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Anemia is a global public health problem affecting both developing and developed countries with major consequences for human health well as social and economic development.

1. Introduction

1.1 Back ground

Anemia is a global public health problem affecting both developing and developed countries with major consequences for human health well as social and economic development. It occurs at all stages of the life cycle, but is more as prevalent in pregnant women and young children. Iron deficiency anemia (IDA) was considered to be among the most important contributing factors to the global burden of diseases. Hemoglobin (Hb) concentration is the most reliable indicator of anemia at the population level. Measuring Hb concentration is relatively easy and inexpensive, and this measurement is frequently used as a proxy indicator of iron deficiency. However, anemia can be caused by factors other than iron deficiency. In addition, in populations where the prevalence of inherited hemoglobin apathies is high, the mean level of Hb concentration may be lowered. ³

Anemia is defined as a low level of hemoglobin in the blood, as evidenced by a reduced quality or quantity of red blood cells. The hemoglobin concentration lower than the established cutoff value defined by the World Health Organization as a hemoglobin value <13gm/dl for men ³ 15y, <12gm/dl for non pregnant women, lactating mother and children of ³ 12:00-14.99 yrs of age group and <11gm/dl in case of pregnancy². Nutritional survey of urban and rural in Bangladesh, 2003 was shows 46% non pregnant and 39% pregnant women were anaemic⁴. Anemia hampers physical and mental performances, immunity and productivity and in pregnancy also related to intrauterine growth retardation². These effects are not only harmful to human health but they also have an impact on social and economic development. Economic losses due to iron deficiency in South Asia have been estimated at USD 5 billion annually.

The cause of anemia are multifactor and amongst others includes iron deficiency and other nutritional deficiencies, heavy blood loss during menstruation, or from gradual blood loss due to parasitic infection, especially hookworm infections,^6-7 malaria and other diseases (tuberculosis, peptic ulcer, gastritis, cancer, HIV, diarrhea caused by bacterial infection). Contributing factors which may cause anemia are inadequate, inappropriate diet and poor absorption of iron by the body, poor nutrition including vitamin A and B_12, folate, riboflavin, copper and dietary knowledge and practices, poor hygiene and sanitation practices, lack of access to health services and poverty. In addition, although iron deficiency anemia accounts for most of the anemia that occurs in underprivileged environments, several other possible causes should be noted. These include haemolysis occurring with malaria; glucose-6-phosphate dehydrogenase deficiency; congenital hereditary defects in hemoglobin synthesis; and deficits in other nutrients, e.g. vitamins A, B12 and C, and folic acid.

World Health Organization has identified anemia is one of the most serious public health problem.² Beside that another study, it was found that anemia and iron deficiency cause reduced physical work capacity.⁹ Iron deficient workers with low hemoglobin concentrations were reported to have lower work outputs than their healthy collegues. Anaemia also results in reduced work productivity. It is estimated that 7.9% of GDP in Bangladesh is lost due to anaemia¹⁰. The effects of childhood under nutrition beginning with a low birth weight sometimes associated with irrevocable elements of growth continue into adolescent adulthood. Inadequate dietary intake of energy, protein and micronutrients constitute the primary and most direct cause of nutritional anemia in Bangladesh. During activities garments worker take on greater responsibilities for their health. They must choose a healthy diet to increase their work productivity.

The government of Bangladesh has recently made an effort to address the health needs of our country people. Under the current Health Nutrition and Population Sector Program (HNPSP) 1998-2003, the government of Bangladesh has created the Maternal Nutrition and Adeloscent Health Program (MNADH) as a component of reproductive health care under the essential service package (ESP) but there is no specific program for garments worker. Some NGO’s are working for them which are not sufficient.

No study has so far been conducted on the work output levels and behavior changes effect of anemia in our population. The present project is the first study which has been undertaken to assess the association between hemoglobin status and related food intake pattern among garments workers attending in Dhaka city.

1.2 Justification of the study

Nearly one-forth population of Bangladesh is aged between 10-19 years. Girls are particularly vulnerable at this age. Available figure are showing that a significant number of adolescent girls suffer from malnutrition and anemia, which is one of the contributing factors for lower female longevity. Ill health and nutrition compromise both the quality of life of garments worker and the potential of benefit they received. Nutritional problems of garment worker may be greater and more widespread than previously thought. It is likely that the scale of nutritional problems of garments worker may have previously been underestimated. More data on health and nutrition of garment worker are needed to assess the scale of their nutritional problems. Poor dietary habit leads decrease the hemoglobin of blood .Anemia makes it more difficult for men and women to earn incomes carry out daily tasks and care for their families. It makes women weaker during pregnancy and delivery, reducing their chances having healthy babies and surviving blood loss during and after child birth. Anemia is a severe public health problem (³ 40%) in Bangladesh. In past 45 years the situation remains almost same. This is probably because of inappropriate dietary intake and also inappropriate micronutrient supplementations.

Although the critical role of nutrition in pubertal growth and development actually begins before adolescent- during childhood, total nutrients needs are higher during adolescent to adult than at any other time in the life cycle. A failure to consume an adequate diet can potentially hamper growth, development and productivity. But information on dietary pattern of garment worker is not adequate. This is the usual scenario in Bangladesh.

