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Prevalence of anemia among late adolescent girls of school going age
*Corresponding author: G. Manoz Kumar, Department of Pediatrics, Sri Narasimha Raja (SNR) District Hospital, Kolar, Karnataka, India. manozshivaji@mail.com
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Received: ,
Accepted: ,
How to cite this article: Raj GM, Kumar GM, Alapati S. Prevalence of anemia among late adolescent girls of school going age. Karnataka Paediatr J. doi: 10.25259/KPJ_35_2026
Abstract
Objectives:
Anaemia in adolescent girls is a major public health concern in India, driven by nutritional vulnerability, menstrual blood loss and socioeconomic disparities. According to the World Health Organization, anaemia remains one of the leading causes of morbidity in adolescent females. The study aims to estimate the haemoglobin level among adolescent school girls and determine the prevalence of anaemia.
Material and Methods:
A cross-sectional study was conducted among 453 female students (15–18 years) selected through convenient sampling from government Pre-University Colleges in Kolar district, Karnataka. Haemoglobin estimation was done using the EzeCheck digital haemoglobinometer, a validated non-invasive device. Data regarding demographic, socioeconomic, menstrual profile, dietary habits, clinical signs and supplementation history were collected using a structured questionnaire. Data were analysed using Statistical Package for the Social Sciences v22.
Results:
The overall prevalence of anaemia was 42.8%, with mild anaemia being the most common category. Significant associations were found between anaemia and: (i) Body mass index (p = 0.02). (ii) Socioeconomic status (p = 0.041). Menstrual duration ≥4 days (p = 0.03). Clinical signs such as conjunctival pallor, pale skin and pale nail beds showed a strong association with anaemia.
Conclusion:
Anaemia among late adolescent girls in Kolar district represents a moderate yet preventable burden, influenced by nutritional status, menstrual characteristics and socioeconomic factors. Strengthening district-level implementation of Anaemia Mukt Bharat, weekly iron and folic acid supplementation and Rashtriya Kishor Swasthya Karyakram, along with routine school screening, nutrition education and menstrual health interventions, is recommended for sustainable reduction in anaemia prevalence.
Keywords
Adolescent anaemia
Body mass index
EzeCheck
Haemoglobin
Menstrual health
INTRODUCTION
India is one of the youngest nations globally. As of 2024–2025, with a population nearing 1.44 billion, about 24% are aged 0–14, and 10–19-year-old comprise around 17–21% of the population. Youth aged 10–24 account for 26–40%, with adolescents alone making up 20–21%.[1] Given such a large adolescent population, adolescent girls, especially in rural and marginalised communities, remain among the most vulnerable, underscoring an urgent need for focused interventions in health, nutrition and education.
While numerous studies in India have documented the prevalence of anaemia in various populations, there is a lack of localised data specific to late adolescent girls in both rural and urban schools of Kolar district. Moreover, previous research has inadequately explored the influence of socio-demographic variables, menstrual history, dietary patterns and anaemia-related symptoms among this age group using modern, non-invasive haemoglobin estimation tools such as digital haemoglobinometers.
Traditional laboratory-based methods
Cyanmethemoglobin method (Drabkin’s reagent)
Haemoglobin is converted to cyanmethemoglobin and measured spectrophotometrically at 540 nm. Blood can be venous or capillary. This method is highly accurate and considered the gold standard. [2] Limitations include the requirement for laboratory infrastructure, trained personnel, reagents and electricity, making it impractical for mass field screening.[2]
Sahli’s method (acid haematin method)
Haemoglobin is converted to acid haematin using hydrochloric acid, and the concentration is estimated by visual comparison with a standard colour scale. Simple and inexpensive, this method suffers from subjectivity and low reproducibility.[2]
Digital and portable haemoglobin estimation methods
HemoCue 301/201+
Uses photometric measurement of microcuvette blood at 570 nm. Results are available in ~1 min, with accuracy ±0.3 g/dL. Suitable for field use, but minimally invasive and requires consumables.[3,4]
TRUEHb haemometer
Employs reflectance photometry, requires a small capillary blood volume, rapid results, portable and validated in multiple field studies. Slightly influenced by environmental factors.[3,4]
Non-invasive devices (EzeCheck, Pronto-7, Masimo)
Use multi-wavelength optical photoplethysmography to estimate haemoglobin. They are non-invasive, pain-free and highly acceptable for adolescent school-based screening, though influenced by skin tone, perfusion and ambient light.[3,4]
MATERIAL AND METHODS
Study design
This was a cross-sectional, observational study from June 2024 to November 2025. Conducted in selected government pre-university (PU) colleges and high schools are located in rural and urban regions of the Kolar district.
