Before she was diagnosed with anemia in 2016, Ayunda Rahmaputri Isnawan, 16, an 11th grade student of SMAN 1 Pasawahan state high school in Purwakarta, West Java, was a vivacious and clever student who not only assisted her classmates in understanding lessons on mathematics and physics, but also joined a number of extracurricular activities, language courses as well as student organizations.

“Then, when I was in the 10th grade, I had to skip classes because I had to be treated at the school clinic for being physically exhausted and lethargic all the time. I couldn’t concentrate on my lessons,” she told The Jakarta Post.

Fortunately, the above-mentioned symptoms did not affect her grades and she continued to make excellent marks on tests. Her extracurricular activities, however, suffered due to her condition.

“I had to skip my extracurricular activities in geology and astronomy, as well as musical activities like angklung [traditional musical instrument made from bamboo] and choir. I also had to skip my English language courses,” she said.

At this point, Ayunda still had no idea what she was suffering from, until one day in 2016, she collapsed at school. After being taken to the hospital by one of her teachers, Nina Soviana, she was diagnosed with severe anemia and had to take medication for up to two months.

Ayunda is not alone. Fauziah Aska, a 16-year-old student of SMAN 5 Karawang state high school in Karawang, West Java, said a number of girls in her school have complained about not being able to concentrate on their lessons, while having to skip extracurricular activities — which the school offers in abundance, from choir to theater.

“We already know from biology class that the human body needs iron as one of the essential nutrients for hemoglobin production. Plus, [we know] the definitions of anemia, and yet, we were not aware when the condition presented itself,” Fauziah said.

Anemia is a condition whereby an individual’s hemoglobin count in the red blood cells decreases. Hemoglobin is the protein that transport oxygen to the whole body. Medical doctor Tutut Sri Purwanti said that risk factors for anemia include iron deficiency, caused by the insufficient consumption of food that supplies micronutrients to the body.

“The body absorbs iron best when it comes from red meat, chicken or ati [chicken or beef liver]. This is why red meat is also needed in our diets. Green vegetables are also good sources of iron,” Tutut explained.

In Indonesia, anemia has become an epidemic among young girls, especially those who live in West Java. According to Director of Community Nutrition, Ministry of Health, Doddy Izwady, the World Health Organization (WHO) revealed in its 2011 Global Prevalence of Anemia survey that around 22 percent of non-pregnant Indonesian women aged 15 to 49 years old are at risk of suffering from anemia. The prevalence of anemia among pregnant women in Indonesia, meanwhile, is 37 percent based on the Indonesian Health Ministry’s 2013 Basic Health Research.
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People living in West Java became particularly vulnerable to anemia due to poor hygienic and sanitation habits, which led to high prevalence of infection by intestinal worms – which indirectly serves as a risk factor for anemia as well.

According to the same research, meanwhile, the prevalence of anemia among girls aged 15 to 24 amounted to 18.4 percent. However, significant inter-province disparities exist with anemia rates in adolescent girls as high as 50% in some areas in the country.

Girls living in West Java are especially prone to anemia: according to some research studies, particularly by Briawan in 2014, anemia prevalence in some districts in the West Java province were between 36 to 56 percent.

Contacted separately, Secretary of Karawang District Health Office, Nurdin Hidayat added that based on a research study in 2012, the Karawang regency has recorded a prevalence rate of 46.62 percent for anemia among the region’s adolescent girls.

Anemia brings serious consequences for adolescent girls, from lagging behind their peers in academic and extracurricular achievements to a high risk of maternal mortality and birth complications in adulthood.

According to Nutrition International (NI) Indonesia Country Director Elvina Karyadi, adolescent girls are more susceptible to anemia than boys because they are at the age at which they start menstruating. This is why adolescent girls have been the focus of the government’s anemia prevention program.

“Lifestyle factors, whereby girls do not want to eat meat or eat just a disproportionally small amount of food because they are afraid of gaining weight, also serve as risk factors for anemia among adolescent girls — not to mention the popularity of nutritionally-void fried snacks,” Elvina explained.

Elvina said that people living in West Java have became particularly vulnerable to anemia also due to poor hygiene and sanitation, which leads to infections of intestinal worms [and] indirectly to anemia as well.

“People here don’t wash their hand with soap regularly and still defecate out in the open,” Elvina said, explaining why intestinal worm infections were still prevalent in West Java.

Tutut explained that intestinal worms disrupt the absorption of micronutrients, including iron, leading to anemia.

To help the West Java province mitigate anemia among young girls, NI has been working closely with a number of stakeholders across regencies — including Purwakarta, Cimahi, and Karawang— to make effective use of their health budgets in devising an effective intervention program, according to Elvina.