In Bangladesh, garment workers are the most deprived and underprivileged group. In every aspect of life they are receiving less attention, especially in terms of food and health care. Female garments worker are the worst suffers. During activity nutritional demand of the garment worker are commonly not met and they lose their vigor and strength. There are only few this type of studies has done in our country. In this study has been taken to assess the association between dietary pattern and hemoglobin level among garment workers. It was hoped that the outcome of this research would facilitate the understanding of nutritional status as well as the dietary pattern of garment worker in Bangladesh

1.3 Research Questions

• What is the hemoglobin status of the garments worker?

• What is the dietary intake pattern of the study garments worker?

• What is the influence of sociodemographic factors on the level of hemoglobin among the garments worker?

• What is the relationship between nutritional status and hemoglobin level of the garments worker?

1.4 Objectives of the study

General objectives

• To find out hemoglobin status and related food intake pattern among garment workers.

Specific Objectives:

• To assess the hemoglobin status of the garment workers.

• To study the dietary intake pattern among the garment workers.

• To study the influence of socio demographic factors on the level of hemoglobin among the garment workers.

• To find out the relationship between nutritional status and hemoglobin level of the garment workers.

1.5 key variables

Personal characteristics

? Age

? Garments worker

Socio-economic variables

? Marital status

? Religion

? Family size

? Family type

? Educational status

? Monthly income

? Hand wash

Food pattern variables

? Iron rich food group

? Vitamin C rich food groups

? Fortified food

Anthropometric variables

? Height

? Weight

2. Literature review

There were very few studies have been done regarding iron deficiency anemia in garments worker in Bangladesh. Studies related to global and Bangladesh situation were cited. The necessary literature was obtained from library, internet browsing, original research papers and test papers and review articles.

2.1 Anemia

Anemia is defined as a decrease in the concentration of circulating red blood cells or in the hemoglobin concentration and a concomitant impaired capacity to transport oxygen². It has serious negative consequences, including increased mortality in woman and children, decreased capacity to learn and decreased productivity in all individuals. Its devastating affects effects on health and physical and mental productivity affect quality of life and translate into significant economic losses for individuals and for countries with high anemia prevalence.

WHO definition

Hemoglobin below 12gm/dl in non pregnant female, 11gm/dl for pregnant woman and 13gm/dl in male. ²

Prevalence of anaemia (%) Category of public health significance

? 4.9 no public health problem

<5.0-19.9 mild public health problem

<20-39.9 moderate public health problem

? 40 severe public health problem

2.2 Causes of Anemia

There are different causes of anemia worldwide. Their relative importance varies by region.

Table 1: Causes of Anemia

Direct causes	Components ( in order of importance)
Poor, insufficient or abnormal red blood cell production	Poor dietary intake or absorption of iron
Excessive red blood cell destruction	Malaria
Excessive red blood cell loss	Helminth infection Bacterial or viral infection Reproduction Contraceptive method
Contributing causes	Components
Knowledge and behavior	Poor knowledge among health workers about anemia and iron supplementation, prevention and control Culturar taboos or bias ( eg, woman eating after others)
Environmental	Contaminat6ion by heavy metals ( lead)
Lack of access to services	Low use of antenatal and others providing iron supplementation Lack of trained birth attendants Lack of access to sanitation services that mitigate helminth infestation Lack of access to bed nets to prevent malaria transmission
Poverty	Lack of income to buy foods

Source: Adapted from Gillespie and Jonston (1998)

2.3 Magnitude, causes and consequences of micronutrient malnutrition

Micronutrient malnutrition is a term used to refer to diseases caused by a dietary deficiency of vitamins or minerals. More than 2 billion people in the world today may be affected by Micronutrient malnutrition. Vitamin A deficiency, iron deficiency anemia and iodine deficiency disorders are the most common forms of Micronutrient malnutrition. People of all population groups in all regions of the world can be affected by Micronutrient malnutrition. Although the most severe problems of Micronutrient malnutrition are found in developing countries, people in developed countries also suffer from various forms of these nutritional problems.¹¹

Region	Iodine Deficiency Disorders1		Vitamin A Deficiency
	At Risk	Affected(Goitre)	At Risk	Affected(Xerophthalmia)	Iron deficient or Anaemic3
Africa	181	86	52	1.0	206
Americas	168	63	16	0.1	94
South-East Asia	486	176	125	1.5	616
Europe	141	97	–	–	27
Eastern Mediterranean	173	93	16	0.1	149
West Pacific	423	141	42	0.1	1058
TOTAL	1572	655	251	2.8	2150

Estimates for vitamin A deficiency are for children from birth to five years of age.

WHO/UNICEF/ICCIDD (1994). WHO/UNICEF (1995). WHO (1992).

