Knowledge, Attitudes, Eating Practices, and Iron (Fe) Consumption among Adolescent Girls (Aged 10-18 Years) in Central Java, Indonesia

1. INTRODUCTION

Adolescent girls with iron deficiency are at risk of developing iron-deficiency anemia [1-10]. According to the 2018 Indonesian Basic Health Survey, 26.8% of children aged 5-14 years and 32% aged 15-24 years suffer from anemia [11-13]. In Central Java Province, the prevalence of anemia among women of childbearing age is 27.1%, exceeding the target of 25% [4]. Anemia in adolescents causes various disorders, including impaired concen- tration during learning, decreased immunity, metabolic disorders, as well as reduced fitness and productivity. When left untreated, iron deficiency in adolescents can lead to serious long-term health effects, especially when compounded by early marriage or unwanted pregnancy, such as disrupting fetal growth and development during pregnancy, increasing the risk of low birth weight (LBW), and elevating the risk of stunting in children [5-7]. In Indonesia, the prevalence of unwanted pregnancy among adolescents aged 15-19 reached 17.9%, and the overall prevalence of stunting from these cases was recorded at 24.4% in 2021.

Stunting is a chronic nutritional problem, posing a significant health concern in Indonesia. According to the 2023 Joint Child Malnutrition Estimates (JME) Report by UNICEF, WHO, and the World Bank, Indonesia has the second highest prevalence of stunting in the Southeast Asia region, after Timor Leste [8]. Indonesian Toddler Nutrition Status Survey (SSGI) shows a downward trend in stunting prevalence among children in Indonesia, from 27.7%, 24.4%, and 21.6% in 2019, 2021, and 2022, respectively [9]. However, this figure still exceeds the WHO target of 20% [8], leading to the effort to reduce stunting to 14% by 2024. In Central Java Province, SSGI data for 2022 recorded that 20.8% of children under 5 were stunted [9]. With a population of approximately 2.4 million, around 49,000 toddlers in Central Java experience stunting. Community-Based Electronic Nutrition Record (e-PPGBM) data show a decreasing trend among children, which ranges from 24.43%, 18.30%, 14.51%, 12.8%, and 11.9% in 2018, 2019, 2020, 2021, and 2022 [4]. Despite these significant reductions, substantial efforts are still needed to prevent stunting in children under 5 years, particularly by targeting the adolescent age group.

Adolescents represent an age group with specific characteristics in the life cycle. This age group is characterized by various changes, including physical, biological, hormonal, and emotional transformations [10]. The changes are often influenced by social pressures from the surrounding environment, showing the need for providing specific nutritional interventions [11]. Adolescent pregnancies are also a concern in this context, as inadequate nutrition during pregnancy is linked to iron deficiency and anemia, further increasing the risk of delivering low birth weight (LBW) babies who are vulnerable to stunting. Current literature shows a trend towards increased fast food consumption among adolescents, which is perceived as more modern and appealing compared to traditional Indonesian foods. However, the nutritional content of fast food is typically inadequate, particularly in micro-nutrients, such as iron (Fe) [12-15]. Iron is an essential micro-nutrient for adolescent girls, playing a significant role in supporting reproductive health [16].

To overcome this condition, the government has implemented several efforts to prevent anemia among adolescents, such as providing supplements containing iron and folic acid. The coverage of iron tablet distribution among adolescents has reached 100%, but compliance with regular consumption remains low [17]. Despite attractive promotion efforts, negative perceptions, such as their fishy smell and the potential to cause nausea, contribute to poor eating practices and low adherence to iron tablet consumption among adolescent girls. Therefore, this study aimed to analyze the knowledge and attitudes toward eating practices and iron tablet consumption among teenage girls aged 10-19 years in Central Java.

2. METHODS

2.2. Sample Respondent

This study was conducted in four selected regencies/districts, namely Semarang City (Kemijen Subdistrict, East Semarang Subdistrict; Bandarharjo Subdistrict, North Semarang Subdistrict), Tegal District (Tuwel Village, Bojong Subdistrict; Kalisapu Village, Slawi Subdistrict), Brebes District (Negla Village, Losari Subdistrict; Kluwut Village, Bulakamba District), and Banyumas District (Cilongok Village, Cilongok District; Gandatapa Village, Sumbang District). The population consisted of adolescent girls aged 10-20 years.