Study population
Female adolescent students aged 15–18 years enrolled in government PU Colleges of Kolar district.
Ethics
The study was approved by the Institutional Ethics Committee of the SNR District. Hospital, Kolar. Written informed consent was obtained from parents/guardians and assent from students.
Socioeconomic class assessed using Kuppuswamy socioeconomic scale (2025 consumer price index [CPI] update).
Height, weight, body mass index (BMI) and BMI classification per the World Health Organization (WHO) standards.
Clinical examination
Assessment of pallor (palpebral conjunctiva, nail beds, tongue, palms)
Fatigue, breathlessness, decreased exercise tolerance.
Study procedure
Consent/assent obtained
Data entered into pre-structured pro forma
Height, weight and BMI recorded using standard methods
Haemoglobin measured using EzeCheck® non-invasive digital haemoglobinometer.
EzeCheck haemoglobin estimation process:
The device connected through Bluetooth to an Android application
Ring finger placed in the sensor (clean, free from mehndi)
Spectrophotometric light absorption used for estimation
Reading generated in 60 s and recorded.
Haemoglobin classification (WHO/Indian Council of Medical Research criteria)
Anaemia was classified according to the WHO criteria for adolescent girls.
WHO classification of anaemia by haemoglobin levels in adolescent girls [Table 1].
| Category | Haemoglobin level (g/dL) |
|---|---|
| Normal | ≥12.0 |
| Mild anaemia | 11.0–11.9 |
| Moderate anaemia | 8.0–10.9 |
| Severe anaemia | <8.0 |
Sampling technique
A convenience sampling technique was adopted.
Data management
Data transcribed into Microsoft Excel
Cross-validated for accuracy and completeness.
Statistical analysis
Analysis performed using Statistical Package for the Social Sciences version 22
Categorical variables → frequency, percentage
Continuous variables → mean ± standard deviation
Chi-square test for associations
Independent t-test for mean comparison.
RESULTS
The majority of the participants belonged to rural schools (57.4%), indicating higher school enrolment and accessibility in rural areas of Kolar district.
The overall prevalence of anaemia was 42.8%, indicating a severe public health problem as per the WHO criteria.
Among the 194 anaemic participants, the majority had mild anaemia (69.6%), followed by moderate anaemia (28.4%), while severe anaemia was observed in only 2.1% of cases.
No statistically significant association was observed between place of residence and anaemia (χ2 = 0.22, p = 0.63). The prevalence of anaemia was similar among rural and urban participants, indicating that place of residence did not have a significant influence on anaemia status in the study population.
A majority (68.9%) were underweight, suggesting a possible nutritional deficit contributing to anaemia risk.
A statistically significant association was observed between BMI and anaemia (χ2 = 5.11, p = 0.02). Anaemia was more prevalent among underweight participants compared to those with normal BMI, indicating undernutrition as a contributing risk factor for anaemia.
The majority of the participants belonged to the upper lower socioeconomic class (Class IV), constituting 56.5%, followed by the lower middle class (Class III) at 43.0%. Very few participants were from the upper middle (0.2%) and lower (0.2%) socioeconomic classes, while none belonged to the upper class.