Micronutrient malnutrition is a major impediment to socioeconomic development and contributes to a vicious circle of underdevelopment, to the detriment of already underprivileged groups. It has long-ranging effects on health, learning ability and productivity. Micronutrient malnutrition leads to high social and public costs, reduced work capacity in populations due to high rates of illness and disability, and tragic loss of human potential. Overcoming Micronutrient malnutrition is a precondition for ensuring rapid and appropriate development. ¹¹

Poverty, lack of access to a variety of foods, lack of knowledge of optimal dietary practices and high incidence of infectious diseases are some of the factors which lead to Micronutrient malnutrition. Policies and programmes must be developed to assure availability of and access to an adequate variety and quantity of safe, good-quality foods for all people of the world. ¹¹

Vitamin A deficiency (VAD) primarily affects children; worldwide, some 250 million children are at risk (WHO 1992). It also contributes to retarded physical growth and impaired resistance to infections, resulting in high rates of sickness and death among young children.

Anemia and iron deficiency affect more than 2 billion people in virtually all countries (WHO 1992). Those most affected are women and pre-school-age children (as many as 50 percent of whom may be anemic), but anemia is also seen in older children and men. Anemia in infants and children is associated with retarded physical growth, reduced resistance to infections and slow development of learning abilities. In adults it causes fatigue and reduced work capacity and may cause reproductive impairment. ¹¹

Blood loss in childbirth is very dangerous for anemic women and is the main cause of about 20 percent of maternal deaths. Maternal anemia also leads to foetal growth retardation, low infant birth weight and increased perinatal mortality (death in the first week of life). Foods such as dark green leafy vegetables, legumes and red meat are rich in iron, as are iron-fortified food products. However, because of the low bioavailability of iron in plant foods and the high cost of red meat, prevention and cure of iron deficiency anemia is not an easy task, even in developed countries. ¹¹

Iodine deficiency disorder (IDD) is a threat to more than 1.5 billion people who live in areas where the soils are iodine deficient; more than 200 million people have goitre and 20 million suffer mental impairments (resulting in significant reduction in IQ) caused by iodine deficiency (WHO 1992). IDD is the most common cause of preventable mental retardation. In severe cases it leads to deaf-mutism, cretinism and other serious disorders, as well as reproductive impairment, which results in increased rates of miscarriage, stillbirth and birth defects. Some seafoods are good sources of iodine and adding iodine to salt is a common and effective method of preventing IDD.

Despite its link to poverty, not all micronutrient malnutrition will simply disappear as development occurs. Moderate levels of IDD still exist in some high-income European countries which have failed to take adequate measures to eliminate it on a sustainable basis.

Effective methods exist to overcome micronutrient malnutrition, but they require concrete, comprehensive, cost-effective efforts by governments to be successful. The unnecessary human suffering and hindrance to economic development caused by micronutrient malnutrition can be eliminated in large part by improving the nutritional quality of the food supply and by educating people about good dietary practices. ¹¹

2.4 Nutrition situation in Bangladesh

Horticulture-based food varieties, namely fruit, vegetables and nuts, are important for the daily diet as these contain micronutrients, fibre, vegetable proteins and bio-functional components. Consumption of fruits and vegetables is vital for a diversified and nutritious diet. Increasing dietary diversification is the most important factor in providing a wide range of micronutrients and this requires an adequate supply, access to and consumption of a variety of foods. However, food surveys¹² show continuing low consumption of fruits and vegetables in many regions of the developing world.

2.4.1 Dietary pattern

Cereals, largely rice, are the main food in Bangladesh. Nearly two-thirds of the daily diet consists of rice, some vegetables, a little amount of pulses and small quantities of fish if and when available. Milk, milk products and meat are consumed only occasionally and in very small amounts. Fruit consumption is seasonal and includes mainly papaya and banana which are cultivated round the year. The dietary intake of cooking oil and fat is meager. The typical rural diet in Bangladesh is, reportedly, not well balanced.¹³

Traditional dietary habits often do not meet good nutritional requirements, with a preference for polished rice and leafy vegetables of poor nutritional quality. In addition, cultural norms dictate a better diet for males over females with the male head of the household getting the best meal portions. Persistent poverty, inadequate nutrition information and gender inequity cause pervasive malnutrition among women, especially pregnant women and lactating mothers.

While food habits vary at regional and even individual household levels, in general, food preparation methods result in significant nutrient loss. Minerals and vitamins, especially B-complex vitamins are lost (40 percent of thiamine and niacin) even during the washing of rice before cooking. Boiling rice and then discarding the water results in even more nutrient losses. The manner of washing and cooking vegetables leads to considerable loss of vitamin C and B-complex vitamins.

Household food consumption studies¹⁴ show that cereals make up the largest share (62 percent) of the diet, followed by non-leafy vegetables, roots and tubers, which together comprise more than four-fifths of the rural people’s total diet. Protein and micronutrient-rich foods like fish, meat, eggs, milk, milk products, fats and oils account for less than 10 percent of the rural person’s diet, and the consumption of vegetables and fruits is declining steadily.

