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Research Article  
 
Exploring the Relationship Between Nutrition Status, 
Reproductive Health Knowledge, and Anemia in 
Adolescent Girls in Depok, Sleman, Yogyakarta 
 
Mustika Cahya Nirmala Dewinta1*, Erni Gustina2  
1 Program Study of Nutrition, Faculty of Public Health, Universitas Ahmad Dahlan, Yogyakarta, 

Indonesia. 
2 Program Study of Public Health, Faculty of Public Health, Universitas Ahmad Dahlan, Yogyakarta, 

Indonesia. 
 
* Correspondence: mustika.dewinta@gizi.uad.ac.id.  
 
Received 03 April 2024; Accepted 24 Nov 2024; Published 02 Dec 2024  
 

ABSTRACT 

Background: The issue of anemia continues to be a significant public health concern 
requiring attention, particularly due to its increasing prevalence. In Sleman District, it has 
been observed that the prevalence of anemia among adolescents has significantly risen 
from 2016 to 2018. This phenomenon underscores the interconnectedness of nutritional 
status, reproductive health, and anemia, especially among adolescent girls. Adolescents, 
particularly girls, require sufficient nutritional intake to navigate the challenges associated 
with their physiological changes, particularly those related to the reproductive system. 
Nutritional status plays a crucial role in influencing reproductive system disorders, impacting 
menstrual irregularities, and closely intertwining with the occurrence of anemia among 
adolescent girls. This paper highlights the relationship between nutrition status, reproductive 
health knowledge, and anemia in adolescent girls in Depok, Sleman, Yogyakarta 
Method: The study employed a cross-sectional method to explore data concerning 
nutritional status and reproductive health knowledge variables. The study was conducted 
on 108 female junior high school students aged 10-15 years in 3 schools in the Depok 
Sleman District. Sampling was done using accidental sampling. Data collection was carried 
out at the schools by measuring anthropometry (body weight, height, BMI), checking 
hemoglobin (Hb), and filling out questionnaires on knowledge and dietary patterns.  
Results: It was found that there was no significant relationship between nutritional status 
and anemia status in adolescents (p-value 0.75). Analysis of the relationship between 
knowledge related to reproductive health and anemia status also revealed no significant 
relationship (p-value 0.772). 
Conclusion: The study concluded that there is no significant relationship between nutrition 
status, knowledge related to reproductive health, and anemia status in adolescent girls. 
Although the results of this study did not show a significant relationship, the urgency for 
adolescents to maintain nutritional status and increase knowledge about anemia prevention 
remains important in the effort to prevent anemia. A comprehensive anemia prevention 
program needs to be implemented through collaboration among schools, health authorities, 
and the community. 

Keywords: Adolescence; Anemia; Nutrition; Reproductive Health. 

https://doi.org/10.26555/eshr.v3i1.3629
https://doi.org/10.26555/eshr.v3i1.3629
mailto:mustika.dewinta@gizi.uad.ac.id


 
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INTRODUCTION 

Anemia is defined as a condition where an individual lacks red blood cells or hemoglobin as 
oxygen carriers in the blood to meet the body's physiological needs.1 Anemia cases, especially 
among adolescent girls, women of childbearing age, and pregnant women, remain a public 
health issue both globally and nationally. Data from the WHO indicates that approximately 
32.4 million (38%) pregnant women and 496 million (29%) women of childbearing age 
between 15-49 years old suffer from anemia.1 In Indonesia, the prevalence of anemia among 
women has increased from 11.3% in 2007 to 23.9% in 2013.2 The latest data obtained from 
the Sleman Health Office in 2020 indicates that the prevalence of anemia among adolescents 
in the Depok sub-district is 9.84%. This figure is still higher than the target of 8.50% according 
to the Strategic Plan of Sleman Regency 2020.3  

Moreover, the topic of adolescent health has become a significant health issue in the Depok 
area, which has the highest population density (131,242 people) in Sleman Regency (Sleman 
Regency Statistics 2022). Additionally, considering the large number of educational 
institutions ranging from elementary schools to universities in the Depok area, the Depok sub-
district is densely populated with adolescents and young adults. Meanwhile, adolescents are 
particularly vulnerable to health issues, especially anemia. 

