The Prevalence and Risk Factors of Anemia among Primary School

Children in North Sumatera, Indonesia

Sri Lestari

*, Isti Ilmiati Fujiati

, Putri Chairany Eyanoer

, Dina Keumala Sari

, Milahayati Daulay

and Nur Hidayah Nasution

Departement of Public Health, Faculty of Medicine, Universitas Sumatera Utara, Jl. dr. Mansur No. 5 Kampus USU,

Medan 20155, Indonesia

Departement of Nutrition, Faculty of Medicine, Universitas Sumatera Utara, Jl. dr. Mansur No. 5 Kampus USU, Medan

20155, Indonesia

Departement of Physiology, Faculty of Medicine, Universitas Sumatera Utara, Jl. Dr. Mansur No 5 Kampus USU, Medan

20155, Indonesia

Master Student in Departement of Administration and health policy, Faculty of Public Health, Universitas Sumatera

Utara, Jl. Universitas No. 21 Kampus USU, Medan 20155, Indonesia

Keywords: Anemia status, risk factors, primary school children.

Abstract: Primary school children are the groups at risk for nutritional problems. The most commonly nutrition

problems suffered among primary school children in Indonesia is anemia and stunting. This research aimed

to determine the prevalence of anemia and the risk factors associated with anemia among primary school

children, North Sumatera Province. This research is a analytic study with cross-sectional approach. Total

sample 400 primary school children between 8-13 years old were include in the study from the Medan City

and Langkat district, In July - September 2017. Data collected by using questionnaire, anthropometric

assessment and hemoglobinometer tool. Chi-square analysis and logistic regression were used to asses the

association between risk factors and anemia. The prevalence of anemia among primary school children

were 45,57%. The factors associated with anemia primary school children were mother’s education

(OR=3,06), income(OR= 2,93), breakfast (OR=2,10) dietary intake of heme sources(OR=3,38). The

dominant factors that influence anemia in primary school children was dietary intake of heme sources. The

conclusion of this study is prevalence of anemia in primary school children in North Sumatera higher than

the national prevalence. interventions nutritional in school children are recommended.

1 INTRODUCTION

Primary school-age children are the nation's youth

that will be the next generation in the future. School

age is the transition from child to adult where

mental, physical, and emotional growth is fast

enough which requires sufficient and appropriate

nutritional needs. The future quality of human

resources in the future is reflected in the nutritional

status of children today, amongst others in primary

school children. Primary school children are one of

the most vulnerable groups. The nutritional and

health problems often experienced by elementary

school children are anemia and stunting.

Anemia is one of the global public health

problems in both developed and developing

countries. World Helath Organization data in 2008

in Worldwide Prevalence of anaemia shows that the

total world population with anemia is 1.62 billion

people with a school-child prevalence of 25.4% and

an estimated 305 million school children worldwide

suffering from anemia. The prevalence of anemia

among children in Asia reached 58.4% (Arisman,

2010). The Basic Health Research Report of 2013

shows that iron nutritional anemia in children aged

5-12 years is 26%. (Ministry of Health Republic of

Indonesia, 2013)

The impact of anemia on primary school children

is that it can cause physical growth disorders, low

resistance to disease, less intelligence, and low

learning / work achievement (Bobonis, 2004). In

addition, anemia in primary school children will

have an impact on the decreased ability and

concentration of learning, disrupting the growth of

both body cells and brain cells resulting in symtoms

Lestari, S., Fujiati, I., Eyanoer, P., Sari, D., Daulay, M. and Nasution, N.

The Prevalence and Risk Factors of Anemia among Primary School Children in North Sumatera, Indonesia.