Rural consumption of leafy and non-leafy vegetables has remained more or less the same over the past two decades after increasing over the preceding 30 years. Fruit consumption has declined in rural areas after more than doubling in the 1970s. With an average national per capita consumption of 23 g of leafy vegetables, 89 g of non-leafy vegetables and 14 gm of fruit, the average Bangladeshi eats a total of 126 g of fruit and vegetables daily. This is far below the minimum daily consumption of 400 g of vegetables and fruit recommended by FAO and the World Health Organization (WHO).¹⁵

2.4.2 Anemia status

Despite considerable improvement in the national rural health status, the nutritional well-being of rural people continues to be neglected.¹⁶ Children and women in Bangladesh suffer from high levels of malnutrition and micronutrient deficiencies such as low birth weight (LBW), under nutrition (underweight, stunting and wasting), vitamin A deficiency, iodine-deficiency disorders (IDD) and iron-deficiency anaemia (IDA). At the same time, new health problems related to over-nutrition such as obesity are emerging.

Maternal under nutrition (body mass index less than 18.5 kg/m²) in non-pregnant women in the country, while declining from 54 percent in 1996–1997 to 38 percent in 2003, is still very high.^17,18 Under nutrition, both before and during pregnancy, causes intrauterine growth retardation and is one of the major reasons for the high LBW (36 percent) prevalence in the country.

Low birth weight is more common among adolescent mothers. Marriage at very young age has serious consequences for pregnancy, future survival, health, growth and development. When combined with positive energy balance (adequate energy intake) in later life, LBW increases the risk of obesity, diabetes, high blood pressure and coronary heart disease. Between 1990 and 2004, underweight levels among children fell from 67 to 48 percent and child stunting fell from 66 to 43 percent,^19,20 but the levels are still unacceptably high.

The consumption of vitamin A-rich foods is still low, suggesting that the underlying causes of vitamin A deficiency require further attention. The diets of pregnant women in low-income groups are deficient not only in micronutrients but also in energy. Anaemia is a severe public health problem affecting pre-school children (49 percent) and pregnant women (47 percent), and a moderate public health problem among non-pregnant women (33 percent) and adolescents (29 percent).²¹ Anemia caused by iron deficiency impairs the growth and learning ability of children, lowers resistance to infectious diseases and increases the risk of maternal death and LBW. Children are malnourished by inadequate dietary intake or infectious diseases.

The underlying causes include (i) household food insecurity resulting from inability to grow or purchase a nutritionally adequate amount and variety of food; (ii) lack of dietary diversity; (iii) inadequate maternal and child care due to inappropriate hygiene, health and nutrition; (iv) low rates of exclusive breast feeding; (v) inadequate access to quality health services; (vi) poor environmental hygiene and sanitation along with low levels of income and maternal formal education. Malnutrition early in life has long-lasting and negative effects on overall growth, morbidity, cognitive development, educational attainment and adult productivity.²²

Because of this, the nutritional status of children, particularly below five years of age, is seen as one of the most sensitive indicators of a country’s vulnerability to food insecurity and overall socio-economic development. Women of child-bearing age are also highly vulnerable to nutritional deficiencies because of increased need for food and nutrients during pregnancy and lactation. ²³

A study shows that among adolescents female garments workers in Dhaka city, 15.5% of the participants were thin (<90% Wt/Ht) and about 7% overweight (>120% Wt/Ht).²⁵ In about 56%, serum vitamin A level was below the adequate level of 1.05 mole/l, with 14% having vitamin A deficiency (<0.70 mole/l). Forty four per cent of the participants were found to be anemic (hemoglobin <120 g/l). Food frequency data on vitamin A rich foods revealed that a large percentage of the participants do not take eggs (41%), milk (64%), liver (85%) and sweet pumpkin (85%); while about 40% of the girls take dark green leafy vegetables (DGLV) and 17% take small fish at least four servings a week. The girls who consumed four or more servings per week of DGLV had significantly higher serum vitamin A level than the girls who took three servings or less. There was a significant positive association between the level of serum vitamin A and frequency of intake of DGLV (r.0.12; P.0.023). When age, level of education, per capita income, hemoglobin concentration, serum protein concentration, menstruation at the time of blood collection, prevalence of current morbidity, frequency of intake of egg, milk, small fish, DGLV, liver and sweet pumpkin were accounted for by multiple regression analysis, a strong relationship was found for serum vitamin A concentration with age, menstruation, hemoglobin level and frequency of intake of DGLV. For every unit change in the frequency of consumption of DGLV, there was 0.013 mole/l change in serum vitamin A level whilst taking other factors into account. ^{25, 26}

2.5 Measures to prevent and control micronutrient malnutrition

Four main strategies – dietary improvement, including increased production and consumption of micronutrient-rich foods; food fortification; supplementation; and global public health and other disease control measures – can be implemented to overcome micronutrient malnutrition. Food-based strategies, which include food production, dietary diversification and food fortification, are the most sustainable approaches to increasing the micronutrient status of populations. These approaches not only prevent micronutrient deficiency problems but also contribute to general malnutrition prevention.

At the International Conference on Nutrition (ICN), jointly convened by the Food and Agriculture Organization of the United Nations (FAO) and the World Health Organization (WHO) in December 1992, representatives of 159 countries endorsed the World Declaration on Nutrition, pledging “to make all efforts to eliminate before the end of the decade iodine and vitamin A deficiencies” and “to reduce substantially… other important micronutrient deficiencies, including iron.”

