The Socio-cultural Determinants of Ane

mia
among Women in Reproductive Age in E
astern Indonesia: Analysis of
Indonesia Family Life Survey East (IFL
S East) 2012

Maretalinia
Institute for Population and Social Research (IPSR)
- Anemia in developing country is more complex than developed country
- South East Asia is the highest prevalence of anemia in the world
- Women in reproductive age 15-49 years in SEA was 41.9% have anemia

Globally, WHO reported

42 % pregnant women have anemia
30 % non-pregnant women have anemia

Background
 Problem Statement
Maternal deaths in Eastern Maluku, Papua and
Indonesia was the highest Nusa Tenggara island
Papua and NTT (489) are the highest poor
Prevalence of anemia National (305) population. 5 of 7
among women aged provinces has very high
15-44 was 35.3% poverty rate
(Riskesdas, 2013)

In Papua access to
community health care
reaches 32 km

Jakarta

The smallest
percentage of skilled
GDP under the birth attendance
national rate Anemia can increase
maternal deaths up to Eastern Indonesia still
22.8% has the strong culture
and belief
 Objectives

To identify individual lifestyle factors; social and community networks;

living and working conditions; and the general socio-economic, cultural, environ
mental conditions that have an influence on anemia of women in reproductive ag
e in Eastern Indonesia.
 Theoretical Framework
& Review of Relevant Research

Ethnicity, food dietary and habit, religion,

patriarchy system, decision making how HH
Social Determinants of Health (SDH) money is spent, place of residence, women
involving in community activity, strong religious
feeling

Migration experience, region, the

sector of workplace

HH food insecurity, birth attendance

General socio-economic, cultural and environmental conditions
Living and working conditions History of malaria, antenatal intake of
Social and community networks iron pills, meal frequency, BMI,
currently pregnant, delivery type,
Individual lifestyle factors
Age, sex and menstruation, breastfeeding, micro
constitutional factors nutrient intake frequency.

Age, Literacy status, Marital status,

Occupation, Income level, level of
Source: Dahlgren and Whitehead (1993) in Dahlgren and Whitehead (2006)
education, parity, number of
miscarriages,
 Conceptual Framework
Age, sex and constitutional factors
• Age
• BMI (Body Mass Index)
• Currently pregnant
Individual lifestyle factors
• Frequency of meat intake in last week
• Frequency of fish intake in last week
• Marital status  
• Income level Anemia Condition
• Level of education • Do not have anemia (Hb> 120
Social and Community Networks g/l for normal women and > 110
• Women involving in community activity
Living and working conditions g/l for pregnant women)
• Internal migration experience
General socio-economic, culture, and environmental • Have anemia (Hb <120 g/l for
conditions normal women and <110 g/l for
• Ethnicity pregnant women)
• Religion  
• Religious feeling
• Female decision maker to select the choice of food at
home
• Place of residence
 Methodology
Study Population  2,330 women in reproductive age (15-49 years old)
Source of data  secondary data IFLS East 2012 (10.759 respondents)

Study location  7 provinces in Eastern Indonesia (East Nusa

Tenggara, East Kalimantan, South-east Sulawesi, Maluku, North
Maluku, West Papua, and Papua).
Research
Method Modul types  HH (K, I, II), individual (IIIA, IIIB, IV, V, EK1, EK2, US).
Current research will use 4 types of module such as K, IIIA, IIIB, and
US
Research ethics  original survey (Gajah Mada University), current
research (IRB-IPSR MU No. 2019/06-197 )
Sampling and recruitment  sampling methods for IFLS East were stratified
multistage sampling
Inclusion criteria (purposive)  Women in reproductive age 15-49 years old,
have been tested for Hb level.
Exclusion criteria  Male, women aged <15 years and >49 years, not tested
for Hb level.
 Study location
East Kalimantan
South-east Sulawesi
North Maluku

