INTRODUCTION

Anemia can be defined as a condition in which the number of red blood cells or Hb level falls below an established cut-off value, consequently impairing the capacity of the blood to transport oxygen to the cells1. Anemia is a global public health problem that affects about 2.3 billion people worldwide2. In developing countries, it has become more of a concern where the incidence and severity of anemia are very high compared to developed countries. An estimated 43% population had been reported to be anemic in developing countries3. Young people are particularly susceptible because of their rapid growth and associated high iron requirements4. Previous studies around the globe reported the prevalence of anemia among young adults6, 5. A Bangladeshi study conducted in the Noakhali region reported 55.3% of adults university students to be anemic7. Around 30% of university students were reported to be anemic in the Hodeida Province of Yemen8. A similar study from South India showed that 43% of university students had anemia. The magnitude of anemia has significant adverse health and economic consequences. Studies reported that anemia is associated with reduced labor productivity in adults and combining the effect of anemia on cognition, total economic loss was estimated to be US$ 16.78 per capita or 4.05 % of the GDP10, 9. Despite the high burden and increasing trend of anemia, both in terms of prevalence and economic impact, there is a limited body of knowledge on anemia among young adults and this population has long been neglected and is an overlooked area of research as compared to children and women.

Dietary deficiency and poor hygiene practices play a major role in the causation of anemia12, 11. Inadequate dietary intake and poor hygiene practice are important public health issues among university students as they are experiencing the transition into university life. Living university hostels away from home badly influence their dietary intakes and hygiene practices. Previous studies have shown that university students tended to skip meals and often failed to meet the recommended intakes for fruits and vegetables13, 8. Personal hygiene is particularly important among university students because they spend most of their time in public places or universities in proximity to others. Poor hygiene practices favor parasite infection which in turn may result in anemia14.

Bangladesh is a heavily densely populated country in South Asia. It has very high population growth, widespread poverty, rising food prices, lack of access to services like education and health care. According to the World Bank, almost 1 in 4 Bangladeshis (24.3 percent of the population) live in poverty15. In Bangladesh, anemia has long been considered as a serious public health problem. Previous studies have shown that the prevalence of anemia in Bangladesh varies between 39.9 % and 51.9 % among women and children, respectively17, 16. Most of the previous studies on anemia in Bangladesh were conducted on children and women. However, there is a relative lack of information about the prevalence and risk factors of anemia among young adults, particularly among adult populations at the university stage. Therefore, the present study aimed to determine the prevalence and risk determinants of anemia among adult students of a major university in Bangladesh.

MATERIALS AND METHODS

RESULTS

The socio-demographic characteristics of the students (n = 150) participated in the study are presented in Table 2. The participants’ mean age was 21.44 (± 1.64) years. Of these 150, nearly 47 % (n = 70) were male and 53% (n = 80) were female. The majority of them (66.7 %) were enrolled in non-biology disciplines. 14.7 % of the students were studying in 2 year, followed by 64.7 % in 3 year and 20.6 % were in 4 year/Masters. Most of the students (90.7 %) were not married. Less than half of the participants’ monthly family income (40.7 %) was in the range BDT 10,001-20,000. About 21 % (n = 32) participants reported that they had some sort of illness in the previous 6 months and the majority of participants (79.3 %) were non-smokers (Table 2).

Among 150 adult students who were participating in the study, 33 (22.0 %) were diagnosed as having anemia, of whom 78.8% (n = 26) were females and 21.2 % (n = 7) were males. Of these anemic students (n = 33), 78.8 % (n = 26) had mild anemia, 7 (21.2 %) had moderate anemia and none of the students were found to be severely anemic (Figure 1). By morphological examination of the RBCs, we observed that the students diagnosed to be mild anemic had normocytic ormochromic anemia and moderate anemic students had microcytic hypochromic anemia. The images of the RBCs of the mild and moderate anemic students are presented in Figure 2 and Figure 3, respectively.