A statistically significant association was observed between menstrual duration and anaemia (χ2 = 7.01, p = 0.03). Participants with a menstrual duration of 4 days or more had a higher prevalence of anaemia (56.5%) compared to those with 3 days or less (39.2%), indicating prolonged menstrual bleeding as a contributing risk factor for anaemia. None of them reported passage of clots or very frequent change of pads (more than 1/h).
Although a slightly lower prevalence of anaemia was observed among participants who reported iron supplement intake (39.2%) compared to those who did not (44.4%), the association was not statistically significant (χ2 = 1.12, p = 0.29).
A lower prevalence of anaemia was observed among participants who had undergone deworming in the past 6 months (38.0%) compared to those who had not (46.7%). However, this association was not statistically significant (χ2 = 3.55, p = 0.06), although it showed a trend toward significance.
General tiredness was reported by a large proportion of anaemic participants (73.2%), whereas the majority of nonanaemic participants (81.2%) did not report tiredness. This finding highlights general tiredness as a common symptom associated with anaemia.
A statistically significant association was observed between pale skin and anaemia (χ2 = 23.21, p < 0.0000015). Participants with pale skin had a higher prevalence of anaemia compared to those without pale skin, indicating that pale skin is a strong clinical indicator of anaemia.
A statistically significant association was observed between pale nail bed and anaemia (χ2 = 17.14, p < 0.00004). Participants with pale nail beds had a higher prevalence of anaemia compared to those without pale nail beds, indicating that pale nail beds are an important clinical sign of anaemia.
Although a slightly higher prevalence of anaemia was observed among participants consuming a mixed diet (43.0%) compared to vegetarians (38.2%), no statistically significant association was found between dietary habit and anaemia (χ2 = 0.55, p = 0.75).
DISCUSSION
In the present study, a total of 453 late adolescent girls aged 15–18 years studying in rural and urban schools of Kolar district were included. Of these, 260 (57.4%) participants were from rural schools, while 193 (42.6%) belonged to urban schools, indicating a predominance of rural participants in the study population. This distribution is comparable to National Family Health Survey-5 (NFHS-5) data, which also shows a slightly higher rural representation of adolescents (52% rural vs. 48% urban).[5]
It is important to note that Premalatha et al.[6] conducted their study exclusively in urban schools, resulting in 100% urban participants, whereas Siva et al.[7] carried out a rural-based study, reporting 100% rural participants.
In contrast, Rana et al.[8] included an equal representation of rural and urban adolescents (50% each). Therefore, variations in rural–urban distribution across studies largely reflect differences in study settings and sampling frameworks, rather than true population differences.
In the present study, the overall prevalence of anaemia among late adolescent girls was 42.8% (194/453), while 57.2% participants were non-anaemic [Table 2]. According to the WHO criteria, this indicates a severe public health problem.[5] The prevalence observed in the present study is slightly lower than the NFHS-5 estimate for Karnataka (46.9%), which may be attributed to the school-based design of the study that excludes out-of-school adolescents who are often at higher nutritional risk.[5,7] Premalatha et al.’s[6] study prevalence was 78%.
Among the 194 anaemic participants, mild anaemia (69.6%) was the most common, followed by moderate anaemia (28.4%), while severe anaemia constituted only 2.1% of cases [Table 3]. This severity distribution is comparable to NFHS-5 Karnataka data and other Indian school-based studies, which consistently report mild anaemia as the predominant form among adolescent girls.[5-7] The low proportion of severe anaemia observed in the present study suggests the benefit of early identification through school-based screening and timely preventive interventions.