West Papua

Papua

Jakarta

Maluku
East Nusa Tenggara
 Result: Univariate
Prevalence of Anemia

Prevalence of Anemia in Women of Prevalence of Anemia in Women of Reproductive Age

Reproductive Age (15-49) in Eastern Indonesia (15-49) in South East Asia Countries (%)

Lao 31

Brunei Darussalam 20

2% Viet Nam 14

23% Philippines 25

-       Severe Cambodia 44

-       Moderate
-       Mild Myanmar 30
56%
Not anemia
Thailad 24
19%
Singapore 22

Malaysia 21

Indonesia 23
0 5 10 15 20 25 30 35 40 45 50

Source: IFLS East, 2012 Source: WHO, 2011

 Result: Univariate
Age, sex and constitutional factors

Age Body Mass Index

30% 18% (BMI)
39%

35%

32%

reproductive age (15-24 years) Mid reproductive age (25-34 years)

eproductive age (35-49 years)

2%
Pregnancy Status 47%

Underweight Normal
Overweight/Obese

98%

Yes No
 Result: Univariate
Individual Lifestyle Factors
2500

2028
Income level in last
2000 12 months
Marital Status
1500
6%
21%
1000
Single
Married
Widow, separated, 500
divorced 208
94
0
73% Low (<Rp. 10,000,000 / Middle (Rp. 10,000,000– High (>Rp.35,000,000 /
<$707) Rp.35,000,000 / $707 - >$2473)
$2473)

University 285 Education level

Meat and fish intake in
1230 last week
Senior High School 689
1998
1100

Junior High School 422

2000 Fish
intake
1500 (twice or
more)
1000 Elementary 789
332
Meat
500 intake
(twice or
0 more)
1 Uneducated 145

Meat intake (twice or more) Meat intake (less than twice)

Fish intake (twice or more) Fish intake (less than twice) 0 100 200 300 400 500 600 700 800 900
 Result: Univariate
Social and Community Networks &
Living and Working Conditions

Have participated in arisan

Internal migration
(saving lottery) in last 12
experience
months

11%

36%

Yes EducationNever
levelmigrate
No 64% Ever migrate
Meat and fish intake in
89% last week
 Result: Univariate
General Socio-Economic, Culture, and Envir
onmental Conditions Religious feeling
1%
12%

Ethnicity by island
597 588 7%
Not religious
428
318 Somewhat religious
278
Religious
100 Very religious
21
nd nd ds ds ds ds ic
a a an an an an ab
Isl Isl Isl sl Isl Isl Ar
va ta
n a iI ku a &
Ja ar es lu pu e
an g w a Pa es
m im ng la in
fro Ka
l T e Su M m h
s
sa ro
m fro ,C
up m fro
m f s er
a
g ro fro Nu ps up at
c ps li/ ps ro
u
gr
o m 79%
ni ou Ba ou Su
E th g r m g r
i cg n ic
m
ic fro ic hn Et
h ro
hn hn Et sf
Et ps Et p 25%
rou ro
u
g Women’s
ic ci g
hn hn
Et Et Involve involvement to
Not involve decide type of food
Religion
2% 75%

Islam 32%
Catholic
Christian protestant 32%
Others (Hindu, Buddhist, 57%
others) Urban
Rural Place of residence
9%
68%
 Result: Multivariate & Discussion
Binary Logistic Regression
95% CI
Age, sex and constitutional factors AOR
Lower Upper
Age (ref: early reproductive age (15-24) )
Mid reproductive age (25-34) 1.331* 1.022 1.732
Late reproductive age (35-49) 1.212 0.925 1.588
Body Mass Index (BMI)(ref: overweight/obese)
Normal 1.244 0.964 1.605
Underweight 3.852*** 2.939 5.050
Pregnancy status (ref: No)
Yes 7.637*** 3.718 15.684

*p<0.05, **p<0.01, ***p<0.001

Age • In Oman, women aged 25-35 tend to experience high parity (Al-
-Mid reproductive age (25-34) Farsi, 2011) .

