Predictors of Iron Supplement Adherence and Hemoglobin Levels Among Adolescent Girls in Bali: A PLS-SEM Analysis
Abstract
Introduction: Anemia among adolescent girls remains a global public health concern. Adolescence is a critical window of rapid growth and increased iron requirements. The World Health Organization recognizes adolescent anemia as a priority. Although weekly iron supplementation programs have been widely implemented, adherence remains suboptimal. Previous studies have primarily identified associated factors using bivariate or conventional regression approaches, with limited application of multivariate pathway modelling to simultaneously examine determinants of adherence and hemoglobin outcomes. This study aimed to examine predictors of iron tablet adherence and their association with hemoglobin levels among adolescent girls using Partial Least Squares Structural Equation Modeling (PLS-SEM) approach.
Methods: A quantitative study with a pretest–posttest one-group design without a control group was conducted. Data were collected using validated questionnaires from adolescent girls (n = 772), of whom 483 participated in final analysis attending schools in Bali, Indonesia, between August and November 2024. Statistical analyses and PLS-SEM were performed to identify key predictors of adherence and hemoglobin levels.
Results: A total of 483 adolescent girls participated in the study (response rate: 62.6%). The structural model explained 4.6% of the variance in iron tablet adherence (R² = 0.046) and 38.4% of the variance in hemoglobin levels (R² = 0.384). Family support (? = 0.051; p = 0.041), school support (? = 0.131; p = 0.011), and attitude (? = ?0.071; p = 0.003) significantly predicted adherence. In turn, adherence showed a positive association with hemoglobin levels (? = 0.570; p < 0.000).
Conclusion: Family support, school support, and attitude were significantly associated with iron supplement adherence among adolescent girls. Although the explanatory power of the model for adherence was modest, adherence was positively associated with hemoglobin levels at post-test measurement. These findings should be interpreted as exploratory and hypothesis-generating. Multifactorial strategies that strengthen social support and sustained monitoring may enhance the effectiveness of anemia prevention programs among adolescent girls.
References
Sasmita AP, Mubashir A, Vijaya N. Impact of nutritional education on knowledge, attitude and practice regarding anemia among school children in Belgaum, India. Glob Heal J. 2022:6(2):91–4. doi.org/10.1016/j.glohj.2022.04.001. Available from: https://doi.org/10.1016/j.glohj.2022.04.001
World Health Organization. Regional Office for South East Asia. Prevention of iron deficiency anemia in adolescents. WHO. Geneva: 2011. Available from: https://www.who.int
Yana IGAAK, Wibowo YI, Sari GAPLP. Tingkat pengetahuan remaja putri terkait anemia dan tablet tambah darah di wilayah Denpasar. Indones J Pharm Nat Prod. 2023:06(02):209–17. doi:10.35473/ijpnp.v6i02.2633. Available from: https://doi.org/10.35473/ijpnp.v6i02.2633
Riset Kesehatan Dasar (Riskesdas). Laporan nasional 2007. Jakarta: Badan Penelitian dan Pengembangan Kesehatan: 2007. 1–291 p. Available from: https://layanandata.kemkes.go.id
Kementerian Kesehatan Republik Indonesia (Kemenkes-RI). Laporan nasional Riskesdas 2018. Jakarta: Badan Penelitian dan Pengembangan Kesehatan: 2018. Available from: https://repository.kemkes.go.id
Kementerian Kesehatan Republik Indonesia (Kemenkes-RI). Pedoman pencegahan dan penanggulangan anemia pada remaja putri dan wanita usia subur (WUS). Jakarta: 2018. Available from: https://repository.kemkes.go.id