Among the socio-demographic variables examined, Chi-square analysis revealed significant association of anemia and socio-demographic factors: gender (χ2 = 11.014, p < 0.05) and monthly family income (χ2 =8.091, p < 0.05) (Table 2).

Table 3 shows the hygiene practices and dietary intakes of the students. The study revealed that 48.7 % (n = 73) students washed their hands with soap before each meal, while 76.7 % (n = 115) washed their hands with soap after using the toilet. The percentages of the students brushing teeth twice per day and cutting nails regularly were 76.0 % and 82.0 %, respectively. Regarding dietary intakes, regular breakfast intake was reported by 42.7 % (n = 64) students. Around thirty-one percent students (n = 47) consumed fruits frequently (≥ 3 times/week) followed by infrequently (<3 times/week) 56.7 % (n = 85) and occasionally 12.0 % (n = 18). More than half of the students (56 %) reported that they consumed green leafy vegetables more than 3 times/week and more than two-third (71.3 %) consumed milk/dairy products more than 3 times/week. The majority, 63.3 % (n = 95) students consumed animal products (meat, fish, egg) more than 3 times/week (Table 3).

Depending on the analysis in the present study, a significant relationship between anemia and hygiene practices was demonstrated. The chi-square analysis showed that the prevalence of anemia was significantly lower among the students who maintained hygiene practices i.e., washed hand with soap before the meal and after using the toilet and regular basis nails cutting (p < 0.05) (Table 2). Binary logistic regression analysis further revealed the significant predictors of lower prevalence of anemia: washing hand with soap before meal (COR = 2.25, 95 % CI = 1.00- 5.07; p < 0.05), washing hand with soap after using the toilet (COR = 2.81, 95 % CI=1.21 - 6.49; p < 0.05) and cutting nail regularly (COR = 2.56, 95 % CI = 1.04 - 6.31; p < 0.05) (Table 4).

The relationship between anemia and dietary intakes was also statistically demonstrated in the present study. The chi-square analysis revealed that the prevalence of anemia was significantly higher among the students who skipped breakfast compared to those who did not (27.9 % 14.1 %, = 4.099, p < 0.05). The analysis also showed that students who frequently (≥ 3 times/week) consumed fruits, green leafy vegetables and animal products (meat, fish, egg) were less likely to be anemic (p < 0.05) (Table 2). In binary logistic regression analysis, daily breakfast intake (COR = 2.36, 95 % CI = 1.01 - 5.52; p < 0.05), frequently intake (≥ 3 times/week) of fruits, green leafy vegetables, and animal products remained significant predictors of lower prevalence of anemia (p < 0.05) (Table 4).

