 28 12 42.86 27 96.43 17 60.71
18 33 21 63.64 30 90.91 18 54.55
Total 358 95 26.53 193 53.91 103 28.77
3.9 WILLINGNESS OF THE GIRLS TO CONSUME IRON TABLETS
When asked to the girls whether they were willing to take iron tablets, if given to them once a
week, over 90% of the rural and urban respondents gave a positive response stating that they
would like to do so. However, only 64% of the tribal girls showed a willingness, and as many as
28% were undecided (Table 25).
The major reasons given by the girls for not willing to take the iron supplement included dislike
of taking medicines (53%), fear of getting side effects such as stomachache and vomiting (23%),
and fear of taking any kind of medicine (18%).
Table 25 : Willingness of the Girls to Take Iron Tablets
Major Responses
Rural
(n=1168)
Tribal
(n=42)
Urban
(n=358)
n % n % n %
Is willing to consume iron tablets
once a week
 Yes
 No
 No response
1083
34
51
92.72
2.91
4.37
27
3
12
64.29
7.47
28.57
328
17
13
91.62
4.75
3.63
Reasons given for unwillingness
to take iron tablets
 Does not like to take medicines
 Fears of side effects like
stomachache and vomiting
 Is scared to take any type of
medicine
 Doesn’t trust the interviewer
enough to take medicines
given to her
 Fears an allergic to medicines
18
8
6
1
1
52.94
23.53
17.65
2.94
2.94
1
-
2
-
-
33.33
-
66.67
-
-
7
10
-
-
-
41.18
58.82
-
-
-

IV. CONCLUSION AND RECOMMENDATIONS
The present survey revealed an extremely high prevalence of anemia (87.75%) among the out-of-
school adolescent girls of Shivpuri district. The highest prevalence was found among the urban
girls (92.87%), followed by the rural girls (87.41%). Girls from the tribal area had a lower
prevalence of about 55% as compared to their urban and rural counterparts. The mean
hemoglobin levels of these girls ranged from 9.7 to 10.3 g/dl. Such alarming prevalence figures
are unquestionably a major cause for concern and concerted efforts are necessary to address this
grave situation.
Improving iron status through iron supplements has been a popular intervention with a focus on
preventing anemia during adolescence and before childbearing. The UNICEF supported Kishori
Shakti project for reduction of nutritional anemia among adolescent girls through once weekly
supplementation has already been launched in Madhya Pradesh. It is going to cater to school
going as well as out-of-school 10-19 year olds.
Along with anemia, the overall nutritional status of the adolescent girls surveyed as measured
through anthropometric measurements was found to be quite unsatisfactory, with 32% girls
having below normal height-for-age, 59% girls having below normal weight-for-age, and 32%
girls having below normal BMI values. These circumstances also need appropriate attention.
Therefore the Key Recommendations which emerge are:
• Devising methods for reaching the out-of-school girls so that they have an access to weekly
iron supplements is vital for having a better coverage of the anemia control strategy. This
could be achieved through the ICDS Anganwadi Workers who operate at the community
level and have a good rapport with the community.
• Although supplementation is an essential intervention for controlling iron deficiency, it must
be combined with other interventions to effectively control anemia. Building linkages with

other health and nutrition programs will broaden the efforts to combat anemia and may
increase the base of support of iron supplementation program. Where other nutrition
interventions are being implemented, aspects of anemia control strategy may be effectively
integrated.
• Besides iron supplements, adolescent anemia should be combated through other interventions
such as food based approaches including dietary modification aiming at improving the
amount of food-iron ingested in the diet, leading to increased consumption of iron and
vitamin C rich foods. As the overall dietary intake increases, the amount of dietary iron
ingested also increases. An improvement in the quality and quantity of diet would also have
beneficial effects from the point of view of enhancing the adolescent nutritional status.
• Fortification of suitable food vehicles with absorbable forms of iron is another highly
desirable approach to prevent iron deficiency. The existence of a fortifiable food at the
community level, which is consumed by many people at risk of iron deficiency, would be an
extremely cost-effective component of controlling iron deficiency.
• Lastly, an effective strategy is needed to communicate the plan and purpose of the anemia
control program at multiple levels. Often health workers who distribute the iron supplements
are needed to be educated regarding iron deficiency as much as the community members.
Communications strategies need to be reviewed and adjusted as the targeted population’s
knowledge and experiences with consuming iron supplements develop and progress.