Mengistu G, Azage M, Gutema H. Iron deficiency anemia among in-school adolescent girls in rural area of bahir dar city administration, north west ethiopia. Anemia. 2019;2019:1–8. doi: 10.1155/2019/1097547. Available from: https://doi.org/10.1155/2019/1097547
Gebreyesus SH, Endris BS, Beyene GT, Farah AM, Elias F, Bekele HN. Anaemia among adolescent girls in three districts in Ethiopia. BMC Public Health. 2019:19(1):1–11. doi: 10.1186/s12889-019-6422-0. Available from: https://doi.org/10.1186/s12889-019-6422-0
Khani Jeihooni A, Hoshyar S, Afzali Harsini P, Rakhshani T. The effect of nutrition education based on PRECEDE model on iron deficiency anemia among female students. BMC Womens Health. 2021:21(1):1–9. doi: 10.1186/s12905-021-01394-2. Available from: https://doi.org/10.1186/s12905-021-01394-2
Sari P, Judistiani RTD, Hilmanto D, Herawati DMD, Dhamayanti M. Iron deficiency anemia and associated factors among adolescent girls and women in a Rural Area of Jatinangor, Indonesia. Int J Womens Health. 2022:14(August):1137–47. doi: 10.2147/IJWH.S376023. Available from: https://doi.org/10.2147/IJWH.S376023
Kemenkes RI. Profil Kesehatan Indonesia 2022. Kementerian Kesehatan Republik Indonesia. Jakarta: 2022. Available from: https://repository.kemkes.go.id
Kementerian Kesehatan Republik Indonesia (Kemenkes-RI). Rencana Strategis Kementerian Kesehatan Tahun 2015-2019. Jakarta: 2015. Available from: https://repository.kemkes.go.id
Andala S, Sofyan H, Hasballah K, Marthoenis. Knowledge and acceptance associated with medication adherence among hypertension individuals in Aceh province, Indonesia. Heliyon. 2024;10(7):e29303. doi: 10.1016/j.heliyon.2024.e29303. Available from: https://doi.org/10.1016/j.heliyon.2024.e29303
Maifitrianti M, Wiyati T, Hasanah N. Relationship between patients’ knowledge and medication adherence of tuberculosis at Islamic Hospital Pondok Kopi Jakarta. J Manajemen dan Pelayanan Farmasi (Journal Manag Pharm Pract. 2024:14(1):69. doi : 10.22146/jmpf.86864. Available from:https://doi.org/10.22146/jmpf.86864
Novianti I, Salman, Laily Hilmi I. Hubungan tingkat pengetahuan, sikap, dan dukungan keluarga terhadap kepatuhan minum obat penderita hipertensi di Puskesmas Batujaya. J Ilmu Kefarmasian. 2022:3(2):349–54. doi: 10.31764/lf.v3i2.9398. Available from: https://doi.org/10.31764/lf.v3i2.9398
Arfania M, Aulia P, Gunarti NS. Hubungan pengetahuan dan sikap terhadap kepatuhan minum obat diabetes melitus tipe 2 pasien geriatri di Puskesmas Karawang. Maj Farm dan Farmakol. 2023:(22):22–5. doi: 10.20956/mff.SpecialIssue. Available from: https://journal.unhas.ac.id/index.php/mff
Ginting SRB. The relationship between diabetes mellitus patients’ knowledge and attitude and compliance with anti-diabetic drug drinking at Puskesmas PB Selayang II. J Pharm Sci. 2023:6(2):713–7. doi: 10.36490/journal-jps.com.v6i2.134. Available from: https://doi.org/10.36490/journal-jps.com.v6i2.134
Hair JF, Hult GTM, Ringle CM, Sarstedt M. A primer on partial least squares structural equation modeling. SAGE Publications. 2022. doi: 10.1016/j.lrp.2013.01.002. Available from: https://doi.org/10.1016/j.lrp.2013.01.002
Shmueli G, Sarstedt M, Hair JF, Cheah JH, Ting H, Vaithilingam S, et al. Predictive model assessment in PLS-SEM: guidelines for using PLSpredict. Eur J Mark. 2019:53(11):2322–47. doi: 10.1108/EJM-02-2019-0189. Available from: https://doi.org/10.1108/EJM-02-2019-0189
Haryono S. Metode SEM untuk penelitian manajemen dengan AMOS LISREL Smart PLS. Jakarta: Intermedia Personalia Utama; 2016.
