The effect of giving blood supplement tablets to adolescent girls on increasing haemoglobin levels in Cirebon District to prevent stunting and develop a quality generation in Cirebon District

Background : Several conditions that affect adolescent health, including adolescent reproductive health are nutritional problems. Nutritional problems that occur in adolescents include anemia and chronic lack of energy. Anemia is a decreasing quantity of red blood cells in the circulation or the amount of haemoglobin under normal limits. The challenge of anemia in young women from 37.1% in Riskedas 2013 which actually increased to 48.9% in Riskesdas 2018, with the proportion of anemia in the age group 15-24 years and 25-34 years. These things clearly reinforce that adolescent health will determine the success of health development, especially in an effort to print the quality of the nation's next generation in the future. Anemia among adolescents can be caused by a lack of macronutrient and micronutrient intake. The micronutrients are needed by the body, especially by teenagers. Insufficiency of micronutrients in the body can cause anemia. Anemia has several types, one of which is nutritional anemia. One of the causes of nutritional anemia is iron deficiency. Based on Permenkes, RI No. 88, 2014, giving blood supplement tablets is one of the important efforts in the prevention and control of anemia because it is an effective way to prevent anemia due to iron deficiency and folic acid deficiency. Blood supplement tablets are tablets that are given to the fertile and pregnant women. For fertile women, it is given once in a week and once a day during period. Purpose : To determine the effect of giving blood supplement tablets to adolescent girls to increase hemoglobin levels, so, it can be seen whether female adolescents are anemic or not. If there are many adolescents with anemia, it is expected that health workers and the community should pay more attention to the importance of anemia-free of adolescents to prevent stunting. Therefore, there many healthy generations born in Cirebon .Method : This study uses a quasi-experimental design, where there is a treatment of giving blood supplement tablets for 3 months to junior high school students who have experienced menstruation whose hemoglobin levels were previously checked. After giving blood tablets for 3 months, the hemoglobin level was rechecked which involved 20 female students at Cirebon district. Result : The average of haemoglobin levels before given the treatment was 11.40 grams% with a standard deviation of 1.7634. Meanwhile the average of haemoglobin levels after given the treatment was increased 2.67 grams% to 14.07 grams% with a standard deviation of 1.3719. The result of statistical tests using the Dependent T test, p=0,000, means at 5% alpha, the final hypothesis accepted. There is a significant difference in haemoglobin levels before and given the treatment (giving the blood supplement tablet). This means there is an effect of giving the blood supplement tablets to adolescent girls on increasing haemoglobin levels. Conclusions : There is an effect of giving blood supplement tablets to adolescent girls on increasing haemoglobin levels.


