Nutritional anemia, particularly iron deficiency anemia, is a common health concern affecting adolescents globally, especially in low- and middle-income countries. Adolescence is a critical period marked by rapid growth, hormonal changes, and increased nutritional requirements, making individuals in this age group more vulnerable to anemia (1). Anemia during adolescence can lead to impaired cognitive function, reduced physical performance, increased susceptibility to infections, and, in females, complications during future pregnancies (2,3).

Globally, anemia affects over 25% of adolescents, with the highest burden observed in South Asia and sub-Saharan Africa (4). In India, the prevalence of anemia among adolescents remains unacceptably high, with recent national estimates indicating rates above 50%, particularly among girls and those residing in rural areas (5,6). Factors contributing to nutritional anemia include poor dietary intake, frequent infections, menstrual blood loss, parasitic infestations, and inadequate access to health services (7,8).

Urban-rural differences in anemia prevalence are attributed to disparities in nutritional awareness, socioeconomic status, access to fortified foods, and healthcare utilization (9). While urban adolescents may benefit from better food diversity and health infrastructure, rural populations often rely on iron-poor diets and face barriers to health education and supplementation programs (10).

Despite several national initiatives such as the Weekly Iron and Folic Acid Supplementation (WIFS) program, anemia continues to be a major concern among adolescents in India (11). Understanding the regional and demographic variations in anemia prevalence and identifying modifiable risk factors is essential for planning effective, targeted interventions.

This study aims to estimate the prevalence of nutritional anemia among school-going adolescents in both urban and rural populations and to assess the socio-demographic and dietary determinants associated with it.

The study aimed to assess the prevalence and determinants of nutritional anemia among adolescents aged 10–19 years. Urban participants were recruited from government and private schools located in the city limits, while rural participants were selected from schools in nearby villages.

Sample Size and Sampling Technique:

A total of 800 adolescents were included in the study, with 400 participants each from urban and rural areas. The sample size was determined based on an expected anemia prevalence of 50%, with a 5% margin of error and 95% confidence level. A multistage stratified random sampling method was used to select schools, followed by systematic random sampling to recruit students from each school.

Inclusion and Exclusion Criteria:

Adolescents aged 10–19 years who provided assent and whose parents/guardians gave written informed consent were included. Students with known chronic illnesses, recent blood transfusions, or those on iron supplementation in the last three months were excluded.

Data Collection Tools and Procedure:

Data were collected using a pre-tested, structured questionnaire administered in the local language. The questionnaire captured socio-demographic information, dietary habits, menstrual history (for females), deworming status, and personal hygiene practices. Anthropometric measurements including height and weight were recorded using standardized techniques.

Hemoglobin Estimation:

Capillary blood samples were collected by trained healthcare workers using aseptic precautions. Hemoglobin concentration was measured on-site using a portable hemoglobinometer (e.g., HemoCue Hb 201+ system). Anemia was classified according to WHO guidelines: mild (11–11.9 g/dL for females, 11–12.9 g/dL for males), moderate (8–10.9 g/dL), and severe (<8 g/dL).

Statistical Analysis:

Data were entered in Microsoft Excel and analyzed using SPSS version 25.0. Descriptive statistics were used to summarize demographic characteristics and anemia prevalence. The chi-square test was applied to assess the association between categorical variables. Binary logistic regression was performed to identify independent predictors of anemia, with significance set at p < 0.05.

A total of 800 adolescents participated in the study, comprising 400 urban and 400 rural students. The overall mean age of participants was 14.8 ± 2.1 years. Among them, 52.5% were female and 47.5% were male. The overall prevalence of nutritional anemia was found to be 52.5%. Rural adolescents had a significantly higher prevalence (61.2%) compared to their urban counterparts (43.8%) (p < 0.001).

Table 1: Prevalence of Nutritional Anemia by Area and Gender

As shown in Table 1, anemia was more prevalent in females (64.3%) compared to males (39.5%), and this difference was statistically significant (p < 0.01).

