CHAPTER 1

INTRODUCTION

1.1 BACKGROUND OF THE STUDY

Health is a state of complete physical, mental, spiritual and social well-being and not
merely the absence of disease or infirmity.1
To be healthy is the fundamental right of each and every individual in all age group
e.g. children, adolescent, adult and geriatrics.1
According to WHO, adolescent age group is defined as life span between 10-19 years.
This period is characterized by rapid physical, psychological and cognitive development.
This is a vulnerable period in the human life cycle for the development of nutritional
anaemia.2
Adolescence, which literally means, “to grow into maturity,” is generally regarded as
the psychological, social and maturational process initiated by the pubertal changes. The
term teenage years is used synonymously with adolescence to describe age 13 to 19 years.3
It involves three distinct sub phases:
- Early Adolescence (age 11-14 years)
- Middle Adolescence (age 15 to 17 years)
- Late Adolescence (age 18 to 20years)
Adolescents constitute more than 1.2 billion worldwide, and about 21% of Indian
population. Morbidity and mortality occurring in this age group is mostly due to
preventable causes. Adolescents form a crucial segment of the society. Their current
nutritional status will decide the wellbeing of the present as well as the future generations. 2
As adolescent age is the formative years for development, anaemia at this stage of
life has some long term consequences, such as stunted growth, poor school performance,

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reduced immunity, menstrual irregularities, later on poor pregnancy outcomes such as
intrauterine growth restriction, low birth weight, increased perinatal morbidity and
mortality.2
In adolescent various health problems occurs such as reproductive health problems,
nutritional health problems, psychosocial problems etc., But due to poor intake and
availability of diet major health problem is anemia. Adolescents especially girls are most
vulnerable towards the problem of anemia and when they grow in age this adverse health
tendency continue to persist and impairs the health and well-being of women population
and increase the risk of maternal, neonatal adverse outcome and child mortality.4
During Adolescent various physiological changes occurs as a result, nutritional
requirements of the body increase tremendously, therefore important to consume a
balanced diet at this stage and also starts menstruation so need to consume foods rich in
iron, calcium, etc.4
In India, the prevalence of anemia is high because of low dietary intake, poor
availability of diet and high incidence of infection such as malaria, hookworm
infestation,etc.4
According to World health Organization (WHO) the haemoglobin level should be
12gm/dl for adolescent girls, haemoglobin level ranges from 11-11.9 gm/dl is considered as
mild anemia, haemoglobin between 8 gm/dl to 10.9 gm/dl is considered as moderate
anemia and haemoglobin less than 8 g/dl is considered as severe anemia.6
Various types of anemia prevalent in India such are Iron deficiency anaemia,
Thalassemia, Aplastic anaemia, Hemolytic anaemia, Sickle cell anaemia, Pernicious
anaemia.
But the iron deficiency anemia is major issues among nursing studentsdue to
chronic blood loss caused by excessive menstruation. Increased demands for iron, such as
children undergoing rapid growth in adolescence.6

Global scenario of anemia (IDA):

As per WHO Global Database on Anemia in Geneva (2013), anemia affects 1.62
billion in the general population which corresponds to 24.8% of the pediatric population.

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 The highest prevalence is 47.4% in adolescent age group (95%, 9 CI: 45.7-49.1). The
World Health Organization estimated that about 30% of the world‟s population suffers
from anemia.7
India has the highest prevalence of iron-deficiency anemia among women,
including adolescents, worldwide.7
70% of Indian nursing studentsare anemic (Hemoglobin (Hb) < 12. Studies have
revealed that 65 % to 75 % of the nursing studentsin India are anemic.8

According to the NFHS-4 (2015-2016), provides information on population, health

and nutrition for India. NFHS 4 provides data on anemia in reproductive age of group of
Dadra and Nagar Haveli as shown table: 9

1. Anaemia database among reproductive age group

Indicators Urban Rural Total

a. Non-pregnant women age 15-49 years who are 72.1 86.1 80.1
anaemic (<12.0 g/dl) (%)
b. Pregnant women age 15-49 years who are anaemic - -
(<11.0 g/dl) (%) 67.9
c. All women age 15-49 years who are anaemic (%) 70.6 86.6 79.5