This intervention is a part of NI’s Right Start and MITRA Youth programs designed to reduce anemia and improve nutrition for adolescent girls across Indonesia. Right Start, funded by the Government of Canada’s Global Affair Canada (GAC) is being implemented in 35 districts in two provinces, West Java and Banten, and will support with advocacy meetings, capacity building activities, provision of IEC materials prototypes, and monitoringuntil 2020. Similarly, adolescent girls in senior high schools in 2 provinces, 20 districts will benefit from weekly IFA tablets through the MITRA Youth program implemented by NI with funding from the Government of Australia’s Department of Foreign Affairs and Trade (DFAT) over 3 years till 2020. Both, Right Start and MITRA Youth, interventions will benefit 5.2 million adolescent girls.

Both Right Start and MITRA Youth interventions include public awareness campaigns, behavior change communication so that the girls are more aware of the need to consume IFA tablets and are well equipped to deal with any side-effects, training of teachers and school staff as well as capacity building of health workers.

Many research studies have suggested that weekly consumption of iron and folic acid tablets, accompanied with proper nutrition counseling to produce long-term health behavior change, could significantly reduce anemia among adolescent girls. Therefore, it is a globally accepted approach to deal with the illness.

According to Head of Nutrition and Family Health Division, Karawang District Health Office Yayuk Sri Rahayu, DHO currently require senior high schools to give their female students Iron and Folic Acid tablets every week, regardless of whether they have anemia or not. In SMAN 5 Karawang, for instance, the supplement is taken by all female students every Monday morning, supervised by their respective teachers.

Many challenges exist in the field, mostly involving a lack of awareness among parents and students on how to consume the supplement properly.

“Some students complain of dizziness or stomachache after consuming the tablets, for instance. This is why we always inform them that to avoid such side effects, they have to consume the tablets only after eating a meal,” Yayuk said, adding that the local health agency has recorded some 30 percent compliance rate of the supplement consumption. Districts where NI has conducted the Right Start program, meanwhile, have recorded a 77 percent compliance rate between January to July 2017.

According to Yayuk, the low compliance rate in Karawang is also due to a number of factors, including the unpleasant taste of the supplement itself, as well as the misconception that it is intended for pregnant women only. Now, the supplement has been sugar-coated to make its taste more acceptable.

“Therefore, in the initial phase of the project, many parents object to having their daughters take these tablets because they are afraid rumors will spread that the girls are pregnant,” she explained, adding that the local agency was working to dispel this misunderstanding.

Public awareness has been one of the greatest obstacles to compliance here. Therefore, among the capacity building programs supported by NI is the empowerment of teachers and students to be local agents of change who spread accurate information on anemia as well as the supplement.

For instance, in its partner schools across West Java, NI has helped designate a number of “nutrition ambassadors” comprising teachers and students who will support local health agencies’ public awareness campaigns on nutrition and anemia. Similar support will be given to 10 districts in East Java and 10 districts in East Nusa Tenggara with funding from DFAT Australia.

Nina Soviana is the nutrition ambassador for SMAN 1 Pasawahan and hopes to start a trickle-down effect of information among fellow teachers, students and parents alike on anemia.

“I conduct regular discussions on anemia and IFA tablets to all teachers as well as school secretariat staff members during staff meetings. Without fail, I also ask teachers and other staffers whether they have questions regarding anemia and its treatment so we can help our students accordingly,” Nina explained.

To make them interesting, she utilized video and multimedia materials developed by the government with support from NI. The video is included in the West Java school health program website, uksjabar.com.

Nina has also asked class teachers to inform parents about anemia and its intervention during parent-teacher conferences.

She advises students to keep an eye on one another and report to their teachers immediately should they suspect that one of their peers may be suffering from anemia.

After taking the necessary medication and recovering from her anemia last year, Ayunda is now back on track, joining her favorite extracurricular activities while making progress in her English courses. She is also serving as her school’s srikandi gizi (nutrition ambassador), helping her teachers monitor students taking of supplement tablets, among others. She is now still taking the iron and folic acid tablets on a weekly basis to prevent anemia.

“We have to come up with various ways to encourage students to take their tablets. For instance, when one said that she didn’t have mineral water as an excuse for not taking the supplement, I went to the canteen and bought bottled water for her so she would no longer have any excuses,” she said smiling, remembering the incident.

Ayunda also encourages her peers to consume the tablets regularly, so that they could reach their dreams.

“I want to be a physics lecturer, because I love physics and get feel very satisfied when I’m able to solve a difficult equation. I also like teaching; my friends come to me, asking me to explain physics and mathematics problems to them and help them understand these subjects. I feel relieved when they understand my explanation, because that means nobody will disturb me anymore,” she said, laughing once again.
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Partners for Change

This page is produced by The Jakarta Post in cooperation with Nutrition International Partnership for Sustainable Community. It promotes best practices in community partnerships. For more information, contact the Supplements & Supplemental Products section at supplement@thejakartapost.com.

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