Anemia severity was also assessed. Among the anemic participants, 67.1% had mild anemia, 28.6% had moderate anemia, and 4.3% had severe anemia.

Table 2: Distribution of Anemia Severity Among Anemic Participants

Table 2 highlights that mild anemia constituted the majority of cases, with a smaller proportion having moderate or severe forms.

Socioeconomic status, dietary habits, and deworming history were analyzed as potential determinants. Adolescents from low socioeconomic backgrounds, those who consumed less than three iron-rich meals per week, and those not dewormed in the past six months had significantly higher odds of being anemic.

Table 3: Determinants of Nutritional Anemia (Multivariate Logistic Regression)

As per Table 3, inadequate iron intake and being female were the strongest predictors of anemia in this population (p < 0.001 for both). Rural residence also emerged as a significant factor after adjustment for confounders.

These findings indicate a substantial burden of nutritional anemia among adolescents, particularly in rural areas and among females, influenced by dietary and socioeconomic factors.

The present study highlights a high prevalence of nutritional anemia (52.5%) among school-aged adolescents, with a notably higher burden in rural areas (61.2%) compared to urban settings (43.8%). This pattern aligns with findings from earlier studies conducted in India and other developing countries, where rural populations consistently exhibit a higher risk due to limited access to iron-rich food, healthcare, and sanitation (1,2).

Female adolescents were disproportionately affected, with a prevalence of 64.3%, supporting the well-documented association between menstruation, inadequate dietary intake, and increased iron requirements during adolescence (3,4). Studies by Bentley and Griffiths (5) and Toteja et al. (6) similarly reported higher anemia rates among adolescent girls, often linked to menstrual blood loss and poor nutritional practices.

In terms of anemia severity, mild anemia was the most common form (67.1%), followed by moderate (28.6%) and severe cases (4.3%). These results are comparable to the NFHS-5 findings, which indicated that most anemia cases among Indian adolescents fall within the mild-to-moderate range (7). The predominance of mild anemia suggests that early detection and intervention can be effective in reversing the condition if appropriate strategies are implemented.

The study also identified several significant determinants of anemia. Low socioeconomic status was associated with over twice the risk of anemia, echoing findings from Pasricha et al. and Kapil, who emphasized the role of poverty in limiting dietary diversity and access to supplementation (8,9). Similarly, adolescents consuming fewer iron-rich meals per week had an increased risk, reinforcing the critical role of diet in maintaining adequate hemoglobin levels (10).

Deworming status was another important factor; those who had not undergone deworming in the last six months were more likely to be anemic. Parasitic infections such as hookworm are known to cause chronic blood loss, contributing to iron deficiency, especially in tropical regions (11,12). The WHO recommends regular deworming in school-aged children as part of anemia prevention strategies (13).

The rural-urban disparity in anemia prevalence observed in this study is likely multifactorial. Urban adolescents generally have better access to fortified foods, health services, and awareness programs, while rural youth often lack these resources (14). Cultural dietary restrictions, greater workloads, and less autonomy in food choices may also contribute to nutritional deficiencies in rural adolescent girls (15).

Despite national initiatives like the Weekly Iron and Folic Acid Supplementation (WIFS) program and Anemia Mukt Bharat campaign, implementation gaps persist, especially in rural areas. Strengthening school-based health screening, improving dietary diversity through midday meal schemes, and ensuring regular deworming and iron supplementation are crucial steps to address this persistent issue.

This study is subject to certain limitations, including its cross-sectional design, which precludes causal inferences. Hemoglobin was measured using a portable device without serum ferritin or other biomarkers, which may affect diagnostic accuracy. Nonetheless, the large, balanced sample and standardized methodology lend strength to the findings.

In conclusion, nutritional anemia remains a pressing public health concern among Indian adolescents, particularly in rural areas and among females. Targeted nutritional education, improved dietary practices, regular deworming, and enhanced implementation of government programs are essential for reducing the anemia burden and improving adolescent health outcomes.

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