Though iron and folic acid supplementation remains the corner stone in treatment of
anaemia nutrition education and food supplementation are long term measures in
preventing the recurrence. Food based approaches are gaining high potential for long
lasting benefits in improving nutritional status of folate and serum iron status.10
Beetroot juice will help in treating anemia by increasing the blood count. Beetroot
juice is particularly beneficial as an anemia remedy for children and teenagers, according to
H. K. Bakhru author of “food that heal”. Beetroot strengthens the body‟s immune power
and has proved to be an excellent remedy for anemia, especially for children and
adolescents where other blood forming remedies have failed.11

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1.2 NEED FOR THE STUDY
Adolescence is an age of opportunity for children and it‟s a pivotal time for us to
build on their development in the first decade of life, to help them navigate risk and
vulnerabilities and to set the path to fulfilling their potential.12
Girls typically start puberty around age 10-12 and achieve their full adult height by
the age of 15. Inadequate nutrition during late childhood and adolescence can therefore
have a significant impact on a woman‟s adult health and the health of her children. Under
nutrition during childhood and adolescence is associated with higher risk for preterm
delivery and still birth or miscarriage.13
Mild to moderate anaemia usually appear in the early life and if proper intervention
is given in adolescent age, majority of maternal and perinatal mortalities and morbidities
can be prevented.13
A high prevalence of anemia among nursing studentswas found higher in low
economic states. It was seen that anemia affects overall nutritional status of adolescent
girls. The problems of adolescence are multidimensional in nature and require holistic
approach. 14
Iron deficiency is the most common cause of nutritional anaemia. Children during
the phase of rapid growth such as pre-school age and adolescence are at higher risk for
development of iron deficiency anemia. The real cause of the widespread iron deficiency
anemia in developing countries is probably attribute to two factors:-decreased absorption of
iron and increased loss due to intestinal parasites.15
Iron deficiency anemia occurs when body doesn't have enough iron. Iron is
important because it helps get enough oxygen throughout body. Body uses iron to make
hemoglobin. Hemoglobin is a part of red blood cells. Hemoglobin carries oxygen through
body. If a person do not have enough iron, body makes fewer and smaller red blood cells.
Then body has less hemoglobin, and a person cannot get enough oxygen. Iron deficiency is
the most common cause of anemia.16
The most severe consequence of iron depletion is iron deficiency anemia (IDA) and
it is still considered the most common nutrition deficiency worldwide. Although the
etiology of IDA is multifaceted, it generally results when the iron demands by the body are
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not met by iron absorption, regardless of the reason. Individuals with IDA have inadequate
intake, impaired absorption or transport, physiologic losses associated with chronological
or reproductive age, or chronic blood loss secondary to disease.17
Iron deficiency to be one of the most prevalent forms of malnutrition, yet there has
been lack of consensus about the nature and magnitude of the health consequences of iron
deficiency and the Public Health importance of iron-deficiency among population, which
was made as part of Global Burden of Disease (GBD) 2000 Project.13
Gayathri et. al (2013) conducted study to assess the effectiveness of beet root juice
on hemoglobin among nursing studentsin Aringar Anna Government Higher Secondary
School, Chennai, Tamil Nadu. A total of 60 nursing studentswere selected for the study, 30
girls were in experimental and 30 girls were in the control group who fulfilled the inclusive
criteria. The freshly prepared beetroot juice was administered to the samples for 20 days in
midmorning. It showed a highly significant improvement in hemoglobin level following the
administration of beetroot juice (p<0.001), in comparison with the control group.11
As iron deficiency anemia is due to faulty diet intake, a good source of iron may
help to protect or treat this condition. Beetroot is one of the good sources of iron and folate
and it easily available in India.
Biradar et al (2012) conducted a cross-sectional study to estimate the prevalence of
anaemia which was 41.1%.It was observed that the prevalence of anaemia was high in late
adolescents (15-19yrs) as compared to that in the early adolescents (10-14yrs). A majority
of the girls had mild anaemia. The prevalence of anaemia was considerably high among the
girls who belonged to the low socio-economic status.18
Personal experience of the investigator and review of literature revealed that
nursing studentsare prone to be anemic and lack knowledge regarding prevention of
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anemia. So, researcher has undertaken the study to assess effectiveness of beetroot juice
on serum iron, CBC and clinical features among nursing studentswith iron deficiency
anaemia.

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 1.3 STATEMENT OF THE PROBLEM

“A study to assess effectiveness of beetroot juice on serum iron, CBC and clinical
features among nursing students with iron deficiency anaemia in selected college of
Jalandhar Cantt.”

