Knowledge and attitudes on anemia and menstrual health among Malaysian female university students

In general, women of reproductive age (WRA) are significantly more prone to be anemic than men⁴, primarily due to menstrual blood loss, insufficient nutrient intake, or parasitic infections²⁴. This study discovered an alarming public health issue where over half of the Malaysian female university students (59.4%) were anemic. Those with mild and moderate anemia were 30.0% and 29.4% respectively. The prevalence of anemic non-pregnant females in this study was almost double the data from the previous National Health and Morbidity Survey (NHMS) year 2015 and 2019, which were 34.8%²⁵ and 29.9%² respectively. Meanwhile, the prevalence of anemic young females in this study was higher than in China²⁶ (16.4%), Indonesia²⁷ (48.9%), and India⁷ (57.0%); but lower than the data reported in Bangladesh²⁸ (63.3%) and Saudi Arabia²⁴ (64.0%). These findings highlight the need for targeted interventions by healthcare providers, including early screening and nutrition education to manage and reduce the prevalence of anemia. With that, the nutritional health and overall health outcomes of WRA, especially among female students can be improved.

In this study, anemic students were found to experience longer menstrual durations and heavier menstrual flows compared to their non-anemic counterparts. Heavy menstrual bleeding is a common medical condition that affects up to 25% of women globally²⁹. Due to the body’s inability to maintain adequate haemoglobin levels and exacerbate menstrual flow, this creates a vicious menstrual cycle with heavy bleeding and leads to abnormality in terms of menstrual frequency, volume, regularity, and duration, which may contribute to higher anemia risk³⁰. Chronic iron deficiency may disrupt normal menstrual cycle regulation, leading to extended periods. Consistent with previous literature, prolonged menstrual duration can be both a cause and an effect of anemia, coupled with other wide-ranging symptoms such as hair loss, fatigue, dizziness, and overall poor health, further impacting their quality of life³¹. Therefore, a proper diagnosis and regular treatment of iron deficiency anemia are crucial to breaking this cycle and restoring normal menstrual function.

Although the subjects of this study were pursuing tertiary education, most of them had poor knowledge about anemia, as shown in Fig. 1. This finding is inconsistent with previous studies^32,33,34, as higher education is often assumed to correlate with better access to household resources, health knowledge, and practices, but it was not observed in this study. While the significant difference lies in the proportion of students with poor and high knowledge levels between the anemic and non-anemic groups, it is notable that even among students with high knowledge, a substantial proportion were still anemic (24%). Several factors that may affect anemia status were not assessed as they were not within the scope of this study, such as environmental factors, dietary practices, and access to healthcare services. To fully understand and effectively combat anemia, future research should explore these factors and their interactions, as they may play a crucial role in influencing anemia status among young females. Thus, while knowledge is vital, policymakers and health professionals must consider these additional factors when developing comprehensive strategies to address anemia in this population. A multifaceted approach to address anemia, going beyond knowledge enhancement is warranted.

Besides that, female students enrolled in health-related majors had significantly higher knowledge scores compared to those in non-health-related disciplines, which is consistent with findings from past studies^12,35. These results highlight the importance of targeted educational interventions for non-health-related students, as they may lack adequate exposure to health information. University curricula for non-health majors could benefit from integrating essential health education topics, including anemia awareness and prevention strategies^3,12. By fostering greater awareness among students across all disciplines, universities can contribute to reducing the prevalence of anemia among young women, ultimately improving overall health outcomes.