DOI: 10.5220/0010083006570662

In Proceedings of the International Conference of Science, Technology, Engineering, Environmental and Ramiﬁcation Researches (ICOSTEERR 2018) - Research in Industry 4.0, pages

657-662

ISBN: 978-989-758-449-7

657

like pale, tired, lethargic so that it can decrease

fitness and learning achievement (Nirmala, 2012)

There are various risk factors for anemia in

primary school children. Research conducted by

(Gutema, 2014) shows that risk factors for anemia in

primary school children in Ethiopia are family

socioeconomic statuses where low incomes increase

the risk of anemia to 9-fold, very poor and poor

childhood nutritional status and presence parasitic

infections (especially worms) in school-aged

children. While similar studies (Ngesa and Mwambi,

2014) in Kenya found the risk factors for anemia

varied, from the age of the child, the sex of the child

(men more than women), low maternal education,

parasitic infections (especially malaria), and

socioeconomic status. some of the causes of anemia,

the most common cause of anemia in developing

countries, is the lack of iron intake, which is the

growing period of iron school children's need

increases but iron intake is low (World Health

Organization, 2001)

Base on these previous research anemia on SD

Juara Medan. We check anemia for primary school

children and found an anemia prevalence of 60%.

The aim of the study to find the prevalence of

anemia and risk factors associated with anemia in

primary school children in North Sumatera.

2 MATERIAL AND METHOD

This type of research is an analytic survey with

cross-sectional study design. Total samples of 400

elementary school children aged 8-13 years coming

from 4 primary schools: SDN 064026, SDN 067246

from Medan City, and SDIT Al Anshar, SDIT

Azdkia from Langkat Regency of North Sumatra

Province. Data is taken in July-October 2017.

Types of data collected in this study were

primary data, using questionnaires and

anthropometry measurements and hemoglobin

examinations. Interviews with structured

questionnaires to find socio-demographic data, diet

and risk factors for anemia. While anthropometric

measurements include height, weight and weight

gain z score and Body Mass Index (BMI). The level

of hemoglobin (Hb) was measured using the

HemoCue blood photometer (Kisworini and Triasih ,

2005 and Akhtar, 2005). The classification of

anemia was divided into four for the two age

categories. For children 5 to 11 years; 11.5 g / dl

normal, 11.0-11.4 g / dl mild anemia, 8.0-10.9 g / dl

moderate anemia, and <8.0 g / dl severe anemia. For

children 12 to 14 years; 12 g / dl normal, 11.0-11.9 g

/ dl mild anemia, 8.0-10.9 moderate anemia, and

<8.0 g / dl severe anemia. (World Health

Organization, 2001)

Data analysis includes univariate, bivariate and

multivariate. Univariate analysis is used to describe

the incidence of anemia in primary school children,

gender and age range of school children. The

bivariate analysis used was a chi-square test to see

the association of anemia with diet and socio-

demography. Multiple logistic regression analysis

was used to determine the dominant factors that

influenced the incidence of anemia in primary

school children. Data were analyzed using SPSS

Software

3 RESULT

Total respondents in this study are 400 primary

school children from Medan City and Langkat

Regency of North Sumatra Province. Most

respondents is aged 10-11 years of 67.3%. Female

was 49.0% of respondents, while 51.0% were male.

Viewed from the father's education category, it is

seen that most of the education level of SMA-DIII /

PT level education is 81.3%, while maternal

education is dominated by most SMA-PT level

which is 60.5%. In terms of number of family

members, 52.8% had less than 4 family members,

while 47.3% had more than 4 family members (table

1).

Table 1: Distribution of socio-demographic characteristics

of primary school children (n = 400)

Characteristics

Catego

ry n %

Gender Male

204 51,0

Female

196 49,0

Age (year) 8-9

119 29,8

10-11

269 67,3

12-13

12 3,0

Education of

Father

Low

75 18,8

High

325 81,3

Education of

Mother

Low

158 39,5

High

242 60,5

Family

members

<=4

211 52,8

189 47,3

Total 400 100,0

ICOSTEERR 2018 - International Conference of Science, Technology, Engineering, Environmental and Ramiﬁcation Researches

658

The results of the study in Figure 1 show that from

400 primary school children found 25.5% primary

school children suffer from mild anemia, 19.3%

moderate anemia and 0.8% severe anemia.

Figure: 1 Prevalence of anemia in primary school children

As many as 54.5% of primary school children do not

suffer from anemia. The prevalence of anemia is

more experienced by girls that is 50,5%, anemia

most often experienced by children with age range

10-11 year that is 62,6% and anemia more suffered

by primary school children in rural that is 55,5%

(table 2).