INTRODUCTION
37.1% in Riskedas 2013 which actually increased to 48.9% in Riskesdas 2018, with the proportion of anemia in the age group 15-24 years and 25-34 years. These things clearly reinforce that adolescent health will determine the success of health development, especially in an effort to print the quality of the nation's next generation in the future. Anemia among adolescents can be caused by a lack of macronutrient and micronutrient intake. Anemia has several types, one of which is nutritional anemia. One  Anemia has several types, one of which is nutritional anemia. One of the causes of nutritional anemia is iron deficiency (5).
In Indonesia, it is estimated that most of the anemia occurs due to iron deficiency as a result of the lack of intake of food sources of iron, Adolescent girls are prospective mothers, with conditions before pregnancy, adolescent nutrition is one of the factors that influence the occurrence of stunting. Stunting occurs from pre-conception when a teenager becomes a malnourished and anemic mother. In 2017, the percentage of young women with short and very short conditions increased from the previous year, 7.9% very short conditions and 27.6% short conditions. If the nutrition of adolescent girls is not improved, in the future there will be more and more prospective mothers who have body-short conditions, lack of energy and anemia (8).
In general, the baby is independent of the mother's diet during pregnancy. What happens is, the baby takes nutrients from the mother's stores, and changes protein and fat in the tissues, which is related to the mother's body composition.
Therefore, the state of nutritional status during life before pregnancy becomes very important to ensure the availability of stored nutrients that will be utilized by the baby. In addition to maternal nutrient stores, the shape and size of the placental surface will also affect the smooth transportation of nutrients from the mother to the fetus. A baby will be born with all the eggs it will have during its lifetime. Therefore, the quality of the eggs reflects the nutritional status of the mother. Or in other words, the quality of eggs (ovum) that will become a grandson, is determined by the nutritional status of his grandmother (9).
The impact of anemia on adolescent girls will carry over until she becomes an anemic pregnant mother which can lead to an increase in the risk of Inhibited Fetal Growth (IPM), prematurity, low birth weight, and child development disorders including stunting and neurocognitive disorders, causing babies to be born with iron (Fe) reserves. low children will continue to suffer from anemia in infancy and at an early age and increase the risk of neonatal and infant morbidity and mortality which will also inhibit child growth (6).  (16) Listyaningrum (2019), factors that influence the implementation of giving suplement tablets is packaging of the tablets that are easily damaged before they are used up (17).
The study based on data from the Cirebon district health office in 2019, the majority of adolescents were anemic. It was becase there were problems in drug availability, drug distribution, limited procurement of drug control cards and the students who refused to take medication (18).
This study will conduct a study on the effect of giving blood supplement tablets to adolescent girls on increasing haemoglobin levels, so, it can be seen whether young women are anemic or not. If there are many adolescents with anemia, it is expected that health workers and the community should pay more attention to the importance of anemia-free of adolescents to prevent stunting. Therefore, there many healthy generations born in Cirebon .

MATERIAL AND METHODS
This study used a quasi-experimental one group design. The independent variable in this study was the administration of Fe tablets, who lack nutrition during their teenage years, pregnant do not consume food according to balanced nutrition, such as not eating a variety of foods, lack of consumption of carbohydrates, proteins, fats, vitamins, minerals and water (8).
The health condition of the baby born is strongly influenced by the nutritional state of the mother during pregnancy. If the nutrients received from the mother are not sufficient, then the fetus will have unfavorable consequences in the next life (10). Adolescent girls are prospective mothers who will give birth to the next generation so that young women become a priority in efforts to prevent stunting by making iron-deficient anemia-free adolescents.

RESULT
The results obtained were data on the respondent's hemoglobin level before giving the added tablet, data on the respondent's hemoglobin level after giving the blood-added tablet and the dependent t-test data for the two variables to see is the difference between the hemoglobin level that has not taken blood-added tablet and after taking the added tablet every week for 3 months    Based on Table 3, the final hypothesis is accepted, meaning that there is a significant difference in haemoglobin levels before and after giving the blood suplement treatment.