• BMI was significantly associated with anemia based on study in

BMI
Tanzania, Myanmar, China, and India (Msemo, 2018; Win, 2018;
-Underweight
Qin, 2013; Ganaphati, 2017).
• Lower BMI level leads the lower level of energy and
hemoglobin.
Pregnancy status
• Consistent with study in India and Myanmar (Ganapathi, 2017;
-Yes
Win, 2018). Pregnant women need to share her iron to the fetus
(Messina, 2013).
 Result: Multivariate & Discussion
Binary Logistic Regression

95% CI
Individual Lifestyle Factors AOR
Lower Upper

Level of education (ref: university)

Senior high school 0.849 0.622 1.161
Junior high school 0.999 0.706 1.412
Elementary 0.972 0.695 1.359
Uneducated 0.458** 0.281 0.746

*p<0.05, **p<0.01, ***p<0.001

Level of education
• Education as general has the association with anemia (Suega,
-Uneducated
2002; Bentley, 2003; Igweonu, 2019).
• As the proxy influencer: uneducated women mostly resided in
rural area  did more physical activities  healthier
• Uneducated women  rural area  were not exposed by toxic
pollutant (wiwanitkit, 2006).
• Uneducated women  rural area  agricultural sector 
consume more vegetables and fruit (Moor, 2017).
 Result: Multivariate & Discussion
Binary Logistic Regression

95% CI
Living and Working Conditions AOR
Lower Upper

Internal migration experience (ref: never migrated)

Ever migrated 1.347* 1.073 1.691

*p<0.05, **p<0.01, ***p<0.001

Internal migration
experience • Supported the study in China (Li, 2013).
- Ever migrated • Migrants faced the new social context, economic, culture,
language, and environmental so they need to adapt (Kristiansen,
2006)
• There was association between internal migration experience
and salary in last 12 months.
• The proxy influencer which migration influence the income to
purchase the nutrient food.
 Result: Multivariate & Discussion
Binary Logistic Regression
95% CI
General Socio-economic, Culture, and Environmental AOR
Conditions Lower Upper

Ethnicity (ref: Ethnic groups from Java Island)

Ethnic groups from Kalimantan Island 0.571* 0.339 0.963
Ethnic groups from Bali/NT Island 0.890 0.614 1.291
Ethnic groups from Sulawesi Island 0.831 0.603 1.144
Ethnic groups from Maluku Island 0.664* 0.471 0.938
Ethnic groups from Papua Island 1.219 0.799 1.860
Ethnic groups from Sumatera Island, Chinese, Arabic 1.157 0.448 2.989
Religion (ref: Islam)
Catholic 0.922 0.637 1.336
Christian Protestant 1.419** 1.109 1.814
Hindu, Buddhist, and others 1.440 0.755 2.785

*p<0.05, **p<0.01, ***p<0.001

• Consistent with study in China (Zhang, 2017), Tanzania (Msemo,
Ethnicity
- From Kalimantan 2018), Pakistan (Baig, 2008).
- From Maluku • Proxy influencer, ethnicity  geographic conditions (fishery,
agricultural)
• Proxy influencer, ethnicity  dietary culture

Religion • Consistent with study in India (Bentley, 2003), Ganapathi,

- Christian Protestant 2017).
• Proxy influencer, religion  dietary practices
 Conclusions and Recommendations

Conclusions:
• Prevalence of anemia among women reproductive age in Eastern Indonesia: 44%
The constitutional factors, individual lifestyle, and the general socioeconomic,
culture, environmental, living, and working conditions are the predictors of anemia.
• The specific determinants are: age, BMI, pregnancy status, education level, internal
migration experience, ethnicity, religion,

Recommendations:

• Emphasizing the distribution of iron pills to high risk population

• Developing the education system
• Arranging the intervention program which in accordance with their sociocultural
condition.
• Further study needs to add the qualitative research such as ethnographic study
“Thank you” in some local languages in Indonesia