Table 2 : Cross-distribution between sex, age and location

with anemia (n=400)

Variable

Anemia

Yes(%) No(%)

Gender

Male 49,5 52,3

Female 50,5 47,7

Age (year)

9-Aug 33,0 27,1

11-Oct 62,6 71,1

13-Dec 4,4 1,8

Research area

Urban 44,5 54,6

Rural 55,5 45,4

Total 100 100

The result of statistical analysis with chi-square test

showed anemia in primary school children had a

close relationship with morning habits P <0,001) and

result of phi test showed that breakfast variable

contributed 40,2% to the incidence of anemia. Dad's

education and father's work are not related to the

incidence of anemia (P> 0.05). While family income

and mother education have close relation with

anemia incidence (p <0,001), with contribution of

each variable is 40,4% and 50,4%. The consumption

pattern of food source of heme and non heme

significantly influence the occurrence of anemia (p

<0,001) with contribution of each variable 49,1%

and 23,3%. Similarly, the consumption of iron-

inhibiting foods significantly affected the incidence

of anemia (P <0.001) with the test value of phi =

15.5%, which means the contribution value was

weak (table 3).

Table : 3 Bivariate analysis of factors related of anemia in

primary school children

Variable Category Anemia

Norma

P Phi

% % value

valu

Breakfast Sometimes 71,9 28,1 0,001

0,40

Every day 30,3 69,7

Father’s

Educatio

Low 48,0 52,0 0,63

0,02

High 44,9 55,1

Income Low 68,2 31,8 0,0001

0,40

High 27,7 72,3

Mother’s

educatio

Low 76,6 23,4 0,001

0,50

High 25,2 74,8

Dietary

sources

of heme

Sometimes 72,4 27,6 0,0001

0,49

Every day 23,3 76,7

Dietary

sources

nonheme

Sometimes 28,2 71,8 0,0001

0,23

Every day 53,3 46,7

Green

vegetable

Sometimes 55,4 44,6 0,0001

0,17

Every day 37,8 62,2

Drink tea

Sometimes 36,6 63,4

0,15

Every day

The result of multivariate analysis by using multiple

logistic regression test showed that there were 5

variables that significantly influence (p <0,005) to

school anemia incidence of anemia, breakfast habit,

parent income, heme food consumption, and

inhibiting food consumption Fe. Among the 5

variables in table 4, it was found that consumption

of heme source variable was the dominant factor that

had an effect on the incidence of anemia in

elementary school children (OR = 3,388).

The Prevalence and Risk Factors of Anemia among Primary School Children in North Sumatera, Indonesia

659

Table 4: Multivariate analysis of multiple logistic

regression variables that affect of anemia in primary

school children

Variable

Independent

B P

(Adju

sted)

CI 95%

Mother’s

education

(x1)

1,12

0,00

3,065 1,495 6,283

Breakfast

(x2)

0,74

0,04

2,107 1,021 4,351

Income

(x3)

1,07

0,00

2,931 1,442 5,958

Dietary

sources of

heme (x4)

1,22

0,00

3,388 1,686 6,809

Consume

iron

barrier

(x5)

0,72

0,05

0,483 0,231 1,007

4 DISCUSSION

The results of this study found anemia prevalence is

45.5%. Primary school children who suffer from

anemia in rural areas are more than those living in

urban areas. The prevalence of anemia is higher

when compared with the national rate of Riskesdas

2013 which is 26%. This suggests that anemia is a

public health problem in North Sumatera, where

nearly half of school children are anemic.

(Sudhagandhi, 2011) study at 900 school children

aged 8-16 at Kattangulathur, Tamil Nadu, India

shows a higher prevalence of anemia that is 52.88%.

Another study conducted by (Iannotti, 2015) which

found anemia prevalence in primary school children

in Haiti was 70.6% . Studi (Gad, 2013) in 1117

primary school children aged 5-12 years in Riyad

Saudi found an anemia prevalence of 22 , 3% (22.4

in boys and 22.2% girls). This reinforces the fact

that anemia in primary school children is still a

public health problem in many developing and

developing countries.