V. REFERENCES
1. WHO (1998). Life in the 21st
century: A vision for all. Report of the Director General of the
World Health Organization, Geneva, Switzerland.
2. International Nutrition Foundation and Micronutrient Initiative (1999). Preventing iron
deficiency in women and children. Report of the UNICEF/UNU/WHO/MI Technical
Workshop, UNICEF, New York, USA.
3. Viteri FE (1998). Prevention of iron deficiency. In: Prevention of micronutrient deficiencies:
tools for policymakers and public health workers. Institute of Medicine, National Academy
Press, Washington, DC, USA.
4. Allen L and Gillespie G (2001). What works? A review of the efficacy and effectiveness of
nutrition interventions. ACC/SCN Nutrition Policy Discussion Paper No. 19 and ADB
Nutrition Development Series No. 5, Asian Development Bank, Manila, Philippines.
5. WHO, UNICEF, UNU (1998). Iron deficiency anemia : prevention, assessment and control.
Report of a WHO/UNICEF/UNU consultation, World health Organization, Geneva,
Switzerland.
6. WHO (2000). Malnutrition, the global picture. World Health Organization, Geneva,
Switzerland.
7. ACC/SCN (2000). Fourth report on the world nutrition situation. ACC/SCN in collaboration
with the International Food Policy Research Institute.
8. Gillespie S (1998). Major issues in the control of iron deficiency. The Micronutrient
Initiative, Ottawa, Canada and UNICEF, New York, USA.
9. United Nations (1990). 1988 Demographic Yearbook. United Nations, New York, USA.
10. Jejeebhoy S (1996). Adolescent sexual and reproductive behavior: A review of the evidence
from India. Working Paper No. 3, International Center for Research on Women, Washington,
DC, USA.
11. Beard JL (2000). Iron requirements in adolescent females. J. Nutr. 130: 440S-442S.
12. Lynch SR (2000). The potential impact of iron supplementation during adolescence on iron
status in pregnancy. J. Nutr. 130: 448S-451S.

13. Gillespie S (1997). Improving adolescent and maternal nutrition: An overview of benefits
and options. UNICEF Staff Working Papers, Nutrition Series, Number 97-002, UNICEF,
New York, USA.
14. Stolzfus RJ and Dreyfuss ML (1998). Guidelines for the use of iron supplements to prevent
and treat iron deficiency anemia. INACG, WHO and UNICEF. ILSI Press, Washington, DC,
USA.
15. Kurz K and Galloway R (2000). Improving adolescent iron status before childbearing. J.
Nutr. 130: 437S-439S.
16. Scoll TO and Reilly T (2000). Anemia, iron and pregnancy outcome. J. Nutr. 130 (2S
Suppl):443S-447S.
17. Bruner AB, Joffe E, Duggan AK, Casella JF and Brandt J (1996). Randomised study of
cognitive effects of iron supplementation in non-anemic iron-deficient adolescent girls.
Lancet 348: 992-996.
18. Kanani S and Poojara R (2000). Supplementation with iron and folic acid enhances growth in
adolescent Indian girls. J. Nutr. 130: 452S-455S.
19. IIPS (2000) National Family Health Survey 2 :India, 1998-99, International Institute of
Population Sciences, Mumbai.
20. Kanani S and Ghanekar J (1997). Anemia and the adolescent girl: A review of some research
evidence and intervention strategies. Prepared for UNICEF, New Delhi, India.
21. Seshadri S et al (1998). Oral iron supplementation to control anemia in adolescent girls-
community trials of effectiveness of daily versus weekly iron supplementation. Department
of Foods and Nutrition, M. S. University of Baroda, Baroda. Supported by UNICEF,
Gandhinagar, India.
22. Kotecha PV, Patel RZ and Nirupam S (2000). Prevalence of anemia among adolescent
school girls, Vadodara district. Department of Preventive and Social Medicine, Medical
College, Baroda and UNICEF, Gujarat.
23. IIPS (2000) National Family Health Survey 2: Madhya Pradesh, 1998-99, International
Institute of Population Sciences, Mumbai.
24. Beard JL (1998). Weekly iron supplementation: the case for intermittent iron
supplementation. Am. J. Clin. Nutr. 68:209-212.
25. Viteri FE (1998). A new concept in the control of iron deficiency: community based
preventive supplementation of at-risk groups by weekly intake of iron-supplements.
Biomedical and Environmental Science 11:46-60.