DISCUSSION
The results of the study shows that there are adolescent girls who still have anemia before consuming blood suplement tablets.This results is accordance with the results of the 2018 Riskesdas. One of the health problems that often occurs at this age, especially teenager, is anemia.
The incidence of anemia in adolescent girls is still quite high. The prevalence rate of anemia in Indonesia in 2018 was 26.50 for adolescents girl.
Anemia that caused by iron deficiency occurs in adolescent girls and it causes various negative impacts, such as low concentration and learning difficulties,fatigue and lack of energy, enervate, sleepy head and lowering the body's resistance so that it makes it easy to get sick. And this anemia has the long-term impact to pregnant young women. Because of anemia, young woman will not be able to fulfil the nutrients for herself and the fetus in the womb, thus causing complications in pregnancy and childbirth. This also increases the risk for low birth weight (LBW) and perinatal mortality (19). Adolescent girls are more prone to IDA (Iron Deficiency Anemia) because they are menstruating. There is a need for additional iron for adolescent girls beyond growth requirements due to the amount of iron lost during menstruation. The need for additional iron to balance menstrual blood loss is about 2.1 mg/day more than the daily requirement (20).
Most pregnant women are in the age of the late teens category, this is also explained by the results of research by Padila et al., (2021) which shows that a young age with a low level of education will also affect the knowledge of pregnant women about pregnancy, such as nutritional needs and iron needs by the fetus for growth during pregnancy (21).
Iron is a group of trace minerals that function for fetal growth and development. The condition of pregnancy causes an increase in the need for iron in the body, so, pregnant women will have anemia (22).
Maternal nutrition during pregnancy is very important for the growth of the fetus. In general, pregnant women with good health conditions who don't have nutritional disorders during prepregnancy or during pregnancy, will produce larger and healthier babies than pregnant women whose conditions have nutritional disorders.
Pregnant women do not have adequate reserves of nutrients to provide the physiological needs of pregnancy, namely hormonal changes and increased blood volume for fetal growth, so that the supply of nutrients to the fetus is reduced as a result of stunted fetal growth and development and low birth weight which is often associated with height. underprivileged or stunting (23).
Teenagers as the next generation experience anemia it will have a tremendous effect in the future. Starting from these young women, they will produce the next generation which is expected to be the next generation that is healthy, intelligent and productive. This anemia will have a big impact when these young women become mothers and give birth to children. In addition, there is the fact that anemia causes a decrease in the work productivity of Indonesian women by 20 percent or about 6.5 hours per week. This condition can certainly be a big obstacle to the development of quality resources in Indonesia. That is why anemia in adolescents is a concern for the country (24).
Adolescents who have taken suplement tablets for 3 months have shown an increase in hemoglobin levels that were previously low to normal or even exceed normal limits.This is in accordance with Hariyati (2020), the results of his research show that the average hemoglobin before being given to students in the intervention and control groups is the same, namely 11.29 g/dl. And after being given to the intervention group, the average increased to 13.69 g/dl and was also supported by the results of Yuanti's study (2020), which stated that the average Hb level of anemic adolescent girls increased by 1.550 after being given Fe tablets (25,26).
In Hermiaty (2021), iron nutritional anemia is anemia that arises due to empty iron reserves in the body so that the formation of hemoglobin is disrupted. Hemoglobin is the part of red blood cells that is used to determine anemia status. The normal value of hemoglobin levels in women is 12-16 g/dl, iron is the main element needed for the formation of hemoglobin, decreased iron intake can reduce hemoglobin levels in the body (27). Giving blood supplement tablets with the right dose can prevent anemia and increase iron reserves in the body (13). Blood supplement tablets given by the government already have the right dose, which contains iron compounds equivalent to 60 mg of elemental iron and 400 mcg of folic acid. Therefore, the consumption of blood-added tablets is one of the efforts to increase hemoglobin levels apart from food substances (16).
Susanti's results explained that in anemia subjects, iron deficiency conditions can accelerate iron absorption. Absorbed iron is first used to normalize plasma hemoglobin concentration, so it can play an important role in oxygen supply to tissues/cells (28).
The results of the test of the effect of giving blood-added tablets with an increase in hemoglobin levels, obtained p value = 0.000 means at 5% alpha, the final hypothesis is accepted, meaning that there is a significant difference in haemoglobin levels before and after giving treatment. The results of this study are in accordance with the statement of the Ministry of Health (2016) which states that blood-added tablets (Fe) are supplements to overcome iron deficiency anemia.
The composition of the blood-added tablet (Fe) that is distributed contains Ferrous sulfate and folic acid (29). This is in accordance with the results of Hartati's (2021) study entitled The Effect of Giving Iron (Fe) Tablets to the Anemia Status of Adolescent Girls (30). Besides, it is also supported by the results of research by Haryanti, et al (2021), which states that there is a difference between the results of the paired t test before and after giving iron tablets (p value = 0.001) (31). The results of the study are in line with research by Permatasari (2018) that the consumption of Fe tablets can affect adolescent haemoglobin levels (32). It is also similar to the research by Tonasih is an effective way because the iron content is supplemented with acid. folate which can prevent anemia due to folic acid deficiency (36).

CONCLUSION AND RECOMMENDATION
The final hypothesis accepted. It also has a meaning that there is a significant difference in haemoglobin levels before and after giving the treatment. It is expected for the future research to conduct the research with real experimental design which is involving adolescent girls including early, middle and late adolescents to see the difference in the effect of giving blood supplement tablets to adolescents for 52 weeks in accordance with the guidelines for giving blood-added tablets for adolescent in 2021.