Unveiling the True Impact of Anemia on Education
In low- and middle-income countries, anemia reduction efforts have long been heralded as a panacea for improving educational outcomes and reducing poverty. However, a rigorous new study challenges this conventional wisdom by examining the relationship between anemia and school attendance among adolescents in India. Co-authored by Santosh Kumar, an associate professor of development and global health economics at the University of Notre Dame, the study employs advanced econometric analysis to reveal a more nuanced reality.
Reassessing Anemia’s Impact on Education
Published in Communications Medicine, the study investigates whether anemia, a condition commonly caused by iron deficiency, significantly affects school attendance. Previous observational studies suggested a strong correlation between anemia and reduced school attendance, even after accounting for variables such as gender and household wealth. However, Kumar’s research, which analyzed data from over 250,000 adolescents aged 15 to 18, found that earlier estimates might have been skewed by unobserved household factors.
“Most previous research on this topic has used conventional study designs or focused on small geographical areas, which limits its policy relevance,” Kumar explains. “Earlier estimates may have been distorted by unobserved household factors related to both anemia and school attendance. So in this study, we focused on the relationship between anemia and attendance among adolescents who were living in the same household.”
Ultimately, the study found no significant link between anemia and school attendance when household-level factors were considered. This revelation debunks the strong connection previously suggested by studies that did not account for these factors. “We found that the link between anemia and schooling is more muted than previously suggested,” Kumar says.
Implications for Educational Policy
The findings carry profound implications for policymakers in countries like India, where both school attendance issues and anemia are widespread. India has been striving to improve educational outcomes in line with the United Nations’ Sustainable Development Goals. However, Kumar’s study indicates that simply targeting anemia may not yield the expected improvements in school attendance.
Policymakers must now seek more evidence-based interventions to address educational challenges. The study underscores the necessity for rigorous statistical analysis to understand the true impact of health conditions like anemia on education. Effective policy formulation requires a clear, evidence-based understanding of the underlying issues.
Ongoing Research & Future Directions
This study is part of a broader project funded by the Alexander von Humboldt Foundation, the Swedish Research Council, and the West Bengal State Department of Health and Family Welfare in India. The research team, including co-authors Jan-Walter De Neve (University of Heidelberg), Omar Karlsson (Lund University, Sweden), Rajesh Kumar Rai (Harvard University), and Sebastian Vollmer (University of Göttingen), is committed to further exploring the relationship between health interventions and educational outcomes.
Building on their previous work, which evaluated the effects of an iron fortification school lunch program for younger students, the team found that while iron fortification reduced anemia, it did not significantly impact academic performance. A forthcoming study, set to launch in the summer of 2024, will investigate the effects of iron fortification on children aged 3 to 5, hypothesizing that early-age nutritional interventions might significantly enhance physical and cognitive development.
Towards Evidence-Based Health Policies
Santosh Kumar’s research aims to support human dignity by identifying effective, evidence-based health policies. “Our findings have implications for policymakers who want to improve educational outcomes and reduce poverty,” he emphasizes. “Effective policies are based on evidence. We need more rigorous statistical analysis to examine the causal relationship between anemia and education.”
In an era where policy decisions must be grounded in solid evidence, Kumar’s work serves as a crucial reminder of the complexities involved in tackling global health and education challenges. By debunking misconceptions and highlighting the need for nuanced approaches, this study paves the way for more targeted and effective interventions that can truly make a difference in the lives of millions.
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Here is the summary of the study:
Background:
– Anemia has been suggested to be related to schooling outcomes in India.
– We aimed to study the relationship between anemia and school attendance while considering household-level factors.
Methods:
– Nationally representative data on adolescents aged 15–18 years were extracted from India’s National Family Health Surveys conducted between 2005 and 2021.
– We compared school attendance between adolescents living in the same household but with varying levels of hemoglobin concentration, controlling for age and period effects.
Results:
– The proportion of adolescents with any anemia is 55.2% among young women and 31.0% among young men.
– Household fixed-effects models showed that anemia had qualitatively small and non-significant effects on school attendance.
Conclusions:
– Little evidence was found that anemia is associated with school attendance among adolescents in India.
– The study highlighted the need to consider all influences that can impact adolescents’ access to education.
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Detailed Summary:
– Anemia can impact the education of adolescents due to decreased capacity to circulate oxygen in the body, resulting in fatigue and weakness.
– Household-level factors are linked with school attendance, and the direct relationship between anemia and attendance was less clear.
Introduction:
– Universal primary and secondary education by the year 2030 is a focus of the United Nations’ Sustainable Development Goals.
– Substantial gaps remain in secondary school enrollment, particularly in low- and middle-income countries.
Context:
– The study used nationally representative data on over 250,000 adolescents aged 15–18 years old in India.
– Multivariable linear regression models with household fixed effects were used to examine the association between anemia and school attendance.