The results of this study showed breakfast habits

have a significant relationship with the incidence of

anemia in primary school children. The results of

this study are in line with a study conducted by

(Sirajuddin and Masni, 2015) in primary school

children in Makassar who found a relationship

between breakfast habits with anemia status. Rare

elementary school children (2-3 times / week) have

anemia 2.95 times more than children who frequent

breakfast. (Murphy, 2007) studies revealed that

children who skip breakfast tend to have symptoms

of anemia such as pale, lethargic and lackluster. The

discovery of (Tandirerung, 2013) also found a

significant association between morning breakfast

habits with anemia status in primary school children

in Manado. The results of the (Latifah and Oboudi ,

2010) study in 120 elementary school students in

Saudi Arabia showed that breakfast had an effect on

hemoglobin levels, found that schoolboys who had

breakfast routine did not suffer from anemia while

school boys who rarely ate breakfast had lower

hemoglobin and anemia. Skipping breakfast results

in a decrease in learning concentration characterized

by a sense of laziness, weakness, lethargy, dizziness,

and drowsiness to a decline in child learning

achievement as well as an impact on low blood

pressure and anemia (Sartika, 2012)

The results of this study indicate that the

educational level of the father is not significantly

associated with anemia in primary school children.

There is an anemic tendency more experienced by

school children with low-educated fathers (SD-

SLTP). This finding is in line with (Hioui, 2008)

study which revealed no significant association

between father education and the incidence of

anemia in schoolchildren in Marocco. Another study

showed different results performed by (Alelign,

2015) in Ethiopia found no significant association

between father work and anemia in primary school

children.

Father’s work has no significant relationship

with the incidence of anemia in school children. The

results of this study are in line with a study

conducted by (Al Zabedi, 2014) who found no

association between father's work with anemia.

However, another study conducted by (Gutema,

2014) showed a significant association between

father work and the incidence of anemia in primary

school children. While the income of parents have a

significant relationship with the incidence of anemia

in primary school children. The results of this study

are supported by the findings of (Gutema, 2014) and

(Al Zabedi, 2014) which revealed a significant

association between parental income and the

incidence of anemia in primary school children.

Children of low-income parents were more likely to

suffer from anemia than children of high-income

parents. Family income is an important variable in

determining the amount and type of food consumed

by the family. Families with high incomes are more

free to choose and prepare nutritious food for their

children so that no shortage of iron intake.

The results of this study indicate a relationship

between maternal education with the incidence of

anemia in primary school children. This study is in

ICOSTEERR 2018 - International Conference of Science, Technology, Engineering, Environmental and Ramiﬁcation Researches

660

line with a study conducted by (Ngesa and Mwambi,

2014) which reveals that the mother's educational

platform provides protection against the incidence of

anemia in children. Mothers with secondary and

higher education tend to have children with normal

hemoglobin levels. Other studies supporting the

results of this study were conducted by (Kahigwa,

2002) and (Leite, 2013) found that maternal

education had a significant effect on the incidence of

anemia in children. Mothers with low education are

likely to have anemic children 4.9 times compared

with higher educated mothers. The higher the

mother's education the easier it is to absorb various

information including nutrition information so as to

influence the selection and preparation of food

variation for the child.

The results study of (Briawan, 2012). showed

that the consumption of food sources of heme and

non-heme is closely related to the incidence of

anemia in primary school children. Iron absorption

is influenced by two factors, namely the absorption

of heme iron and nonheme which indicate the

existence of two different types of iron in the food.

The sources of heme in human food are meat, fish,

and poultry, whereas nonheme sources are cereals,

nuts, vegetables and fruits. (Sirajuddin and Masni,

2015) study in Makassar also found an influence of

food consumption of heme sources with the

incidence of anemia. Another study conducted by

(Mesfin, 2015) also shows elementary school

children who rarely consume food sources of heme

have anemia risk of 5 times compared with children

who frequently consume food sources of heme.