In the present study, anaemia prevalence was 43.8% among rural participants and 41.5% among urban participants, with no statistically significant association between place of residence and anaemia (χ2 = 0.22, p = 0.63). Similar findings have been reported in NFHS-5 Karnataka data, which also showed comparable anaemia prevalence between rural and urban adolescent girls.[5]
However, Rana et al.[8] (2023) reported a significantly higher prevalence of anaemia among rural adolescents (70.2%) compared to urban adolescents (56.7%). This difference may be attributed to variations in socioeconomic conditions, dietary diversity, access to health services, sanitation and regional nutritional practices across different study settings. The lack of a significant rural–urban difference in the present study may be explained by similar dietary patterns, widespread nutritional deficiencies and relatively uniform exposure to school-based health and supplementation programs in both rural and urban areas of Kolar district.
In the present study, 68.9% of participants were underweight, while 29.8% had normal BMI and only 1.3% were overweight or obese, indicating a high burden of undernutrition among late adolescent girls. Similar BMI distribution patterns have been reported in other Indian studies, where underweight status was the predominant nutritional category among adolescent girls.[6,7,9] The high prevalence of underweight observed in the present study suggests chronic nutritional inadequacy during adolescence, which may contribute to an increased risk of anaemia.
In the present study, a statistically significant association was observed between menstrual duration and anaemia (χ2 = 7.01, p = 0.03). Participants with a menstrual duration of 4 days or more had a higher prevalence of anaemia (56.5%) compared to those with 3 days or less (39.2%). Similar findings have been reported in other studies, which consistently demonstrate that prolonged menstrual bleeding increases cumulative iron loss, thereby predisposing adolescent girls to anaemia.[6,10,11] A study by Hillard showed that a flow duration of 2–7 days is normal, and passage of clots and very frequent change of pads will play a major role in anaemia.[12] This finding highlights the importance of menstrual health assessment and early identification of prolonged bleeding as part of anaemia-prevention strategies among adolescents.
In the present study, anaemia prevalence was slightly lower among participants who reported iron supplement intake (39.2%) compared to those who did not (44.4%); however, this difference was not statistically significant (χ2 = 1.12, p = 0.29). Similar findings of non-significant association between iron supplementation and anaemia status have been reported in other studies among adolescent girls.[6,7,10] The absence of a significant association may be attributed to irregular intake, poor compliance due to side effects, inadequate duration of supplementation and inconsistent supply, which can reduce the effectiveness of iron supplementation programs in improving haemoglobin levels.
In the present study, anaemia prevalence was lower among participants who had undergone deworming in the past 6 months (38.0%) compared to those who had not (46.7%); however, this association was not statistically significant (χ2 = 3.55, p = 0.06), though it showed a trend toward significance. Similar findings have been reported in Indian studies where deworming alone did not show a statistically significant reduction in anaemia prevalence.[6,10] In contrast, a systematic review and meta-analysis reported a significant reduction in anaemia following deworming, particularly in settings with a high burden of helminth infections.[13] The lack of statistical significance in the present study may be due to low baseline helminth prevalence, reinfection or the need for combined interventions such as iron supplementation along with deworming.
In the present study, general tiredness was reported by 73.2% of anaemic participants, whereas the majority of non-anaemic participants (81.2%) did not report tiredness. indicating a strong association between tiredness and anaemia. Similar findings have been reported in other studies, where fatigue and reduced physical endurance were commonly observed symptoms among anaemic adolescents.[6,7,14] General tiredness occurs due to reduced oxygen-carrying capacity of blood, leading to impaired tissue oxygenation and decreased energy levels. This finding emphasises that general tiredness can serve as an important clinical indicator of anaemia among adolescent girls and highlights the need for early screening when such symptoms are reported.
In the present study, a statistically significant association was observed between pale skin and anaemia (χ2 = 23.21, p < 0.0000015). Participants with pale skin showed a higher prevalence of anaemia compared to those without pale skin, indicating that pallor is a strong clinical marker of reduced haemoglobin levels. Similar findings have been reported in other studies, where visible pallor was commonly associated with anaemia among adolescents.[6,7,14] Pale skin occurs due to reduced haemoglobin concentration and diminished oxygenated blood flow, making it a reliable and easily identifiable clinical indicator of anaemia, particularly in resource-limited settings.