This issue of anemia warrants attention as per BAPPENAS and UNICEF (2017), achieving 
zero hunger is one of the parameters of the Sustainable Development Goals (SDGs). One of 
the indicators for zero hunger is the prevalence of anemia among women of reproductive age 
not exceeding 12%. However, the prevalence of anemia among adolescent girls aged 15-24 
years remains high at 32% based on the Basic Health Research (RISKESDAS) data in 2018. 
Furthermore, data from the Sleman Health Office in 2018 revealed a significant increase in 
the prevalence of anemia among adolescent girls from 12.6% in 2017 to 22.86% in 2018.4  

This high prevalence of anemia among adolescents needs to be addressed seriously as it can 
have negative impacts on the future of adolescents and the next generations. Untreated 
anemia during adolescence can lead to short-term effects such as reduced immunity, 
decreased ability to concentrate in learning, and decreased productivity or achievement of 
adolescents.5 In the long term, adolescent anemia can lead to complications during 
pregnancy, increased risk of maternal mortality, risk of premature birth, low birth weight babies 
(LBW), and growth and developmental disorders in children.6 

The status of anemia in adolescents is influenced by various determinants. Some 
determinants of anemia among adolescent girls include malnutrition, imbalanced nutrient 
intake, and suboptimal reproductive health. Iron, protein, vitamin C, Vitamin B12, folic acid 
deficiencies, and menstrual cycle disturbances are some factors known to affect adolescent 
anemia.7 

Regarding the reproductive health of adolescent girls, knowledge about menstrual patterns 
and the required nutritional intake during menstruation are known to be factors that can 
influence the risk of anemia among adolescent girls.8 Adolescent girls need to have a good 
understanding of normal menstrual patterns, including the causes and effects of abnormal 
menstrual patterns. One of the impacts of abnormal menstrual patterns is the increased risk 
of anemia among adolescents.9 

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Given the urgency of the issue of anemia among adolescent girls and the complexity of 
determinants influencing this issue, various strategies are being implemented to address 
anemia among adolescents. One of them is through the provision of iron supplementation 
tablets (TTD), adolescent integrated health posts (posyandu remaja), and other health 
education platforms for adolescents. Some areas that need to be studied regarding 
adolescents are the balance of adolescent nutrition, healthy life skills, adolescent reproductive 
health, nutrition, physical activity, and counseling on other health issues.10 

Based on this background, the researchers conducted this study to identify the relationship 
between adolescent nutritional status and adolescents' knowledge about reproductive health 
on the status of anemia among adolescent girls. Hopefully, the results of this study will 
contribute to enriching information about determinants influencing adolescent anemia status, 
thus enabling the planning of more effective educational approaches to reduce and prevent 
cases of anemia among adolescents. 

METHOD 

The research subjects consisted of 108 female junior high school students aged 10-14 years 
in 3 schools in the Depok Sleman District. The minimum sample size was calculated using the 
Slovin formula, resulting in a minimum sample size of 100 individuals. Sample selection was 
done accidental sampling until the minimum required sample size was met. 

The research was conducted using a cross-sectional method to gather data related to 
variables such as nutritional status, reproductive health knowledge, and anemia status among 
adolescent girls. Nutritional status was assessed using the BMI indicator based on weight and 
height. Weight was measured using a digital scale, and height was measured with a 
microtoise. Knowledge about reproductive health, specifically about prevention of anemia 
during menstruation, was evaluated using a validated questionnaire derived from the research 
by Mularsih (2017).11 Hemoglobin levels were assessed through peripheral blood testing using 
the Quick Cek device by professional medical personnel from UAD Hospital. The research 
has obtained ethical approval from the UAD Ethics Committee with reference number 
012309208. 

This study involves female adolescents aged 10-15 years, so parental/guardian consent is 
required. Since it would be impractical to approach each parent/guardian individually for 
permission, ethical approval was represented by the teachers or class guardians at the school. 

