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rna
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l J
o
urna
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f
P
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bli
c
H
ea
lt
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(
I
J
P
H
S)
Vo
l.
15
,
No
.
3
,
Sep
tem
b
er
20
26
,
p
p
.
7
7
7
~
7
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5
I
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Phys
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terv
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s
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y
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S
a
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s d
o
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e
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si
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e
a
c
c
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n
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q
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.
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C
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iffere
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a
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b
e
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a
fter
th
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terv
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t
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wa
s
a
n
a
ly
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e
d
u
sin
g
th
e
p
a
ired
t
-
tes
t
.
Ba
se
d
o
n
th
e
re
su
lt
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sta
ti
stica
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tes
t,
a
p
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(p
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wh
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d
ica
ted
th
a
t
t
h
e
d
iffere
n
c
e
wa
s sta
ti
stica
ll
y
sig
n
ifi
c
a
n
t.
K
ey
w
o
r
d
s
:
Ad
o
lescen
ts
An
em
ia
Go
o
d
h
ea
lth
Ph
y
s
ical
-
m
atu
r
atio
n
W
ell
-
b
ein
g
T
h
is i
s
a
n
o
p
e
n
a
c
c
e
ss
a
rticle
u
n
d
e
r th
e
CC B
Y
-
SA
li
c
e
n
se
.
C
o
r
r
e
s
p
o
nd
ing
A
uth
o
r
:
Desta
Ay
u
C
ah
y
a
R
o
s
y
id
a
Mid
wif
er
y
Stu
d
y
Pr
o
g
r
am
,
Facu
lty
o
f
Hea
lth
Scien
ce
s
,
PGR
I
Ad
i Bu
an
a
Un
iv
er
s
ity
o
f
Su
r
ab
ay
a
Su
r
ab
ay
a,
E
ast J
av
a,
I
n
d
o
n
esia
E
m
ail:
d
esta@
u
n
ip
asb
y
.
ac
.
id
1.
I
NT
RO
D
UCT
I
O
N
An
em
ia
am
o
n
g
ad
o
lescen
ts
w
h
o
m
ar
r
y
at
a
y
o
u
n
g
ag
e
is
a
s
er
io
u
s
p
u
b
lic
h
ea
lth
is
s
u
e,
es
p
ec
ially
in
d
ev
elo
p
in
g
c
o
u
n
tr
ies,
in
clu
d
i
n
g
I
n
d
o
n
esia.
An
em
ia
ca
n
d
i
s
r
u
p
t
th
e
q
u
ality
o
f
life
as
w
ell
as
p
h
y
s
ical
an
d
m
en
tal
d
ev
elo
p
m
en
t
in
ad
o
le
s
ce
n
ts
,
wh
ich
u
ltima
tely
h
as
an
im
p
ac
t
o
n
t
h
e
h
ea
lth
o
f
w
o
m
en
a
n
d
c
h
ild
r
en
.
On
e
o
f
th
e
f
ac
to
r
s
th
at
p
lay
s
an
im
p
o
r
tan
t
r
o
le
in
th
e
in
c
id
en
ce
o
f
an
em
ia
is
p
h
y
s
ical
m
atu
r
atio
n
[
1
]
.
I
n
ad
o
lescen
ts
wh
o
m
ar
r
y
at
a
y
o
u
n
g
a
g
e,
th
e
p
h
y
s
ical
m
atu
r
ity
p
r
o
ce
s
s
is
n
o
t
o
p
tim
al,
w
h
ich
ca
n
lead
t
o
th
e
r
is
k
o
f
an
em
ia.
An
em
ia
is
a
s
ig
n
if
ican
t
h
ea
lth
p
r
o
b
lem
,
wh
ich
is
ch
a
r
ac
ter
ized
by
a
lo
wer
n
u
m
b
er
o
f
r
e
d
b
lo
o
d
ce
lls
o
r
h
em
o
g
l
o
b
in
le
v
el
th
an
n
o
r
m
al,
wh
ich
ca
n
d
is
r
u
p
t
th
e
b
o
d
y
'
s
ab
ilit
y
to
ca
r
r
y
o
x
y
g
en
to
b
o
d
y
tis
s
u
es
[
1
]
.
An
em
ia
in
a
d
o
lescen
ts
wh
o
m
ar
r
y
at
a
y
o
u
n
g
ag
e
n
ee
d
s
s
er
io
u
s
atten
tio
n
f
o
r
s
ev
er
al
r
ea
s
o
n
s
th
a
t
ca
n
af
f
ec
t
th
eir
h
ea
lth
.