Data Sources:
– Data were extracted from India’s National Family Health Surveys conducted between 2005 and 2021.
– The surveys have high quality interviewer training, standardized data collection procedures, and consistent content over time.
Adolescent Sample Analysis:
– A study focused on late adolescence (age 15-18), involving 251,401 adolescents.
– Exclusions made for pregnant adolescents and extreme hemoglobin values, resulting in a final sample size.
Household Variation:
– 26% of adolescents lived in households with multiple adolescents aged 15-18.
– Variation seen in hemoglobin concentration and anemia status within these households.
Outcome Measure:
– Primary outcome: binary indicator for an adolescent’s school attendance.
– Utilization of NFHS household questionnaire for data on school attendance.
Exposure and Anemia Definition:
– Exposure defined as any anemia based on hemoglobin levels.
– Anemia categories specified for both men and non-pregnant women.
Hemoglobin Measurement:
– Hemoglobin measured using capillary blood samples and analyzed with HemoCue Hb 201+ device.
– Adjustments made for smoking status, altitude, and other factors.
Control Variables:
– Data extracted on age, gender, household wealth index, and urban vs. rural location.
– Various covariates considered in the analysis, including household fixed effects.
Statistical Analysis:
– Analysis conducted in five models to estimate the relationship between anemia and school attendance.
– Consideration of heterogeneity by anemia severity, gender, and household characteristics.
Sensitivity Analyses:
– Supplementary analyses performed to enhance confidence in the main results.
– Consideration of misalignment between exposure and outcome timing.
Sampling Strategy:
– The study utilized a sampling strategy targeting households with older adolescents aged 19–22 years to ensure larger birth spacing between siblings in the household.
– The use of this strategy aimed to obtain a subset of households with larger birth spacing between siblings.
Incorporation of Sample Weights:
– Sample weights were added to the analysis to enhance the robustness of the findings.
– This addition of sample weights aimed to address potential controversies and increase the reliability of the analysis.
Assessment of Learning Outcomes:
– The study assessed several learning outcomes available in the NFHS, including literacy, frequency reading, knowledge, progression through school, and educational level attained.
– Furthermore, the assessment included a proxy for knowledge acquired through the formal school curriculum or public health campaigns.
Ethical Approval:
– The analysis of the existing anonymized dataset obtained a determination of non-human subjects research by the institutional review board of the Harvard T. H. Chan School of Public Health.
– This determination rendered a full ethical review unnecessary.
Results Data Sample Description:
– The survey participants showed high prevalence of anemia and school attendance, with significant gender disparities in health and schooling outcomes.
– The findings revealed a substantial proportion of adolescents with anemia and provided demographic insights into school attendance and educational levels.
Relationship Between Anemia and School Attendance:
– Regression analysis indicated a negative relationship between having any anemia and school attendance, even after adjusting for socio-demographic characteristics.
– Alternative empirical approaches, including household fixed-effects regression models, suggested a more muted relationship between anemia and school attendance.
Heterogeneity by Anemia Severity Group and Socio-Demographic Characteristics:
– Different anemia severity groups had minimal effects on school attendance, with household fixed-effects models providing little evidence of a significant association.
– Analysis of heterogeneity by gender and other socio-demographic characteristics yielded qualitatively similar results, indicating limited influence of anemia on school attendance across these groups.
Sensitivity Analyses for Anemia and School Attendance:
– Sensitivity analyses, including various model specifications and additional covariates, consistently supported the main findings regarding the limited effects of anemia on school attendance.
– The study also showed few detectable effects of anemia on secondary outcomes, further reinforcing the robustness of the findings.
Effect of Anemia on Literacy Skills:
– In household fixed effects models, having any anemia was associated with a 0.5 percentage point reduction in literacy skills.
– Relationship between anemia and other outcomes like knowledge and grade progression was qualitatively small in household fixed effects models.
Anemia and School Attendance:
– School attendance’s relationship with anemia appeared less pronounced in observational studies not considering all household factors.
– Household fixed-effects models found little evidence that anemia was associated with school attendance.
Trends in Anemia and School Attendance:
– Although anemia among adolescents in India has increased recently, school attendance also increased during the same period.
– Policymakers should be cautious of estimates ignoring household characteristics when addressing anemia’s impact on school attendance.
Limitations of the Study:
– Study lacked data on hemoglobin concentration for younger adolescents (aged 10-14 years).
– Household fixed effects models assumed similar unobserved confounders within households, potentially limiting generalizability.
– Sensitivity analyses showed robustness to exposure-outcome timing variations.
Implications for Interventions:
– Targeting adolescents at risk of anemia may not significantly improve school attendance at the population level.
– Other interventions beyond anemia reduction may be necessary to enhance school attendance.
For Full research article click the link:
https://www.nature.com/articles/s43856-024-00533-8
– Chandana Guchaait