Linked to the World Declaration on Nutrition is the Plan of Action for Nutrition, which recommends that governments give priority to food-based strategies to control and prevent micronutrient deficiencies. Policy makers and planners have recognized that the short-term supplementation programmes implemented during the last two decades in many developing countries (in which populations were supplied with vitamin A capsules, iron tablets and iodine injections) have not succeeded in solving the problem of micronutrient malnutrition in a sustainable manner. ¹¹

2.6 Iron deficiency anemia

Iron deficiency is defined as a decreased total iron content in the body. It is occurs when iron deficiency is sufficiently severe to diminish erythopoesis and cause the development of anemia. ²²

2.7 Iron deficiency anemia prevention and control

2.7.1 Implementing Food-based Strategies

Micronutrient deficiencies hinder both national economic development and the development of individual human potential. Because children are frequently the victims of this deficiency, failure to overcome micronutrient malnutrition in a sustainable fashion jeopardizes a nation’s future. Reasons for implementing food-based strategies to overcome micronutrient deficiencies include the following.

? Food-based strategies

? are preventive, cost-effective, sustainable and income generating;

? are culturally acceptable and feasible to implement;

? promote self-reliance and community participation;

? take into account the crucial role of breastfeeding and the special needs of

infants during the critical weaning period;

? foster the development of environmentally sound food production systems; and ? build alliances among government, consumer groups, the food industry and other relevant organizations to achieve the shared goal of preventing micronutrient malnutrition.

? Food, fortification, one of the food-based strategies has the potential for wide

populations’ coverage and can involve a combination of micronutrients.

? Nutrition education as a component of food based strategies emphasizes.

? Adoption of food-based strategies can make possible redirection of funds previously

devoted to curative health care and social welfare to other developmental activities. ²²

2.7.2 Micronutrient supplementation¹²

? Provide iron and folic acid supplements to pregnant woman and children 6 to

months of age.

? To maximize iron absorption.

? Promote other vitamin, mineral and nutrition supplements such as folic acid and

vitamins A and B-12 to combat anaemia caused by these nutritional deficiencies

? Promote complementary interventions to reduce anaemia such as birth spacing,

malaria and hook worm prevention and treatment.

2.7.3 Dietary approaches

? Encourage consumption of fortified food

? Promote production year-round production and collection of micronutrient-rich foods

? Suggest that food rich in vitamin C (fruits, tubers and green leafy vegetables).

Vitamin C improves absorption of iron from plants

? Educate families about the importance of animal products (meat) in the diet.

? Promote the consumption of legumes which are excellent source of folic acid.

? Promote consumption of foods with adequate vitamin A and receive minimal

cooking to loss of vitamin A.

? Restrict consumption of tea, coffee and coca to young children to between meals or

at least one hour after meals since caffeine inhibits iron absorption

Enhancers of iron absorption include:

? Haem iron, present in meat, poultry, fish and seafood

? Ascorbic acid or vitamin C, present in juce, tubers and other vegetables

?Some fermented or germinated food and condiments such as sauerkraut and soy sauce

Inhibitors of iron absorption include:

? Phytates present in cereals bran, grain, high extraction flour, legumes, nuts and seeds

? Foods with high inositol content

? Calcium particularly from milk and milk products

? Iron binding compound such as tea, coffee and coca

Besides this Evidence suggests that micronutrient deficiencies may be associated with problems in early development and behavior.²⁸

Iron deficiency is the most common nutritional deficiency in the world and a major cause of anemia ^{27, 28}, particularly during infancy and toddler hood when there is rapid growth and a high nutritional demand. ²⁹ Less is known about the prevalence of zinc deficiency, but supplementation trials in developing countries suggest low zinc intake among infants and toddlers ³⁰, which leads to the consensus that both iron and zinc deficiency are major public health problems ^28,29. In low-income societies, where dietary resources are inadequate to meet children’s requirements for iron and zinc, micronutrient supplementation or fortification may be necessary.

Iron deficiency anemia is one of the most prevalent forms of malnutrition in the world. Anemia affects the capacity of the body to work and the brain’s capacity to think and learn by causing permanent neurological damage. It hampers the national productivity and economic growth of a nation. Anemia in the adolescent age group is a major threat for their growth and optimal development. Anemia in pregnancy is directly and indirectly related to maternal mortality and a major contributing factor for low birth weight and infant mortality. ^29,31

2.8 Anemia situation in Bangladesh:

A nutrition survey of rural Bangladesh was conducted in 1975-76 and shows that 70% of non-pregnant females (age ³15y) were anaemic³². No improvements were observed in the nutrition survey in 1981-83.³³ Helen Keller International (HKI) and the Institute of Public Health Nutrition (IPHN) conducted a national survey in 1997-98, where 43% of the participating adolescent girls were anaemic³⁴. In sequential surveys in 2001 and 2004 the prevalence of anemia was 30% and 38.7% respectively³¹. UNICEF (2006) stated that there was no evidence of significant improvement in the global incidence of anemia during the past 15 years³⁴. However, the survey results from the various studies conducted in Bangladesh indicate that the situation is improving, but that there is still extremely high prevalence of anemia in the country.