Pro
p
er
m
ed
ical
m
an
ag
em
e
n
t
f
o
r
an
e
m
ia
ca
n
p
r
ev
en
t
c
o
m
p
licatio
n
s
th
at
m
ay
en
d
an
g
er
th
e
h
ea
lth
o
f
t
h
e
ch
ild
to
b
e
b
o
r
n
[
2
]
.
An
em
ia
is
ass
o
ciate
d
with
p
o
o
r
co
g
n
itiv
e
d
e
v
elo
p
m
en
t
in
c
h
ild
r
en
an
d
wo
r
k
ca
p
ac
ity
in
ad
u
lts
,
th
u
s
af
f
ec
tin
g
th
e
c
o
u
n
t
r
y
'
s
ec
o
n
o
m
ic
d
ev
el
o
p
m
e
n
t
[
3
]
.
I
n
p
r
e
g
n
an
t
wo
m
en
,
ir
o
n
d
ef
icien
cy
an
em
ia
is
also
ass
o
ciate
d
with
ad
v
er
s
e
r
ep
r
o
d
u
c
tiv
e
o
u
tco
m
es
s
u
ch
as
p
r
em
at
u
r
e
b
ir
th
,
l
o
w
b
ir
th
weig
h
t
b
ab
ies,
a
n
d
r
ed
u
ce
d
i
r
o
n
s
to
r
es
in
b
ab
ies,
wh
ich
m
ay
ca
u
s
e
ab
o
r
tio
n
,
b
ir
th
d
e
f
ec
ts
o
r
g
r
o
wth
an
d
d
ev
elo
p
m
e
n
t f
o
r
th
e
f
etu
s
o
r
b
ab
y
[
4
]
.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
SS
N
:
2
2
5
2
-
8
8
0
6
I
n
t J Pu
b
lic
Hea
lth
Sci
,
Vo
l.
15
,
No
.
3
,
Sep
tem
b
er
20
26
:
7
7
7
-
7
8
5
778
At
th
e
g
lo
b
al
lev
el,
a
n
em
ia
in
ad
o
lescen
ts
an
d
wo
m
en
o
f
c
h
ild
b
ea
r
in
g
a
g
e
r
em
ain
s
a
s
er
io
u
s
co
n
ce
r
n
b
ec
au
s
e
it
is
clo
s
ely
r
elate
d
to
th
e
q
u
ality
o
f
h
u
m
a
n
r
eso
u
r
ce
s
an
d
m
ater
n
al
h
ea
lth
.
W
HO
d
ata
f
o
r
2
0
2
1
s
h
o
wed
th
e
p
r
ev
alen
ce
o
f
an
em
ia
in
wo
m
en
ag
ed
1
5
-
4
9
y
ea
r
s
at
2
9
.
9
%
an
d
th
e
p
r
e
v
alen
ce
o
f
an
em
ia
in
ch
ild
r
en
at
6
0
.
2
%
[
5
]
.
I
n
I
n
d
o
n
esia,
an
em
ia
r
em
ain
s
a
s
ig
n
if
ican
t
h
ea
lth
p
r
o
b
lem
.
Acc
o
r
d
in
g
to
d
ata
f
r
o
m
th
e
I
n
d
o
n
esian
Min
is
tr
y
o
f
Hea
lth
,
co
n
d
u
ct
ed
th
r
o
u
g
h
th
e
I
n
d
o
n
esian
Hea
lth
Su
r
v
ey
an
d
B
asic
Hea
lth
R
esear
ch
,
th
e
p
r
ev
alen
ce
o
f
an
em
ia
am
o
n
g
ad
o
lescen
t
g
ir
ls
h
as
in
cr
ea
s
ed
in
r
ec
en
t
y
ea
r
s
.
B
ased
o
n
d
ata
d
er
iv
ed
f
r
o
m
th
e
I
n
d
o
n
esian
Hea
lth
Su
r
v
ey
(
2
0
2
3
)
,
th
e
p
r
ev
alen
ce
o
f
an
em
ia
f
o
r
all
ag
e
g
r
o
u
p
s
in
I
n
d
o
n
esia
was
1
6
.
2
%;
an
d
it
was
r
elativ
ely
h
ig
h
er
f
o
r
th
e
f
em
ale
g
r
o
u
p
b
y
1
8
%
co
m
p
a
r
e
d
to
1
4
.