1.4 OBJECTIVES OF THE STUDY

The objectives of the study were to:

1. assess prevalence of anemia among adolescent girls

2. assess the pretest level of serum iron, CBC and clinical features among nursing students
among control and experimental group.

3. assess the posttest level of serum iron, CBC and clinical features among nursing
students among control and experimental group.

4. assess effectiveness of beetroot juice on serum iron, CBC and clinical features among
nursing students between control and experimental group.

5. find association between pretest level of serum iron with selected demographic variables
among nursing students between control and experimental group.
1.5 HYPOTHESES
H1: There will be significant difference between the level of serum iron, CBC and clinical
features before and after the administration of beetroot juice among nursing studentsin
experimental group.

H2: There will be a significant association between the pretest level of serum iron with
selected demographic variables among adolescents girls among control and experimental
group

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1.6 OPERATIONAL DEFINITIONS
1. Effectiveness

In this study effectiveness refers to extent to which the beetroot juice given is effective

in improving the serum iron, CBC and minimize clinical features among the adolescent girls.

2. Beetroot juice

In this study beetroot juice refer to a juice prepared from commercially available beet root
powder mixed with sugar, lemon juice, ginger juice and water as follow:

Nutrient content of beetroot juice

Sr. Nutrient Beetroot Sugar Lemon juice Ginger juice

No. powder
100gm 100ml 10ml
(100gm)
a. Calories 355 kcal 387kcal 26kcal 08kcal
b. Carbohydrate 82.11gm 99.89gm 8.9gm 1.78%
c. Fat 0.50gm - - -
d. Phosphorus 219mg - - -
e. Vitamin C 40mg - 79% 0.32gm
f. Iron 4.8mg - - 1.60mg
g. Calcium 74mg - 1% 0.05mg

Sr. Item Quantity

no.
1 Commercially Available Beet 100gm
Root Powder
2 Sugar 100gm

3 Lemon Juice 100ml

4 Ginger Juice 10ml

5 Water 1000ml

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3. Serum Iron
In this study serum iron refers to estimated level of blood iron of blood collected
from nursing students.

4. Complete blood cell count (CBC)

In this study CBC count refers to assessment or evaluation of haemoglobin,
hematocrit, MCV (Mean corpuscular volume), Mean Corpuscular haemoglobin (MCH),
Mean Corpuscular haemoglobin Concentration (MCHC), RDW (Red Cell Distribution
Width) among nursing students.

5. Clinical features

In this study clinical features refers to observation of clinical features

present in nursing students having iron deficiency anemia by using self–structured
observation rating scale.

6. Nursing students

In this present study nursing students refer to the females belonging to the age
group of 19-24 years, having iron deficiency anaemia.

7. Iron Deficiency Anemia

In this study Iron deficiency anemia refers to a condition in which serum iron level
is less than 33 mcg/dl and haemoglobin concentration of the blood is lower than 12
gm/dl in nursing students.

1.7 CONCEPTUAL FRAME WORK

Conceptual frame work is defined as a written or visual presentation that explain the
main things to be studied in either graphically or narrative form –the key factors, concepts
or variables and the presumed relationship among them.(Miles and Huberman,1994)
A conceptual model gives a clear picture for logical thinking for systematic
observation and interpreting the observed data. The model also gives direction for relevant
question on phenomenon and point out solution to practical problems.

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 A conceptual model frame work deals with the concepts of the research problem
assembled together that provide a certain frame of reference. The frame work helps and
guides the researcher to gain insight into the problems by explaining the relationship
between the facts. One of the important purposes of theoretical framework is to
communicate clearly the relationship of various concepts.
The theoretical frame work for the present study is developed from “Nora J
Pender‟s Health Promotion Model (1982; revised 1996) was designed to be a
“complementary counterpart to models of health protection”.19
Health promotion is directed at increasing a client‟s level of wellbeing.
Health promotion model describes the multi-dimensional nature of persons as they
interact within their environment to pursue health.
The model focuses on the following areas:
 Individual characteristics & experiences
 Behavior specific cognition and affect
 Behavior outcome

INDIVIDUAL CHARACTERISTICS & EXPERIENCE

1) Prior related behavior
Prior related behavior describes the frequency of similar behavior in the past direct
and indirect effects on the likelihood engaging in health promoting behaviors.
In this study the prior related behavior includes the assessment of demographic
characteristics such as age, educational class, have you attained menarche, age of
menarche, regularity of menstruation, monthly family income, type of family, religion,
diet.
2) Personal factors
Personal factors are categorized as biological, psychological and socio cultural
factors that are predictive of a given behavior and shaped by the nature of the target
behavior being considered.
In this study personal factors include:

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Biological factors: age, have you attained menarche, age of menarche, regularity of
menstruation.
Psychological factors: Not included
Sociological factors: Educational class, monthly family income, type of family, religion,
diet.