A multi-stage sampling method was used to ensure a focused and representative sample. Initially, purposive sampling was used to select four districts with the highest incidence of stunting based on inclusion criteria targeting the most affected areas. In each district, another round of purposive sampling identified two villages, focusing on those with the highest rates of stunting. The sample size was determined using Lemeshow's formula for proportions as follows:

The total sample size was increased by 20% from the minimum required to account for potential dropouts, resulting in a total of 484 respondents. This sample size was evenly allocated across the selected districts, each consisting of approximately 100 adolescent girls. Data collection in each village was conducted using simple random sampling to ensure an equal chance of selection. This even distribution ensured that each district contributed equally to the overall sample.

3. RESULTS

4. DISCUSSION

Adolescent girls are burdened with the responsibility of being adequately informed about iron tablet consumption, which significantly influences attitudes and eating practices. This study showed that 58.2% of respondents possessed sufficient knowledge concerning iron consumption measures. A substantial proportion remained unaware of the correct timing and frequency for taking iron tablets. According to the Indonesian Ministry of Health, it was recommended that all adolescent girls and women of childbearing age consume one iron tablet per week to prevent anemia [18]. Younger adolescents with sufficient knowledge understood the benefits, such as increasing blood flow during menstruation, reducing the risk of blood shortages, enhancing the blood supply, and preventing anemia. In this study, 89.1% of respondents showed positive attitudes, expressing agreeable or hard feelings. Positive attitudes were reflective of health-promoting behavior, while negative attitudes showed avoidance [19]. This result was supported by Muthmainah (2023), where 52.8% of respondents showed positive attitudes. Approximately 47.2% had negative attitudes due to aversions to the odor and flavor of iron tablets or a lack of knowledge about their benefits. Positive attitudes were primarily caused by health concerns, particularly regarding the prevention of anemia [20].

Despite favorable attitudes, a majority of adolescents did not fully comprehend the need to maintain normal hemoglobin levels, often confusing low hemoglobin with low blood pressure [21]. The practice of iron tablet consumption among adolescent girls, influenced by knowledge and attitudes, was evaluated based on their consumption in the past week [8]. Only 14.7% of respondents showed good practices, while 85.3% had poor practices, including laziness, bad taste, foul smell, nausea, and vomiting as side effects [22].

However, when comparing districts with high and low stunting rates, distinct patterns emerge. In districts with lower stunting prevalence, resources are more readily available, and access to diverse food sources is easier. These areas also tend to have more active health workers engaged in promotive and preventive health efforts. In contrast, districts with higher stunting incidence are often economically disadvantaged, with lower levels of community knowledge and a greater prevalence of stigma surrounding health interventions. This suggests that, beyond knowledge and attitudes, factors like logistical barriers in accessing tablets may play a crucial role. Socio-cultural stigmas, such as fears of liver damage or constipation from iron tablets, are also significant in communities. Gender norms, especially around women’s health, can make discussing menstruation-related iron needs difficult, as seeking help may be seen as taboo or a sign of weakness [23]. Cultural beliefs about pregnancy add further complications, with some women fearing that taking iron tablets could result in larger babies and more difficult deliveries. Additionally, the fear of being perceived as poor or malnourished may deter adolescent girls from using iron supplements, as this need is often linked to economic disadvantage. Low social support also plays a significant role in improving adherence to iron supplements [24]. Support comes from four primary sources-parents, peers, teachers, and health workers-providing information and reminders to consume the supplements regularly. Respondents in some studies reported greater confidence when peers reminded them to take iron supplements, as peer connections are prominent in the adolescent social structure [25].

The majority of respondents consumed iron tablets distributed at schools by community health centers but often described the taste and smell as unpleasant. Some prefer iron tablets sold in pharmacies due to their better taste [23, 24]. Common barriers to consumption included nausea, dizziness, and a fishy or rancid taste [27]. The study conducted by Nuradhiani showed that the color, smell, and taste of iron tablets significantly influenced perceptions, as only 22.5% of respondents had a high preference for taste. Lestari further stated that taste acceptance was significantly related to adherence [28].

A significant relationship had been identified between knowledge and attitudes concerning iron consumption, with a p-value of <0.05. This suggested that attitudes were influenced by early knowledge. Adolescents with high levels of knowledge were motivated by the need to prevent anemia [29]. In this study, all adolescent girls with inadequate knowledge showed poor practice, with 90.1% falling into the category. The results showed the high significance of the relationship between knowledge and practice. Similarly, Runiari (2020) found a significant association between knowledge and adherence to iron tablet consumption, with a p-value of 0.03 [30]. The role of knowledge in influencing consumption patterns was also shown by Panangin, where a general lack of awareness often originated from inadequate information on iron tablets and anemia [30].