4
%
f
o
r
th
e
m
ale
g
r
o
u
p
[
6
]
.
Acc
o
r
d
in
g
t
o
a
p
r
elim
in
ar
y
s
u
r
v
e
y
co
n
d
u
cted
in
B
an
g
k
alan
d
is
tr
ict,
th
er
e
wer
e
5
4
ad
o
lescen
ts
wh
o
m
ar
r
ied
at
a
y
o
u
n
g
ag
e
,
4
4
o
f
wh
o
m
h
a
d
an
em
ia,
in
clu
d
in
g
m
ild
,
m
o
d
er
ate
,
an
d
s
ev
er
e
an
em
ia
[
7
]
.
T
h
ey
r
e
v
ea
led
th
at
an
em
ia
in
ter
f
er
ed
with
d
aily
ac
tiv
ities
,
wh
er
ein
th
ey
w
er
e
o
f
te
n
tire
d
an
d
h
ad
d
izzy
ey
es.
On
e
o
f
t
h
e
r
esp
o
n
d
e
n
ts
was
an
ad
o
lescen
t
with
an
em
ia
wh
o
h
ad
a
b
ab
y
with
s
tu
n
tin
g
[
8
]
.
T
h
e
n
atio
n
al
b
u
r
d
en
o
f
a
n
em
ia
n
o
t
o
n
l
y
im
p
ac
ts
in
d
iv
id
u
al
h
ea
lt
h
b
u
t
also
h
as
co
n
s
eq
u
en
ce
s
f
o
r
th
e
q
u
ality
o
f
f
u
tu
r
e
g
en
e
r
atio
n
s
.
T
ee
n
a
g
er
s
with
an
em
ia
ar
e
at
h
ig
h
er
r
is
k
o
f
h
ig
h
-
r
is
k
p
r
eg
n
an
cies.
Failu
r
e
to
m
an
a
g
e
an
em
ia
c
an
r
esu
lt
in
im
p
air
ed
h
ea
lth
an
d
q
u
ality
o
f
life
am
o
n
g
m
illi
o
n
s
o
f
wo
m
en
,
an
d
it
ca
n
d
is
r
u
p
t
c
h
ild
r
en
'
s
d
ev
elo
p
m
en
t
a
n
d
lear
n
i
n
g
in
th
e
f
u
tu
r
e
[
9
]
.
At
a
y
o
u
n
g
ag
e,
ad
o
lescen
ts
'
b
o
d
ies
ar
e
s
till
in
th
e
g
r
o
wt
h
an
d
d
ev
elo
p
m
en
t
p
h
ase,
b
o
th
p
h
y
s
ically
an
d
m
e
n
tally
.
At
th
e
s
am
e
tim
e,
ad
o
lescen
ts
h
av
e
to
f
ac
e
th
e
p
h
y
s
ical
an
d
p
s
y
ch
o
lo
g
ical
b
u
r
d
en
s
o
f
n
ew
r
o
les
in
m
ar
r
iag
e
an
d
p
r
eg
n
an
cy
[
1
0
]
.
Ho
r
m
o
n
al
ch
an
g
es
th
at
o
cc
u
r
d
u
r
i
n
g
p
u
b
er
ty
a
n
d
im
b
al
an
ce
s
in
n
u
tr
itio
n
al
n
ee
d
s
o
f
ten
af
f
ec
t
n
u
tr
itio
n
al
s
tatu
s
,
in
clu
d
in
g
ir
o
n
lev
els,
wh
ich
ar
e
im
p
o
r
tan
t
f
o
r
p
r
e
v
e
n
tin
g
an
e
m
ia.
E
-
m
o
d
u
les
o
r
el
ec
tr
o
n
ic
m
o
d
u
les
as
a
m
ea
n
s
o
f
h
ea
lth
e
d
u
ca
tio
n
h
a
v
e
g
r
ea
t
p
o
ten
tial
to
in
cr
ea
s
e
ad
o
lescen
ts
'
k
n
o
wled
g
e
ab
o
u
t
n
u
tr
itio
n
,
r
ep
r
o
d
u
ctiv
e
h
ea
lth
,
an
d
th
e
p
r
ev
en
tio
n
o
f
an
em
ia
[
1
1
]
.