Therefore, the research team first explained the purpose and procedures of the study through 
an information sheet to the school authorities, including the designated teachers or guardians 
responsible for the students. The selection of potential respondents was carried out by 
requesting recommendations from the teachers to ensure that the respondents met the criteria 
set by the research team. Respondents were included in the study only after the teacher 
granted permission by signing the informed consent form. 

Data analysis was conducted in stages, namely 1) measuring the basic characteristics of 
research participants, 2) analyzing each data variable descriptively, and 3) performing simple 
bivariate tests Pearson Chi Square to examine the relationship between independent 

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variables and dependent variables (nutritional status to anemia, and reproductive health 
knowledge to anemia). 

RESULTS 

The data obtained from this research implementation include age, height, weight, BMI-for-age 
Z-score, level of knowledge, and Hb levels. Age, height, and weight data were processed to 
calculate the BMI-for-age Z-score as an indicator of nutritional status in adolescents. The total 
number of research subjects in this study was 108 adolescent girls, with an average age of 
13.38 years. The respondents from the three schools are 10th-grade junior high school 
students. 

Nutritional status is categorized according to Minister of Health Regulation No. 2 of 2020 on 
Child Anthropometric Standards, with categories including severe undernutrition (<-3 SD), 
moderate undernutrition (-3 SD to <-2 SD), balanced nutrition (-2 SD to +1 SD), overweight 
(>+1 SD to +2 SD), and obese (>+3 SD). The level of adolescent knowledge about 
reproductive health was analyzed based on the total questionnaire score, categorized as 
inadequate knowledge (<60%), sufficient (61-74%), and good (≥75%). Hb levels were used 
as an indicator of anemia status in adolescents. Adolescents were considered anemic if Hb 
levels were <12.0 mg/dL, and non-anemic if Hb levels were ≥12 mg/dL. 

Descriptively, it was found that 63.9% of adolescents had good knowledge about reproductive 
health. The nutritional status of adolescents in this study showed that 6.5% of adolescents 
had moderate to severe malnutrition, while overnutrition to obesity was 12% and 13.9%, 
respectively. Meanwhile, based on Hb levels, it was found that 13% of adolescent girls in this 
study experienced anemia (Table 1). 

Table 1. Characteristics of subject 
 

Variable N % 

Age (years) 

11  2 1.85 
12  10 9.26 
13 56 51.85 
14 32 29.63 
15 8 7.41 

Total 108 100 

Knowledge 

Inadequate 16 14.8 
Sufficient 23 21.3 

Good 69 63.9 
Total 108 100 

Nutrition status 

Severe undernutrition 2 1.9 
Undernutrition 5 4.6 

Balanced nutrition 73 67.6 
Overweight 13 12.0 

Obese 15 13.9 
Total 108 100 

Anemia status 
Non-anemic 94 87 

Anemic 14 13 
Total 108 100 

 

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Data analysis was conducted using SPSS software to test the relationship between nutritional 
status, level of knowledge, and anemia status among adolescent girls. Based on the analysis 
results, it was found that there was no significant relationship between nutritional status and 
anemia status in adolescents (p-value 0.75). Analysis of the relationship between knowledge 
related to reproductive health and anemia status also revealed no significant relationship (p-
value 0.772). 

Table 2. Relationship between nutrition status and anemia status 

Nutrition status (BMI/age) 
Anemia status 

p-value Anemic Non-anemic 
N % N % 

Severe undernutrition 0 0 2 100 

0.750 
Undernutrition 0 0 5 100 
Balanced nutrition 11 15,3 62 84,7 
Overweight 2 15,4 11 84,6 
Obese 1 6,7 14 93,3 

 

Table 3. Relationship between knowledge related to reproductive health and anemia status 

Knowledge 
Anemia status 

p-value Anemic Non-anemic 
N % N % 

Inadequate 2 50 2 50 
0.772 Sufficient 4 44,4 5 55,6 

Good 8 11,4 62 88,6 

DISCUSSION  

The results of this study indicate that there is no relationship between the level of knowledge 
about reproductive health and the incidence of anemia in adolescent girls. There are several 
reasons that may explain why there is no significant relationship between the variables in this 
study. The first possibility is that the characteristics of the respondents tend to be 
homogeneous, particularly in terms of age, which may lead to similar eating patterns and 
activities, resulting in insufficient variation. Secondly, the respondents belong to the early 
adolescent group, whose eating patterns are still more strongly influenced by family dietary 
habits rather than individual knowledge, resulting in better intake levels. Thirdly, it is known 
that the majority of respondents in this study have good nutritional status. Most respondents 
also have normal hemoglobin levels or are not anemic, including those in the group with 
excess nutritional status. 