(Zuffo, 2016) study in Brazil found a strong

influence between the consumption of dietary

sources of heme (meat) and anemia in

schoolchildren (p <0.005). The results of this study

indicate that the most frequent food sources of heme

(5-7 times / week) are fish and chicken. While the

food sources of nonheme are often consumed is tofu

and tempeh.

The results of this study also found an

association between dietary intake of iron absorption

inhibitors and the occurrence of anemia, but showed

a weak contribution (value of ph = 15%) (Briawan,

2012). The type of food constraint that is often

consumed by school children is a good drink made

at home and in the cup sold at school with a

relatively affordable price of children. Studies

supporting the results of this study were conducted

by (Ferreira, 2016) in primary school children in

Brazil, finding an prevalence of anemia is more

prevalent in school children who consume iron-

inhibiting foods, ie drinking more than 1 serving per

day.

5 CONCLUSION

The results of this study indicate that the

prevalence of anemia in primary school children in

North Sumatera is still high (45.5%). Risk factors

for anemia incidence in schoolchildren (p <0.05)

were maternal education (OR = 3.06), parent income

(OR = 2,93), breakfast habits (OR = 2,10),

consumption of heme sources OR = 3.38). The

dominant factor affecting the incidence of anemia in

primary school children is the consumption of food

sources of heme (OR = 3.38). So it is necessary to

immediately do nutritional intervention in primary

school children to reduce the incidence of anemia

and improve the quality of life of children in the

future.

ACKNOWLEDGEMENTS

The authors gratefully acknowledge that the present

research is supported by Ministry of Research and

Technology and Higher Education Republic of

Indonesia. The support is under the research grant

BP-PTN USU of Year 2016 Contract Number

1140A/UN5.IR/PPM/2017.

REFERENCES

Akhtar, K., Sherwani, R.K., Rahman, K., Hasan, J. and

Shahid, M., 2008. HemoCue photometer: a better

alternative of hemoglobin estimation in blood

donors?. Indian Journal of Hematology and Blood

Transfusion, 24(4), pages 170-172.

Alelign, T., Degarege, A. and Erko, B., 2015. Prevalence

and factors associated with undernutrition and

anaemia among school children in Durbete Town,

northwest Ethiopia. Archives of Public Health, 73(1),

pages 34.

Al-Zabedi, E.M., Kaid, F.A., Sady, H., Al-Adhroey, A.H.,

Amran, A.A. and Al-Maktari, M.T., 2014. Prevalence

and risk factors of iron deficiency anemia among

children in Yemen. American Journal of Health

Research, 2(5), pages 319-326.

Arisman., 2010. Nutrition in Jakarta Life Cycle: EGC

Medical Book Publishers. Jakarta

Briawan, D., Adrianto, Y., Ernawati, D., Syamsir, E. and

Aries M. 2012. Food consumption, iron bioavailability

and anemia status of female students in Bogor

Regency. In Proceedings of the Seminar on Research

Results. Bogor. IPB.

The Prevalence and Risk Factors of Anemia among Primary School Children in North Sumatera, Indonesia

661

Bobonis, G.J., Miguel, E. and Puri-Sharma, C., 2006.

Anemia and school participation. Journal of Human

resources, 41(4), pages 692-721.

da Silva Ferreira, H., de Assunção Bezerra, M.K., de

Assunção, M.L. and de Menezes, R.C.E., 2016.

Prevalence of and factors associated with anemia in

school children from Maceió, northeastern

Brazil. BMC public health, 16(1), pages 380.

Gad, A., Al-Quaiz, J., Khoja, T., As-Sharif, A., Al-Manea,

H., Al-Edriss, A. and Shafi, S., 2013. Anemia among

primary school children (5-12 years) in Riyadh

Region, Saudi Arabia: a community-based

study. Canadian Journal of Clinical Nutrition.

Gutema, B., Adissu, W., Asress, Y. and Gedefaw, L.,

2014. Anemia and associated factors among school-

age children in Filtu Town, Somali region, Southeast

Ethiopia. BMC hematology, 14(1), p.13.