Abu-Baker NN, Eyadat AM, Khamaiseh AM. The impact of nutrition education on knowledge, attitude, and practice regarding iron deficiency anemia among female adolescent students in Jordan. Heliyon. 2021:7(2):e06348. doi: 10.1016/j.heliyon.2021.e06348. Available from: https://dx.doi.org/10.1016/j.heliyon.2021.e06348
Noviyanti H, Mulyati R, Wulandari S. Pengaruh pendidikan kesehatan melalui media scrapbook terhadap pengetahuan remaja putri tentang tablet tambah darah. J Keperawatan. 2021:13(1):213–26. Available from: https://journal.stikeskendal.ac.id/index.php/Keperawatan
Zuraida R, Susianti, Sayekti WD, Angraini DI, Pramesona BA, Gemayangsura, et al. The effect of the anemia free club model implementation and iron supplement on the treatment of anemia in adolescent girls in junior high school. Int J Heal Educ Soc. 2022:5(10):32–44. doi: 10.1234/ijhes.v5i10.271. Available from: https://www.ijhes.com
Fariba P, Shamsaddin N, Fatemeh A. The effect of iron deficiency anemia prevention blended education package on knowledge, attitude and practice of adolescent girls. Issue 5 J Nurs Educ. 2021:10(5). Available from: https://jne.ir/article-1-1165-en.html
Guerin RJ, Toland MD. An application of a modified theory of planned behavior model to investigate adolescents’ job safety knowledge, norms, attitude and intention to enact workplace safety and health skills. J Safety Res. 2020:72:189–98. doi: 10.1016/j.jsr.2019.12.002. Available from: https://doi.org/10.1016/j.jsr.2019.12.002
Alfiah E, Briawan D, Khomsan A, Dewi M, Ekayanti I, Mardewi, et al. Coverage and adherence of weekly iron folic acid supplementation among school going adolescent girls in indonesia. J Nutr Sci Vitaminol (Tokyo). 2020;66:S118–21. doi: 10.3177/jnsv.66.S118. Available from: https://doi.org/10.3177/jnsv.66.S118
Haile B, Oumer A, Negese T, Temesgen M, Kebede A, Abdurahman D, et al. Factors associated with compliance with weekly iron and folic acid supplementation among school adolescent girls in Debub Achefer district, northwest Ethiopia: school-based cross-sectional study. Sci Rep. 2024:14(1):1–9. doi: 10.1038/s41598-024-60800-5. Available from: https://doi.org/10.1038/s41598-024-60800-5
Niza AWC, Buanasita A, Mujayanto, Nugroho RF, Hafid F, Ishak SIZS. The relationship between knowledge and attitude about anemia with compliance to consume iron supplement tablets in female adolescents of grade x at State Senior High School 13 Surabaya. J Nutr Explor. 2024:2(3):405–14. doi: 10.36568/jone.v2i3.370. Available from: https://doi.org/10.36568/jone.v2i3.370
Silitonga HTH, Salim LA, Nurmala I, Wartiningsih M, Raga AD. The association between social support with compliance of IFA supplement intake among adolescent girls in Sidoarjo, Indonesia. Nutr Health. 2023:31(2):625–32. doi: 10.1177/02601060231206310. Available from: https://doi.org/10.1177/02601060231206310
Sultan U, Tirtayasa A, Gustia M, Khairani MD, Abdullah A, Wati DA. Associations between knowledge and family support with adherence to consumption iron supplements in adolescent females. J Gizi Kerja dan Produkt. 2024:5(1):29–35. doi: 10.62870/jgkp.v5i1.24991. Available from: https://dx.doi.org/10.62870/jgkp.v5i1.24991
Prayudhistya BA, Syahadatina Noor M, Istiana I, Juhairina J, Sterina Skripsiana N. Hubungan dukungan keluarga dengan kepatuhan konsumsi obat tablet tambah darah pada remaja putri di Smait Ukhuwah Banjarmasin. Homeostasis. 2023:6(1):9. doi: 10.20527/ht.v6i1.8783. Available from: https://doi.org/10.20527/ht.v6i1.8783