This finding is consistent with previous research conducted at SMK Bangsa Kota Bogor, which 
found that the majority of respondents who experienced anemia had good knowledge levels 
about anemia and its prevention.12 In other words, there is no association between knowledge 
and the occurrence of anemia. Moreover, a study conducted in several districts in Indonesia 
revealed that the level of knowledge does not always guarantee someone to be free from 
anemia.13 This research discusses a systematic review on the relationship between 
knowledge about anemia and its prevention, as well as dietary intake and consumption of iron 
supplementation tablets. The knowledge variable in this study focuses on adolescents' 

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understanding of menstruation, the relationship between menstruation and the risk of anemia, 
as well as behaviors related to anemia prevention. Other factors need to be considered, such 
as the dietary habits of adolescent girls both at home, in school environments, and in 
recreational settings, which may lack adequate nutritional intake. Additionally, the desire to 
have a slim body often leads them to restrict the consumption of foods essential for meeting 
hemoglobin needs. Therefore, many adolescents still experience anemia despite having good 
knowledge and understanding of the condition and the importance of adequate nutrition.14 

Furthermore, the lack of association between the level of knowledge among adolescent girls 
and the incidence of anemia may be attributed to the tendency of adolescent girls to follow 
their parents' dietary patterns in planning their daily meals. This results in both adolescent girls 
with poor knowledge and those with good knowledge not influencing the selection of foods 
that can prevent nutritional anemia.13 

In theory, knowledge is influenced by various factors, including age, occupation, education 
level, environment, and culture. The lack of understanding among female students about 
anemia is one factor that leads to less supportive behaviors in efforts to prevent anemia during 
menstruation. This lack of knowledge may be due to the students' misunderstanding or 
receiving incomplete information. An individual's knowledge influences their behavior, such as 
in the prevention of anemia during menstruation. Therefore, increasing knowledge about 
anemia is essential to encourage supportive behaviors in preventing anemia during 
menstruation.15 

The first important aspect of reproductive health knowledge to understand is menstrual 
patterns. A normal menstrual pattern is a cycle that lasts 21-35 days, with a menstruation 
duration ranging from 2-8 days and a blood volume ranging from 20-80 mL/day. An abnormal 
menstrual pattern occurs when the cycle, duration, and volume of menstrual blood are less or 
more than those described above.9 Previous research has revealed that adolescent girls with 
abnormal menstrual patterns are more susceptible to anemia compared to those with normal 
menstrual patterns.16–18  

Abnormal menstrual patterns, especially when menstruation lasts >7 days with short 
menstrual cycles <21 days, are more likely to cause anemia because adolescents lose more 
blood during this period.19 Therefore, it is important for adolescent girls to have a good 
understanding of what constitutes a normal menstrual pattern. This enables adolescent girls 
to identify whether their own menstrual pattern is normal or not, so they can recognize what 
needs to be improved to address the situation. 