DISCUSSION

Anemia is a common public health problem in developing countries. Anemia occurs at all ages19. However, there is a limited body of information on anemia among young adults. In the present study, we were able to determine the prevalence and its risk determinants of anemia among adult’s students of Jahangirnagar University, Bangladesh. The study found the overall prevalence of anemia among university students 22.0 % (n = 33), of whom 78.8 % (n = 26) were females and 21.2 % (n = 7) were males. However, the present study showed a lower prevalence of anemia than a similar study that was conducted among university students of the Noakhali Region, Bangladesh, which reported it to be 55.3 %7. The possible reason for the lower prevalence of anemia in the current study might be differences in the study period. Bangladesh Govt. along with national and international NGOs has delivered health education through mass media/print media and tried to promote healthy behaviors among the general population. Students might be exposed to these interventions which in turn, influences the prevalence of anemia in the present study. As in Bangladesh, university students of other countries were also affected by anemia reported by several studies. The anemia prevalence rate was reported to be 30.2% among medical students in India20. A similar study in Saudi Arabia revealed that anemia was prevalent in 64% of female students of University21. In the present study, the prevalence of mild anemia among the students was higher than moderate anemia and there was no student having severe anemia. This finding is consistent with other studies22, 21. In the present study, we also found that mild anemic students had normocytic ormochromic anemia while moderate anemic students had microcytic hypochromic anemia. The causes of normocytic normochromic anemia are either increased red blood cell destruction or decreased red blood cell production and overexpansion of plasma volume23. Microcytic hypochromic anemia usually results from iron deficiency24. The findings of the study showed that female students were more likely to be anemic compared to males. Previous studies reported similar findings that females are at more risk to develop anemia than males6, 7. Females are prone to anemia because of menstruation. An estimated 42 mg of iron losses per menstrual cycle in females with heavy blood flow, which may lead to anemia25. Other possible reasons might be illiteracy, poor dietary habits, and sanitation26, 7. The study showed that monthly family income had an effect on anemia. This finding is consistent with previous studies28, 27. Low household income badly affects an individual’s food purchasing capacity. In addition, people living in poor households are found with inadequate dietary intakes and a high risk of nutritional deficiencies30, 29. Good hygiene practice is an important measure to prevent anemia26. In this study, good hygiene practice i.e., handwashing with soap before the meal and after using the toilet and cutting nails regularly is significantly associated with a lower prevalence of anemia. This finding agrees with previous studies29, 26. Poor hygiene practice favors parasite infections26. Parasites cause blood loss which may lead to direct anemia31. Inadequate dietary intake plays an important role in the causation of anemia. The findings of the study revealed that the students who skipped breakfast were at increased risk to develop anemia than others. Missing meal means cutting calories which in turn cause weight loss and may lead to anemia. University students might miss breakfast meals due to waking up late, not being hungry in the morning, or dislike of served food. The study also revealed that the students who frequently consumed fruits and green leafy vegetables (≥3 times/week) were less likely to be anemic than others. Previous studies on Bengali students and Saudi women have demonstrated that low consumption of fruits and vegetables is associated with anemia31, 7. While the etiology of anemia is multifactorial, it is primarily caused by the deficiency of micronutrients (., vitamins A, B12 or folate) and minerals (commonly iron)32, 9. Fruits and vegetables are good sources of vitamins and minerals and adequate consumption of fruits and vegetables promotes Hb level in the individuals. The study also revealed that the students who frequently consumed animal products (meat, fish, and eggs) had a lower prevalence of anemia. Animal products such as meat, fish, and egg are generally enriched in iron11 and these types of foods enhance the iron status, as the form of iron in animal products absorbs more easily than the iron in vegetables9. However, we did not find any association between the intake of milk/dairy products and anemia. This may possibly because of the small sample size.

CONCLUSION

The proportion of anemia was found to be significantly higher in females. Further study with a large sample is needed to validate the findings as well as to safeguard the health of these future mothers. Proper health education to increase knowledge about anemia, benefits of healthy dietary habits and the importance of hygiene practice can be implemented among the students.

LIMITATIONS

The present study had several limitations. Lack of adequate funding was a major problem in this study. Due to limited funding and resources, other hematological parameters, except Hb, such as hematocrit, red blood cell count, serum ferritin, etc. were not estimated. In addition, the dietary habit was based on self-reported data, thus recall bias could be problematic. The study was confined to a single university and included a limited sample size. So, the results might not be generalized.

ABBREVIATIONS

Hb: Hemoglobin

GDP: Gross Domestic Products

WHO: World Health Organization

COR: Crude Odds Ratio

AOR: Adjusted Odds Ratio

CI: Confidence Interval

RBC: Red Blood Cell

CONFLICT OF INTEREST

No conflict of interest.

CONTRIBUTORS

Mst. Sabrina Moonajilin conceived and planned the experiments. Quazi Maksudur Rahman and Abid Hasan Khan carried out the experiments. Mst. Sabrina Moonajilin and Md. Estiar Rahman planned and carried out the simulations. Mst. Sabrina Moonajilin, Md. Estiar Rahman, Quazi Maksudur Rahman and Abid Hasan Khan contributed to the interpretation of the results. Md. Estiar Rahman took the lead in writing the manuscript. All authors provided critical feedback and helped shape the research, analysis, and manuscript.

ACKNOWLEDGEMENT

The study conducted with partial support from Jahangirnagar University. The authors would like to thank all the students who voluntarily participate in the study.