The Government of Bangladesh has taken some initiative to address anemia with iron-folic acid (IFA) supplementation of adolescent girls, pregnant and lactating women especially in the project areas of the National Nutrition Program (NNP) areas and its predecessor the former Bangladesh Integrated Nutrition Program (BINP) ³⁵. The NNP has intensified actions for addressing anemia through IFA supplementation, de-worming, addressing food security and strengthening target-specific behavior change and communication (BCC) activities.

Hidden hunger and the silent loss of human capacity and quality of life due to anemia is a huge burden for Bangladesh. While the findings of the survey show no significant change in the anemia status of adolescent girls the report however, illustrates several positive behavioral changes which may contribute to improved program efforts to reduce adolescent anemia. It is hoped that the policy makers, program implementers, researchers and all relevant stakeholders take cognizance of these changes and intensify these and other appropriate initiatives to address and control anemia.

3. Methods and Materials

3.1 Study Type:

This study was a descriptive cross sectional study, part of this study was qualitative in nature. Data was collected once to assess the current situation of anemia base on hemoglobin level and related food in take pattern among garments worker in Dhaka city. Purposive sampling method was used for data collection.

3.2 Study period:

The study extended for six months, from March to July 2010. To complete the study in time, a work schedule was prepared depending on different task attached at annexure. The first three months were spent for literature review, topic selection, development of protocol and approval by the board. The subsequent three months were spent for questionnaire development and pre testing, data collection, compilation and analysis, report writing printing and submission. Literature review was simultaneously going on till the final report was written.

3.3 study subjects

The study population comprises of male and female garments workers in Dhaka city, Bangladesh.

3.4 Inclusion Criteria

n Presently working and have at least six months working experience in a garment.

n Age should be 15 years and above of age

3.5 Exclusion Criteria:

n Pregnant woman

n Lactating mother

3.6 Study area

The place of the study was Mirpur thana in Dhaka city. A purposive sample selection was made because of convenience. The residence of garment worker at Mirpur section number seven was selected for the present study.

3.7 Determination of sample size

Sample size estimation:

Formula for sample size estimation is:

n = Z²pq/d²

= (1.96) ² * (0.43) * (0.57) / (0.05) ²

= 377

Here, p= prevalence rate, 43 %

q= 1-p = 57 %

d= Standard Error, 5 %

Z=1.96 (at 95% level of significance)

According to HKI/IPHN (2006) 46% of non pregnant and 39% of pregnant woman is suffering from anaemia. Using the sample size estimation formula, calculated sample size (n) was 377. Due to a short time for the preparation of dissertation paper, a sample size of 106 was collected.

3.8 Measuring instruments and analysis:

3.8.1 Subjects and Methods

The study was conducted by using a standard interviewer-administered questionnaire. Pre-test was carried out for measuring the suitability of the contents, clarity, sequence and flow of the questionnaire.

3.8.2 Biochemical Parameter

Haemoglobin was measured by Cyanmethemoglobin method.Haemoglobin level of the garments worker was recorded from Shakti Foundation, Mirpur and Z H Sikder Hospital at Gulshan.

3.8.3 Dietary History

Iron, Vitamin C rich foods was taken by using food frequency questionnaire.

3.8.4 Ethical consideration

All ethical issues, which are related to the research involving human subjects was followed according to the guideline of BADAS ethical review committee.

3.8.5 Statistical Analysis

All statistical analysis was performed with the software SPSS 11.5 for Windows (SPSS, Inc. Chicago. IL. USA). A written consent was taken from all subjects after full explanation of the nature, purpose, and potential risks of all procedures used for the study.

4. Results

Table 2: characteristics of the study subjects (n=106)

This table shows that the age (years, mean ± SD) of the study subjects was 24.85 ±7.11 among the participants. 34% were male and 66% were female. Majority of the participants were Muslims (97%). Among the participants 56% were married and data revealed that proportion of participant 33% had up to primary, 46% had secondary. The monthly income and expenditure (BDT, mean ±SD) of the study subjects was 7363.21±2525.46 and 3166.98±1153.19 respectively.

Table 2: characteristics of the study subjects (n=106)

Parameters
Age (yrs)	24.85 ±7.11
Sex
Male Female	36 (34%) 70 (66%)
Religion
Islam Hindu	103 (97 %) 3 (3%)
Marital status
Unmarried Married	49 (46%) 57 (56%)
Education
Illiterate Primary Secondary Higher secondary	15 (14%) 35 (33%) 49 (46%) 7 (7%)
Monthly Income (BDT)	7363.21±2525.46
Monthly Expenditure (BDT)	3166.98±1153.19

Result are express as mean±SD, number (%)

Table 3: Distribution of the study subjects by the level of hemoglobin (Hb) (n=106)

This table shows that the Hb level (gm/dl, mean ± SD) of the study subjects was 11.29± 1.91.Among the female participants 41% were mild anemic, 30% moderately anemic and rest of other 6% were severely anemic. On the other hand, among the male participants 14% were mild anemic, 3% were moderately anemic. There was not found any severely anemic in male participants.