Knowledge factors related to adolescent reproductive health that are associated with anemia 
are inseparable from adolescent understanding of the nutritional needs that need to be met 
during adolescence, including when adolescent girls experience menstruation every month. 
Previous study revealed that in groups of adolescent girls with inadequate intake of protein, 
iron, and vitamin C, the prevalence of anemia was higher compared to groups with sufficient 
intake.17 

This study also revealed that there is no significant relationship between nutritional status and 
the incidence of anemia in adolescent girls. Similar results were reported by a study at SMAN 
8 Kendari, which found no association between nutritional status and the occurrence of 

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anemia.20 Consistent with these findings is the research in South Galesong, Takalar, which 
examined nutritional status and anemia in adolescent girls, and found no relationship between 
nutritional status and anemia.21 

These findings may occur because nutritional status in the form of BMI-for-age is 
predominantly influenced by macronutrient intake such as carbohydrates, proteins, and fats. 
Meanwhile, anemia is caused by deficiencies in micronutrients such as iron, folic acid, vitamin 
B6, and vitamin B12. Therefore, it can be understood that good nutritional status based on the 
proportion of weight and height is not a guarantee that micronutrient needs are met.21  This 
reinforces the foundation that every adolescent girl needs to understand the appropriate 
strategies for preventing anemia. This is supported by research conducted by Pareek et al. 
(2022) which indicates that an inadequate intake of dietary iron, along with a concurrent 
inadequate intake of dietary micronutrients, appears to be the primary factors responsible for 
anemia and iron deficiency in adolescent girls.22 

Fundamentally, adolescent eating behavior is greatly influenced by peer influence and the 
body image they hold. A negative body image leads adolescent girls to feel dissatisfied with 
their body shape, leading them to adopt unhealthy eating patterns, ultimately impacting their 
nutritional status.23 Ironically, most adolescents who claim to reduce their food intake to 
achieve their desired weight adopt unhealthy eating patterns such as consuming fast food and 
insufficiently consuming high-fiber foods.24  

Anemia, particularly iron-deficiency anemia, is a significant public health issue affecting 
adolescent girls worldwide. Various stakeholders play crucial roles in its prevention, including 
schools, healthcare providers, parents, and community organizations. Schools, healthcare 
providers, parents, community organizations, and government policies all play critical roles to 
work collaboratively in addressing anemia issues in adolescents. Schools serve as a primary 
setting for health education and intervention programs. They can implement nutritional 
programs, provide meals, and educate students about healthy eating habits.25  

One of the best practices of the school feeding program is in the Philippines, by the 
Department of Education (DepEd) – the School-Based Feeding Program (SBFP). This 
program aims to provide meals for severely malnourished schoolchildren from kindergarten to 
Grade 6 for a duration of 100–120 days, utilizing standardized recipes that include malunggay 
in a 20-day rotating menu. Additionally, the DepEd established a categorization system for 
foods and beverages sold in schools. Healthy items that should always be available in school 
canteens are labeled Green, while unhealthy options that should not be present are marked 
Red. Items that fall in between and may be sold once or twice a week are categorized as 
Yellow. The objective is to encourage healthy eating habits and help children steer clear of 
empty calorie foods. Evaluation results showed that mean scores related to knowledge, 
attitudes, and behaviors of schoolchildren in the intervention groups significantly increased by 
the end of the program. It reflects that the combination of school lunch provision and nutrition 
education was effective in enhancing the knowledge, attitudes, behaviors, and nutritional 
status of the students.26  

Limitation of this study is the age variation among respondents in this study is limited due to 
the restriction of students allowed by the school to participate only from grade 10. As a result, 
the variation in nutritional status and knowledge levels tends to be consistent.  

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CONCLUSION 

The study concluded that there is no significant relationship between nutrition status, 
knowledge related to reproductive health, and anemia status in adolescent girls. Further 
research is encouraged to explore deeper understanding regarding to determinants of anemia 
among adolescents. Even though this study's results did not indicate a significant relationship, 
it is still crucial for adolescents to sustain their nutritional status and enhance their 
understanding of anemia prevention in order to effectively combat anemia. Even though this 
study's results did not indicate a significant relationship, it is still crucial for adolescents to 
sustain their nutritional status and enhance their understanding of anemia prevention to 
effectively combat anemia. 

Declarations 

Authors' contribution 

MD contributed to the data collection, analysis, and manuscript. EG contributed to the 
research design and manuscript.  

Funding statement 

This research is funded by Lembaga Penelitian dan Pengabdian Masyarakat (LPPM) 
Universitas Ahmad Dahlan 

Conflict of interest 

There is no conflict of interest in this research.  

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