Students from this study had inadequate knowledge about the causes of anemia and were unsure about the examples of iron-rich foods, such as fish, eggs, and fruits. This deficiency in knowledge suggests that current educational efforts among Malaysian female university students might be insufficient. Students in this study may underestimate their risk and severity of anemia, believing it to be predominantly affecting older populations. While older age does correlate with higher anemia prevalence, young women may also experience anemia due to other underlying reasons related to environmental factors³⁶ that could affect their diet. For instance, students who stayed in the hostel within the campus area were more likely to be anemic, probably due to limited access to household resources, stress, long study hours, limited dietary choices, and poor eating habits^37,38. which might affect their dietary quality and subsequently, nutritional status. This underscores the urgent need for targeted nutritional interventions and educational initiatives to enhance knowledge about anemia and its dietary management, particularly to prioritise the implementation of comprehensive health programmes within university settings.

Almost half of the students in this study were from low-income households or had low personal allowance. Limited knowledge regarding the importance of dietary iron intake, particularly among students from low-income households could contribute to an increased risk of anemia³⁸. A comprehensive meta-analysis³⁹ found that those with food insecurity due to low socioeconomic status had a higher anemia risk. These students might have financial challenges, which affect their dietary choices. For instance, iron-rich foods such as red meat, fish, and some vegetables can be more costly, pushing students towards more affordable but less nutritious alternatives. Hence, there is a high possibility that students may skip meals or rely on low-cost but energy-dense foods, which further exacerbates the risk of anemia⁴⁰. Hence, nutrition education should aim to foster a health-conscious culture by promoting healthy eating, including consumption of iron-rich foods within a budget to mitigate this health concern.

Attitudes towards anemia play a crucial role in its management and prevention which may vary widely based on awareness, cultural context, and personal experience with the condition. Although this study did not identify the association between attitude and anemia status among the study population, the study revealed that 84.1% of female students exhibited poor attitudes towards anemia, indicating a widespread lack of concern or awareness about the condition. The findings were inconsistent with previous data⁴¹, where positive attitudes were shown with adequate awareness of anemia among female university students in Malaysia, which can be attributed to the medical-related academic background of the participants. In contrast, the current study included students from all fields and not limited to medical, which showed a better representativeness of the population. Students with medical training from a medical university are more likely to have better awareness and understanding of anemia, leading to more proactive attitudes towards the condition. This educational background fosters a proactive approach to health, including regular health check-ups and the incorporation of iron-rich foods into their diet. The knowledge, attitude and practices (KAP) theory suggests that change in practice is a gradual process involving the acquisition of knowledge and the subsequent generation of positive attitudes⁴². Previous study found that enhancing the females’ knowledge about anemia prevention is essential for improving their understanding and fostering a better attitude towards managing and preventing the condition⁴².

This study found that female students with good knowledge of anemia were more likely to have better anemia status compared to those with poor knowledge, showing a significant protective effect of knowledge against anemia. This suggests that a better knowledge level may mitigate anemia risk. Previous studies also revealed that the majority of Ghanaian students were aware of anemia and its prevention in theory⁴³, but they did not translate the knowledge into practical dietary habits that could improve anemia status. Hence, knowledge as a modifiable risk factor that crucially links to anemia prevention should be highlighted and enhanced through targeted health education and interventions. While health education helps to raise awareness about anemia, its effectiveness must be complemented by practical support measures. Hence, it is essential to conduct further research to identify specific obstacles faced by these students in applying their knowledge. Collaborative efforts from health educators and policymakers are also important in ensuring that awareness translates into practices to foster sustainable behavioural actions that mitigate anemia risks and subsequently, improving the students’ overall health outcomes.

The study adds to the existing body of knowledge by providing data on the relationship between knowledge, attitude, menstrual health, and anemia status among female university students in Malaysia. This contribution is valuable for researchers and policymakers working on anemia prevention. By concentrating on females, the study addresses a high-risk group for anemia. This information is crucial for designing targeted educational interventions to meet the specific needs and challenges faced by this demographic. However, this study is not without limitations. The causal relationship between the knowledge and attitudes toward anemia status remains unknown due to the cross-sectional study design. BFesides, this study implied the convenience sampling method for subject recruitment in three universities, thus, the participants may not be representative of the broader population of female university students in Malaysia, limiting the generalisability of the findings.