Table 3: Distribution of the study subjects by the level of hemoglobin (Hb) (n=106)

Parameter
Level of the hemoglobin(g/dl)	11.29± 1.9
Female (n=70)
>12.00gm/dl (normal)	16	23
10.00-11.99gm/dl (mild anemia)	29	41
7.00-9.99gm/dl (moderate anemia)	21	30
<7gm/dl (severe anemia)	4	6
Male (n=36)
>12.00gm/dl (normal)	30	83
10.00-11.99gm/dl (mild anemia)	5	14
7.00-9.99gm/dl (moderate anemia)	1	3
<7gm/dl (severe anemia)	0	0

Result are express as mean±SD, number (%)

Figure 1: Distribution of the female subjects by the level of Hb status (n=70)

Among the female participants 23% were non anemic, 41% were mild anemic, 30% were moderately anemic and rest of other 6% were severely anemic.

Figure 1: Distribution of the female subjects by the level of Hb status (n=70)

Figure 2: Distribution of the male subjects by the level of Hb status (n=36)

Among the male participants 83% were non anemic, 14% were mild anemic, 3% were moderately anemic. There was not found any severely anemic in male participants.

Figure 2: Distribution of the male subjects by the level of Hb status (n=36)

Figure 3: Comparison of Hb status between male and female (n=106)

Among the participants in a comparison of haemoglobin level of male and female, male were less anemic than female participants which is 17% male were anemic, where 75% female were anaemic. On the other hand, 83% male were non anemic and 25% female were non anemic.

Figure 3: Comparison of Hb status between male and female (n=106)

Figure 4: Monthly income of the study subjects (n=106)

Among the groups 26% of the participants had monthly income was < 5000 taka, 57% had in between 5000 taka to 10,000 taka and the rest of 17% were more than 10,000 taka

Figure 4: Monthly income of the study subjects (n=106)

Figure 5: Monthly expenditure of the study subjects (106)

The figure shows that majority of the participants (64%) monthly expenditure was below 5,000 taka, 25% participants had the expenditure was in between 5,000 to 10,000 taka and others (11%) had the expenditure was more than 10,000 taka.

Figure 5: Monthly expenditure of the study subjects (106)

Table 4: Weekly consumption of iron (Fe) rich food among the study subjects (n=106)

This table shows that weekly consumption of Fe rich food like Kachki fish 35 (33) ; Eel fish 15 (14); Mola fish 11 (10), Mula shak (redish leaves) 21 (20); Indian spinach (Pui shak ) 30 (28), Taro arum leaves (Kochu shak) 11 (10) , Tamarind pulp (Paka tetul) 23 (22) were 1-3 times intake per week significantly.

Compare to other foods, Bengal gram 103 (97), Amaranth leaves 103 (97) were taken in less than usual amounts.

Food Items	1-3times/wk (%)	4-6times/wk (%)	>6times/wk (%)	Never (%)
Bengal gram (Chola)	3 (3)	0 (0)	0 (0)	103(97)
Kachki fish	35 (33)	39 (37)	0 (0)	32 (30)
Eel fish (Baim fish)	15 (14)	1 (1)	0 (0)	90(84.9)
Mola fish	11 (10)	1 (1)	0 (0)	94 (89)
Liver	1 (1)	0 (0)	0 (0)	105 (99.)
Amaranthleaves (Data shak)	3 (3)	0 (0)	0 (0)	103 (97)
Mulashak (redish leaves)	21 (20)	5 (5)	0 (0)	80 (75)
Indian spinach (Pui shak )	30 (28)	18 (17)	0 (0)	58 (55)
Taroarum leaves (Kochu shak)	11 (10)	2 (2)	0 (0)	93 (88)
Tamarind pulp (Paka tetul)	23 (22)	2 (2)	0 (0)	81 (76)

Result are express as number (%)

Table 5: Weekly consumption of iron rich food items among anemic subjects (n=60)

The frequency consumption of food items intake in weekly by the anemic subjects is shows in this table. It was found that the subjects taking various type of food in a week. They had taken iron rich food like Kachki fish 12 (20), Mola fish 53 (88), Baim fish51 (85), Liver 59 (98), Amaranth leaves (Data shak) 59 (98), Redish leaves (Mulashak) 44 (73), Indian spinach (Puishak) 33 (55), Taro arum (Kochu) 56 (93), Drum stick (Sajna) 54 (90), Tamarind pulp (paka tetul) 43 (72)were intake 1-3 times per week significantly.