Gosdin L, Sharma AJ, Tripp K, Amoaful EF, Mahama AB, Selenje L, et al. A school-based weekly iron and folic acid supplementation program effectively reduces anemia in a prospective cohort of Ghanaian adolescent girls. J Nutr. 2021:151(6):1646–55. doi: 10.1093/jn/nxab024. Available from: https://doi.org/10.1093/jn/nxab024
Apriningsih, Madanijah S, Dwiriani CM, Kolopaking R. Determinant of highschool girl adolescent’adherence to consume iron folic acid supplementation in Kota Depok. J Nutr Sci Vitaminol (Tokyo). 2020:66:S369–75. doi: 10.3177/jnsv.66.S369. Available from: https://doi.org/10.3177/jnsv.66.S369
Diani AAP, Amalia RB, Sudaryanti L, Lestari P. Knowledge and attitude with adherence to Fe tablet consumption in anemic adolescent girls. Indones Midwifery Heal Sci J. 2024:8(3):250–9. doi: 10.20473/imhsj.v8i3.2024.250-259. Available from: https://doi.org/10.20473/imhsj.v8i3.2024.250-259
Nurhaera N, Utami RP, Saputri RM. Correlation between knowledge and attitudes of female adolescents towards compliance with iron supplements. J Heal Nutr Res. 2023:2(3):181–9. doi: 10.56303/jhnresearch.v2i3.182. Available from: https://doi.org/10.56303/jhnresearch.v2i3.182
Isnaini YS, Pihahey PJ, Bahra, Mintaningtyas SI, Simanjuntak MK, Fabanjo IJ. Knowledge, attitude, practice and compliance to weekly iron supplementation among female public junior high school students in West Papua. Public Heal Indones. 2024:10(4):38–48. doi: 10.36685/PHI.V10I4.858. Available from: https://doi.org/10.36685/PHI.V10I4.858
Myer DG, Twenge JM. Social Psychology. 14th ed. New York: McGraw-Hill; 2022.
Handiso YH, Belachew T, Abuye C, Workicho A, Baye K. A community-based randomized controlled trial providing weekly iron-folic acid supplementation increased serum- ferritin, -folate and hemoglobin concentration of adolescent girls in southern Ethiopia. Sci Rep. 2021:11(1):1–7. doi: 10.1038/s41598-021-89115-5. Available from: https://doi.org/10.1038/s41598-021-89115-5
Kedir S, Abate KH, Mohammed B, Ademe BW. Weekly iron-folic acid supplementation and its impact on children and adolescents iron status, mental health and school performance: a systematic review and meta-analysis in sub-Saharan Africa. BMJ Open. 2024:14(6):1–10. doi: 10.1136/bmjopen-2024-084033. Available from: https://doi.org/10.1136/bmjopen-2024-084033
Copyright (c) 2026 Journal of Public Health and Pharmacy
This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.
Authors who publish with Journal of Public Health and Pharmacy retain the copyright of their work. The journal applies a Creative Commons Attribution-ShareAlike 4.0 International License (CC BY-SA 4.0), which grants the following rights:
-
Copyright Retention: Authors retain the copyright of their work, maintaining full control over their intellectual property without restrictions.
-
Right of First Publication: Authors grant the journal the right of first publication of their work. This ensures that the work is initially published and credited in Journal of Public Health and Pharmacy.
-
License to Share and Reuse: The work is licensed under CC BY-SA 4.0, allowing others to copy, distribute, remix, and build upon the work for any purpose, even commercially, as long as proper credit is given to the authors, and any new creations are licensed under the same terms.