In the present study, a statistically significant association was observed between pale nail bed and anaemia (χ2 = 17.14, p < 0.00004). Participants with pale nail beds had a higher prevalence of anaemia compared to those without this sign, indicating that nail bed pallor is an important and reliable clinical indicator of anaemia. Similar associations have been reported in other studies, where nail bed pallor was frequently observed among anaemic adolescents.[6,7,14] Pallor of the nail bed reflects reduced haemoglobin concentration and diminished peripheral perfusion, making it a useful bedside sign for identifying anaemia, especially in school and community settings.
In the present study, anaemia prevalence was slightly higher among participants consuming a mixed diet (43.0%) compared to vegetarians (38.2%); however, no statistically significant association was observed between dietary habit and anaemia status (χ2 = 0.55, p = 0.75). Similar non-significant associations have been reported in other studies among adolescents.[3,7,14] This may be explained by the fact that although participants reported consuming a mixed (non-vegetarian) diet, intake of meat was occasional and infrequent, which may not provide sufficient bioavailable iron. In addition, dietary classification alone does not reflect the quantity, frequency, or bioavailability of iron intake, and mixed diets may still be deficient in iron or contain inhibitors of iron absorption. Hence, anaemia among adolescents appears to be influenced more by overall nutritional adequacy rather than dietary habits alone.
Limitations of the study
This study has certain limitations that must be considered when interpreting the findings:
Convenience sampling limits generalisability beyond the selected schools and population.
Haemoglobin estimation was done using a digital haemoglobinometer, and results were not validated against laboratory-based automated analysers due to feasibility constraints.
The study did not differentiate between nutritional deficiency anaemia and other aetiologies, such as haemoglobinopathies or chronic diseases.
Dietary intake was assessed through self-reported recall, which may be subject to reporting bias.
The menstrual history provided was subjective and was not clinically verified, which may affect accuracy in associating menstrual blood loss with anaemia.
The study did not measure serum ferritin or iron profile, which would help in confirming iron deficiency anaemia specifically.
The findings represent only school-going girls and may not include out-of-school adolescents who are often at higher risk.
The statistical analysis is limited to bivariate methods without adjusting for confounding variables, multivariate analysis cannot be done.
These limitations highlight the need for larger, multi-centric studies with biochemical confirmation of anaemia types to support targeted interventions.
CONCLUSION
The present study demonstrates that anaemia continues to be a significant public health problem among late adolescent girls in Kolar district, with an overall prevalence of 42.8%.
Nutritional status, socioeconomic factors and menstrual health were the primary determinants associated with anaemia.
According to the WHO classification, mild anaemia was the predominant category among the anaemic late adolescent girls, highlighting the need for early screening and preventive interventions.
Clinical pallor (skin, conjunctiva, nail-bed) proved to be a useful bedside indicator and can be effectively utilised for early screening at the school level. Strengthening existing government programs such as Anaemia Mukt Bharat, weekly iron and folic acid supplementation, National Deworming Day and menstrual health awareness campaigns through Rashtriya Kishor Swasthya Karyakram is essential to reduce the burden of adolescent anaemia.
Early screening, nutritional counselling, regular supplementation, community awareness and school health reinforcement are key strategies to address the problem. Future studies should explore biochemical profiling, dietary patterns, menstrual disorders and intervention outcomes to strengthen anaemia prevention frameworks in similar settings.
Ethical approval:
The research/study was approved by the Institutional Review Board at SNR District Hospital, approval number SNRDH/EC/C-2/2024, dated 15 June 2024.
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given consent for clinical information to be reported in the journal. The patient understands that the patient’s names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript, and no images were manipulated using AI.
Financial support and sponsorship: Nil.
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