Food Items	1-3times/wk (%)	4-6times/wk (%)	>6times/wk (%)	Never (%)
Kachki fish	12 (20)	22 (37)	26 (46)	0 (0)
Mola fish	53 (88)	6 (10)	1 (2)	0 (0)
Baim fish	51 (85)	8 (13)	1 (2)	0 (0)
Liver	59 (98)	1 (2)	0 (0)	0 (0)
Amaranthleaves (Data shak)	59 (98)	1 (2)	0 (0)	0 (0)
Redish leaves (mulashak)	44 (73)	12 (20)	4 (7)	0 (0)
Indianspinach (puishak)	33 (55)	17 (28)	10 (17)	0 (0)
Taroarumleaves(kochushak)	53 (88)	7 (12)	0 (0)	0 (0)
Taroarum (kochu)	56 (93)	4 (7)	0 (0 )	0 (0)
Drum stick (sajna)	54 (90)	6 (10)	0 (0)	0 (0)
Tamarind (paka tetul)	43 (72)	15 (25)	2 (3)	0 (0)
Watermelon (tarmuj)	32 (53)	28 (47)	0 (0%)	0 (0%)

Result are express as number (%)

Table 6: Weekly consumption of iron rich food items of Non anemic subjects (n=60)

The frequency consumption of food items intake in weekly by the Non anemic subjects is shows in this table. It was found that the subjects taking various type of food in a week. They take iron rich food like Kachki fish 20 (44), Bengal gram (Chola) 20 (44), Taro arum (Kochu) 40 (87), Drum stick (Sajna) 42 (91), Tamarind pulp (paka tetul) 38 (83), Water melon (tarmuj) were 1-3 times per week were taken significantly.

Food Items	13times/wk (%)	4-6times/wk (%)	>6times/wk (%)	Never (%)
Kachki fish	20 (44)	13 (28)	13 (28)	0 (0)
Bengal gram (Chola)	43 (93)	3 (7)	0 (0)	0 (0)
Mola fish	41 (89)	5 (11)	0 (0)	0 (0)
Baim fish	39 (85)	8 (15)	0 (0)	0 (0)
Liver	46(100)	0 (0)	0 (0)	0 (0)
Amaranth leaves (Data shak)	44 (95)	2 (4)	0 (0)	0 (0)
Mula shak (redish leaves)	36 (78)	9 (20)	1 (2)	0 (0)
Indian spinach (Pui shak )	25 (54)	13 (28)	8 (18)	0 (0)
Taro arum leaves (Kochu shak)	53 (88)	7 (12)	0 (0)	0 (0)
Taroarum(Kochu shak)	40 (87)	4 (9)	2 (4)	0 (0)
Sajna (drumstick)	42 (91)	4 (9)	0 (0)	0 (0)
Paka tetul ( tamarind)	38 (83)	8 (17)	0 (0)	0 (0)
Tormuj (water melon)	24 (52)	22 (48)	0 (0)	0 (0)

Result are express as number (%)

Table 7: Weekly consumption of Vitamin C rich food among the study subjects (n=106)

This table shows that weekly consumption of Vitamin C rich food by study subjects like kolmileaves (Kolmi shak) 20 (19), Spinach (Palong shak) 26 (24), Snake gourd (chichinga) 40 (38), Bottle gourd (Law shak) 31 (29) 1-3 times were taken significantly compared to other foods. Green chili 106 (106) had taken more than 6 times per week.

Even amaranth leaves 103 (97), Indian spinach (palonk shak) 74 (70) were taken in less than usual amounts

Food Items	1-3times/wk (%)	4-6times/wk (%)	>6times/wk (%)	Never (%)
Kolmi shak (kolmileaves)	20 (19)	6 (6)	0 (0)	80 (7)
Palongshak (spinach)	26 (24)	6 (6)	0 (0)	74 (70)
Green chili	0(0)	0(0)	106 (100)	0(0)
Chichinga(snake gourd)	40 (38)	28 (26)	3 (3)	35 (33)
Bottle gourd (Law shak)	31 (29)	7 (7)	1 (1)	67 (63)
Amaranth leaves (Data shak)	3 (3)	0 (0)	0 (0)	103 (97)
Tamarind pulp (Paka tetul)	23 (22)	2 (2)	0 (0)	81 (76)

Result are express as number (%)

Table 8: Distribution of the study subjects by their BMI class (n=106)

The Body Mass Index (BMI) of the participants were mean± SD 20.59 2.96. Among the participants 25% were underweight, 56% were obtained normal weight, 17% were overweight and the rest of 2% was obese.

Parameter	Number	Percentage
BMI status	20.59±2.96
<18.49 (underweight)	27	25.
18.5-22.9 (normal)	56	56
23-27.49 (over weight)	18	17
>27.50 (obese)	2	2

Result are express as mean±SD, number (%)

Figure 6: Distribution of the study subjects by washing hands and utensils before eat (106)

This figure shows that 98% respondents were wash their hand and utencils before eat and rest of them 2% were not wash their hand utencils before eat.

Figure 6: Distribution of the study subjects by washing hands and utensils before eat (106)

Figure 7: Distribution of the study subjects by practice of boiling water use (106)

Majority (92%) of theparticipant was drinking boil water and 8%were not drink boil water.

Figure 7: Distribution of the study subjects by practice of boiling water use (106)

Table 9: Difference of the education level vs and Hb status of the study subjects (n=106)

Among the illiterate groups 47% were non anemic, 7% were moderately anemic and 47% were mild anemic. In the primary groups 31% were non anemic and rest of others were anemic. The majority who had secondary level education 51% of them were non anemic. The participants who had higher secondary level education among them