A total of 89.7% of adolescent girls showed good knowledge of healthy eating habits, such as the daily consumption of fruits and vegetables, avoiding fast foods and drinks, regular breakfast, and avoiding extreme diets. However, some lacked principles of balanced nutrition or did not eat a varied diet. Increased knowledge was attributed to targeted nutrition education and the effective use of media to motivate behavior change [31]. Adolescent girls with positive attitudes toward nutrition showed a high tendency to consume foods that meet their nutritional requirements. Meanwhile, those with negative attitudes toward food would have poor nutritional status. Sempati stated that respondents were more positively disposed to modern food than traditional [32]. The study by Pantaleon (2019) also emphasized a significant relationship between eating habits and the nutritional status of adolescent girls. Common patterns in adolescent diets included frequent snacking, irregular meal times, skipping breakfast, frequent fast food, and low consumption of vegetables, fruits, and animal products. The prevalence of unhealthy dietary behaviors among adolescents remained significantly high [33].

Adolescent girls in Central Java typically consume a diet that includes staples like rice, tofu, tempeh, eggs, and occasionally meat. Still, their intake of iron-rich foods such as red meat, leafy green vegetables, and legumes remains inconsistent. Adolescent girls showed a low preference for eating vegetables due to perceived bad taste. In contrast, the consumption of fast food, which is often low in nutritional value and lacks essential micronutrients like iron, has been observed in many adolescent diets. The preference for modern foods was attributed to taste, innovativeness, social influence, and convenience [34]. This was further supported by Imtihani, who reported that most respondents consumed fast food due to convenience and eagerness to try new tastes [35]. This is also particularly concerning in relation to the high consumption of sweetened beverages such as sweet tea (teh manis), a culturally significant beverage in Indonesia. Sweet tea is a popular accompaniment to meals and is often consumed multiple times a day. While it is an ingrained part of the diet, excessive consumption of sugary drinks like sweet tea can negatively affect iron absorption due to the high tannin content found in tea, which inhibits non-heme iron absorption. The irregularity in the consumption of iron-rich foods, combined with the high intake of fast foods and sweetened beverages, may contribute to iron deficiency. In this study, the majority of respondents had poor eating practices, particularly those who reported a higher intake of fast food and sugary beverages. This suggests a clear link between poor eating practices and an increased risk of iron deficiency anemia.

This study has several limitations. First, while it provides valuable insights into the knowledge, attitudes, and practices surrounding iron (Fe) consumption among adolescent girls, it was conducted in Central Java, which may limit the generalizability of the findings to other regions in Indonesia or similar settings in other developing countries. Central Java may differ socioeconomically or culturally from different areas, potentially affecting dietary habits and iron tablet adherence differently. Socioeconomic variations, such as access to healthcare, food diversity, and education levels, may result in different adherence patterns, especially in more urbanized or remote regions. These regional differences need to be considered when applying the findings to broader populations.

Additionally, measuring hemoglobin levels to indicate anemia in the samples was not a primary objective. A larger, more diverse sample size would have captured a broader range of adolescent experiences, particularly given Indonesia's cultural diversity. In regions with different religious or traditional practices, food choices, and health beliefs, adherence to iron tablets may be influenced by local customs. Future studies should aim for a more representative sample across various regions of Indonesia to provide a more comprehensive understanding of how cultural differences affect dietary behaviors and adherence to iron tablet recommendations. Moreover, to ensure the sustainability of health interventions such as iron supplementation programs, future research should consider employing longitudinal study designs. These studies would allow for the examination of long-term adherence patterns and the sustained impact of health education programs over time. These limitations underscore the importance of addressing broader geographical and cultural contexts in future research to enhance the generalizability and robustness of the results.

CONCLUSION

In conclusion, this study showed the significant impact of knowledge and attitudes on iron tablet consumption and eating practices among adolescent girls. Despite positive attitudes, actual adherence remained low due to factors such as taste and side effects. The majority of teenage girls also lacked an understanding of hemoglobin levels and their importance. Consequently, improving knowledge about iron tablet consumption and healthy eating practices through targeted education and addressing barriers to adherence, such as the taste and side effects of iron tablets, were recommended for better health outcomes among adolescent girls.

The balanced distribution of good and bad eating habits among adolescent girls showed the need for targeted nutritional interventions. Therefore, efforts should focus on educating adolescent girls about the importance of regular food, the nutritional benefits of fruits and vegetables, and the risks associated with high fast food consumption.

REFERENCES