26. Viteri FE, Ali F and Tujague J (1999). Long-term weekly iron supplementation improves and
sustains non-pregnant women’s iron status as well or better than currently recommended
short-term daily supplementation. J. Nutr. 129:2013-2020.
27. Government of Madhya Pradesh (1999). Madhya Pradesh State Nutrition Policy. Department
of Women and Child Development, Government of Madhya Pradesh.
28. WHO/UNICEF/UNU (1996). Indicators for assessing iron deficiency and strategies for its
prevention. World Health Organization, Geneva, Switzerland.
29. National Center for Health Statistics (1983). In: Measuring changes in nutritional status,
WHO, Geneva, Switzerland.
30. Must A, Dallal GE, and Dietz WH (1991). Reference data for obesity: 85th
and 95th
percentiles of body mass index (wt/ht2
) and triceps skinfold thickness. Am. J. Clin. Nutr.
53:839-846.

VI. APPENDICES
APPENDIX 1
List of Villages and Towns Surveyed
Sample size of Nutritional Anaemia Project in Shivpuri Distt.
S. No. Name of the Block Name of the
Sample Village
Rural
Sample
Urban
Sample
Block wise Total
Sample
1. Narwar 36
Magroni 18
Therkheda 17
Sonhar 16
Karhi 19
Sehore 22
Hatera 18
110 146
2. Pohri NA
Kheda 28
Mararahir 20
Pohri 20
Nadora 24
Jhiri 41
Bhatnawar 26
Bhadera 16
Aichwada 29
Wairad 23
227 227
3. Kolaras 26
Rajgarh 20
Daherwada 19
Sesaisadak 33
Luckwasa 22
Dangora 22
Panchwali 26
142 168
4. Badarwas 45
Khatora 20
Alawadi 15
Indar 20
Rannod 19
Madwasa 25
Pironth 16
115 160
5. Karera 56
Silanagar 17
Salayakarera 22
Sirsod 08
Dinara 20
Kharai 20
Banhari 20
Machawali 20
Narhi 20
147 203
6. Picchore 59
Bhaunti 19

S. No. Name of the Block Name of the
Sample Village
Rural
Sample
Urban
Sample
Block wise Total
Sample
Vaumarodamron 25
Mahovadam 20
Mahalawani 21
Umrikala 19
Manpura 20
Khod 20
144 203
7. Khanyadana 60
Vankheda 17
Pahadpur 17
Gudar 17
Chamroha 15
Achroni 17
Mohari 18
Gajora 18
Lehra 18
Pipra 21
158 218
8. Shivpuri 78
Indergarh 29
Khajuri 32
Dhaulagarh 33
Mithloni 28
Sihniwas 26
Then 22
170 248