El Hioui, M., Ahami, A.O.T., Aboussaleh, Y., Rusinek, S.,

Dik, K., Soualem, A., Azzaoui, F.Z., Loutfi, H. and

Elqaj, M., 2008. Risk factors of anaemia among rural

school children in Kenitra, Morocco. East African

Journal of Public Health 5(2) pages 62-66

Iannotti, L.L., Delnatus, J.R., Odom, A.R., Eaton, J.C.,

Griggs, J.J., Brown, S. and Wolff, P.B., 2015.

Determinants of anemia and hemoglobin concentration

in haitian school-aged children. The American journal

of tropical medicine and hygiene, 93(5), pages 1092-

1098.

Kahigwa, E., Schellenberg, D., Sanz, S., Aponte, J.J.,

Wigayi, J., Mshinda, H., Alonso, P. and Menendez, C.,

2002. Risk factors for presentation to hospital with

severe anaemia in Tanzanian children: a case–control

study. Tropical medicine & international

health, 7(10), pages 823-830.

Kisworini., Triasih, S., 2005. Anemia Defisiensi Besi:

clinical practice guidelling anemia defisiensi besi.

Medika-Fakultas Kedokteran UGM pages 39-81.

Al-Oboudi, L.M., 2010. Impact of breakfast eating pattern

on nutritional status, glucose level, iron status in blood

and test grades among upper primary school girls in

Riyadh City, Saudi Arabia. Pakistan Journal of

Nutrition, 9(2), pages 106-111.

Leite M, Cardoso A, Coimbra C Jr, Welch J, Gugelmin S,

et al. 2013. Prevalence of anemia and associated

factors among indigenous children in Brazil: results

from the First National Survey of Indigenous People’s

Health and Nutrition. Nutr J volume 12 pages 69.

Mesfin, F., Berhane, Y. and Worku, A., 2015. Anemia

among primary school children in Eastern

Ethiopia. PloS one, 10(4), p.e0123615.

Ministry of Health Republic of Indonesia, 2013.

Riskesdas. Basic Health Research Agency for Health

Research and Development Ministry of Health of the

Republic of Indonesia. Jakarta.

Mesfin, F., Berhane, Y. and Worku, A., 2015. Anemia

among primary school children in Eastern

Ethiopia. PloS one, 10(4), p.e0123615.

Murphy, J.M., 2007. Breakfast and learning: an updated

review. Current Nutrition & Food Science, 3(1), pages

30-36.

Ngesa, O. and Mwambi, H., 2014. Prevalence and risk

factors of anaemia among children aged between 6

months and 14 years in Kenya. PLoS One, 9(11),

p.e113756.

Nirmala, D., 2012. Nutrition Children School. Book

Publishers Kompas. Jakarta

Sartika, R.A.D., 2012. Application of Communication,

Information, and Nutrition Education on Breakfast

Behavior of Primary School Students. Journal of

National Public Health 7 (2)

Sirajuddin, S. and Masni, M., 2015. Incidence of Anemia

in Elementary School Students. Public Health:

National Public Health Journal, 9 (3), pages 264-269

Sudhagandhi, B., Sundaresan, S., William, W.E. and

Prema, A., 2011. Prevalence of anemia in the school

children of Kattankulathur, Tamil Nadu,

India. International Journal of Nutrition,

Pharmacology, Neurological Diseases, 1(2), pages

184-188.

Tandirerung, R.U., Mayulu, N., Kawengian, S.E.S., 2013.

Relationship between breakfast habits and the

incidence of anemia in students of Manado 3

Elementary School. E-Biomedic Journal (eBM).

Volume 1 pages 53-58.

World Health Organization., 2001. Iron deficiency

anemia: assessment, prevention, and control. A guide

for programme managers. Geneva.

World Health Organization., 2008. Worldwide Prevalence

of Anemia1993-2005. Global Database on Anaemia.

WHO.

Zuffo, C.R.K., Osório, M.M., Taconeli, C.A., Schmidt,

S.T., Silva, B.H.C.D. and Almeida, C.C.B., 2016.

Prevalence and risk factors of anemia in

children. Jornal de pediatria, 92(4), pages 353-360.

ICOSTEERR 2018 - International Conference of Science, Technology, Engineering, Environmental and Ramiﬁcation Researches

662