BEHAVIOR COGNITIONS AND AFFECT

1) Perceived benefits of action – perceptions of the positive or reinforcing consequences
of undertaking a health behavior.
In this study the perceived benefits of action , that is, ingestion of beetroot juice will
helps the nursing studentsto increase serum iron, CBC count and improved clinical features
among the nursing students with iron deficiency anemia.
2) Perceived barriers to action – perceived barriers can constrain commitment to action,
a mediator of behavior as well as actual behavior.
In this study perceived barriers to action
 Lack of knowledge
 Poor availability
 Lack of practice and motivation
 Loss of blood due to menstruation
 Poor absorption
 Unhealthy diet
 Poor cooking style
 Lack of choice of healthy food
 Lack of time
 Unhealthy food choice
 Cost
 Intestinal infestations
3) Perceived self-efficacy
Perceived self-efficacy is judgment of personal capability to organize and execute a
health promoting behavior. Perceived self-efficacy influences perceived barriers to the
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action so that higher efficacy results in lowered perceptions of barriers to the performance
of barrier.
In this study, the efficacy is the nursing students realizes the importance of taking
of beetroot juice it will help to increase serum iron, CBC count and improve clinical
features among the nursing students with iron deficiency anemia.

4) Activity related affect

Activity related effect describes subjective positive or negative feelings which occur
before, during and following behavior based on the stimuli activity related affect influence
perceived self-efficacy, which means the more positive the subjective feeling, the greater
feeling of efficacy. In turn increased feeling of efficacy can generate further positive affect.
In this study activity related affect administration of beetroot juice nursing students
feels need to consume daily life and it helps to increase serum iron and CBC count and
improve clinical features among the nursing students with iron deficiency anemia.

5) Interpersonal influences
According to this theorist the interpersonal influences includes the cognition
concerning, behaviors, beliefs, or attitudes of the others, norms, social support, and
modeling. Primary sources of interpersonal influences are families, peers and health care
providers.
In this study interpersonal influences is the intervention and interaction of
researcher during administration of beetroot juice with nursing students in experimental
group which will motivate to continue ingestion of beetroot juice.

f) Situational influences
According to the theorist situational influences are personal perceptions and
cognition of any given situation or impede behavior that include perceptions of options
available, demand characteristics and aesthetic features of the environment in which given
health promoting is proposed to take place. Situational influences may have direct or
indirect influences on health behavior.
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 In this study situational influences is refers to the efforts of the researchers made to
improve the aesthetic sense in environment that is a deliberate efforts of researcher to
ensure clean, hygienic and healthy physical environment of a mess before, during and after
administration of beetroot juice.

BEHAVIORAL OUTCOME

1) Immediate competing demands and preferences

According to this theory, competing demands are those alternative behaviors over
which individuals have low control because there are environmental contingencies such as
work or family care responsibilities. Competing preferences are alternative behavior over
which individual exert relatively high control.
In this study intake of beetroot juice is an alternative behavior along with normal
meal pattern which may influence the nursing students to gain knowledge on taking
beetroot juice.
2) Commitment to plan of action
According to the theorist commitment to plan of action is the concept of intention
and identification of a planned strategy leads to implementation of health.
According to this study intake of beetroot juice administered for continuous 60 days
at fixed time as a implementation of planned strategy helped the nursing students with iron
deficiency anemia in experimental group to have regular intake of it.

3) Health promoting Behavior

According to the theorist health promoting behavior is an end point or action
outcome directed towards the attainment of health outcome such as optimal well-being,
personal fulfillment and productive living.
In this study the post intervention level of Hb, CBC, Serum Iron and clinical
features was informed to the study subjects and was asked to foster the same behavior for
future.

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 CONCLUSION

This chapter deals with background of the study, need of the study, statement of the
problem, objectives of the study, hypothesis, operational definition, and conceptual
framework.

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