APPENDIX 2A
Questionnaire Used for Interviews

APPENDIX 2B
Results of Focus Group Discussion at different blocks of Shivpuri District in Tabular Form
Nutritional anaemia is a disease syndrome caused by malnutrition in its widest sense. It is a
condition in which the hemoglobin content of the blood is lower than the normal as a result of
deficiency of one or more essential nutrition. Generally it has been found that majority of female
population are suffering from anaemia in the developing countries though there has been
continuous efforts by national and international agencies to reduce its incidence. More
specifically, any attempt towards the improvement of anemic status of adolescent girls pre-
requisites answers to the question such as: what are the expectations and demands of the
community from these services . What exactly are the services that the people want and how the
provision of services is to be designed to fulfill the need of the public. Needless to add that the
communities perception towards health services delivery in general and services related to
reduce the incidence of anaemia in particular is to be designed by taking into consideration of
their socio-economic status and geographical locations. Though qualitative information related
to these variables were collected through the structured questionnaire, it is widely accepted that
focus grouped discussion with the community gives more meaningful results on this aspect.
Keeping this point in mind, the present study, attempted to conduct FGDs in various blocks of
Shivpuri District. The discussions were carried out in eight places, which includes both rural and
urban areas of five blocks of Shivpuri District. Though it was proposed to conduct eight FGDs,
one in each block of the district, we could cover only in five blocks where eight FGDs were
carried out. Due to time and other related constraints we could not conduct the FGDs at three
blocks. However, our verbal communication with the community during the fieldwork is also
combined with the FGDs to assess the need of the community.
The discussions were conducted in order to take the opinion of the community on the following
aspect related to nutritional anaemia problems in the district.
1. Community’s understanding regarding anaemia.
2. Perception of the community on the services provided by the ANM or Anganwadi kendra.
How does the community looked at the ANM in providing the services for the anaemia and
other health problems.
3. Involvement of community and specially women groups in improving the status regarding
anaemia among adolescent girls.
4. The general expectation of the community on the provision of services required for
reduction of anaemia in the District.
Methodology used for Analysis :
The topics as mentioned above were the key points for conducting FGDs. The response of the
FGD participants were recorded in the note book and analyzed below. The method of content
analysis was used for analyzing the results. Organizing and simplifying the complexity of
(qualitative) data into some meaningful and manageable themes or categories is the basic
purpose of content analysis. The most common uses of content analysis are to know the
frequency and intensity with which certain items, symbols or themes appear in a document .The
framework for content analysis is based on the construction of categories into which the data can
be grouped . These categories should reflect the theoretical concepts on which the study is based
and bear close relation to the research problem.
We have used the concepts of key words in context (KWIC) in developing the categories. This
concepts takes into account the meaning of the key words in content in which it is occurring. The
discussion notes were written up in a pre coded manner following the same aspect, which were

provided in the discussion guide. Since the total number of groups were less , there were not
much difficulty in summarizing the information manually, though it was a laborious process.
Results:
The main strands of the of the groups view and perceptions are presented here .The details of
these are presented in the tabular form .The frequency of occurrence of various responses was
calculated and their percentages were calculated in eight(which was the total number of focus
group discussions conducted). However these percentages are only meant to be a measuring rod
for the extent and depth of a certain perception or attitude among the groups and as there are
multiple responses which are not mutually exclusive the total number of responses will not add
up to 8 nor will the total up to 100 percent. Care has been taken to present the various shades of
perception and attitudes in the peoples own words with minimum editing for the shake of
clarity.
Table 1 : Perception on anaemia in local term .
Kind of responses by Groups Number of Groups Percentage
Loss of appetite and pain in
abdomen
1 12.5
Khoon ki kammi 8 100
Know by the name Anaemia 1 12.5
Weakness 4 50
Matha Misi 1 12.5
Note :Due to multiple responses , the total responses will not add to 8 which are the total no of FGDs .
Percentage is calculated in 8 as a measure of the extent and depth of Particular Perception or attitude.
As could be seen from Table 1, the majority of the people in the district understand the meaning of
anaemia as KHOON KI KAMMI. Some of the respondents in the group knew it by the term weakness
and some understand it as loss of appetite and pain in abdomen. Only one group knows it by the local
term “ Matha Misi”.
Table 2 : Perception regarding signs and symptom’s of anaemia
Signs and symptoms of anaemia
given by different groups
Number of responses Percentage
Weak and thinner with frequent
vomiting
6 75
Nail becomes yellow 7 85
Hungriness 4 50
Body becomes yellowish and thin 6 75
Note :Due to multiple responses , the total responses will not add to 8 which are the total no of
FGDs . Percentage is calculated in 8 as a measure of the extent and depth of Particular
Perception or attitude.
As could be seen from Table 2, six out of eight groups identify anaemia by body weakness and
thin in stature with frequent vomiting, seven out of eight groups identify anaemia by paleness of
the body.

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