T
h
e
u
s
e
o
f
e
-
m
o
d
u
les
r
eg
ar
d
in
g
h
ea
lth
ed
u
ca
tio
n
ca
n
p
r
o
v
id
e
in
f
o
r
m
atio
n
th
at
is
ea
s
y
to
ac
ce
s
s
an
d
in
ter
ac
tiv
e,
s
o
th
at
a
d
o
lescen
ts
m
ay
b
etter
u
n
d
er
s
tan
d
h
o
w
t
o
m
ain
tain
th
eir
h
ea
lth
,
esp
ec
ia
lly
in
th
e
co
n
tex
t
o
f
g
ettin
g
m
ar
r
ied
at
a
y
o
u
n
g
ag
e.
T
h
i
s
is
in
l
in
e
with
a
p
r
ev
io
u
s
s
tu
d
y
o
n
ch
ild
r
e
n
'
s
attitu
d
es
r
eg
ar
d
in
g
th
e
s
af
ety
o
f
s
n
ac
k
s
.
I
t
was
r
ev
ea
led
th
at
th
e
m
ea
n
s
co
r
e
b
ef
o
r
e
h
e
alth
ed
u
ca
tio
n
was
6
2
.
1
8
,
a
n
d
af
ter
h
ea
lth
ed
u
ca
ti
o
n
it
in
cr
ea
s
ed
to
8
0
.
7
0
.
T
h
e
t
-
test
o
b
tain
ed
a
p
-
v
alu
e
o
f
0
.
0
0
0
<
α
0
.
0
5
[
1
2
]
.
Su
ch
a
f
in
d
in
g
in
d
icate
d
th
a
t
th
er
e
was
a
s
ig
n
if
ican
t
d
if
f
er
en
ce
in
ch
ild
r
e
n
'
s
attitu
d
es r
eg
ar
d
in
g
th
e
s
af
ety
o
f
s
n
ac
k
s
b
ef
o
r
e
an
d
af
ter
h
ea
l
th
ed
u
ca
tio
n
.
T
h
e
f
ailu
r
e
o
f
cu
r
r
e
n
t
in
te
r
v
en
tio
n
s
,
s
u
c
h
as
ir
o
n
s
u
p
p
lem
en
tatio
n
a
n
d
r
ep
r
o
d
u
cti
v
e
h
ea
lth
co
u
n
s
elin
g
,
is
p
r
im
ar
ily
d
u
e
to
th
e
lack
o
f
in
teg
r
atio
n
o
f
th
ese
ap
p
r
o
ac
h
es
with
ad
o
lescen
ts
'
p
h
y
s
ical
an
d
b
io
lo
g
ical
m
at
u
r
atio
n
[
1
3
]
.
M
o
s
t
p
r
o
g
r
am
s
f
o
c
u
s
s
o
lely
o
n
p
r
o
v
id
i
n
g
ir
o
n
s
u
p
p
l
em
en
ts
o
r
p
r
o
v
id
in
g
g
e
n
er
al
in
f
o
r
m
atio
n
ab
o
u
t
an
em
ia,
wit
h
o
u
t
co
n
s
id
er
in
g
th
at
a
d
o
lesce
n
ts
wh
o
m
ar
r
y
at
an
ea
r
ly
ag
e
ar
e
s
till
in
a
s
tag
e
o
f
r
e
p
r
o
d
u
ctiv
e
o
r
g
an
d
ev
elo
p
m
en
t
an
d
p
h
y
s
io
lo
g
ical
d
ev
elo
p
m
en
t
th
at
is
n
o
t
y
et
o
p
tim
al.
T
h
is
co
n
d
itio
n
in
cr
ea
s
es
ir
o
n
r
eq
u
ir
e
m
en
ts
d
u
e
to
m
en
s
tr
u
atio
n
,
b
o
d
y
g
r
o
wth
,
an
d
th
e
p
o
s
s
ib
ilit
y
o
f
ea
r
ly
p
r
eg
n
a
n
cy
.
W
h
en
s
u
p
p
lem
en
tatio
n
is
p
r
o
v
id
ed
with
o
u
t
a
g
o
o
d
u
n
d
er
s
tan
d
in
g
o
f
th
ese
b
io
lo
g
ical
ch
a
n
g
es,
c
o
m
p
lian
ce
with
ir
o
n
tab
let
co
n
s
u
m
p
tio
n
ten
d
s
to
b
e
lo
w
,
an
d
th
e
in
ter
v
e
n
tio
n
'
s
b
en
ef
its
ar
e
n
o
t m
a
x
im
ized
[
1
]
.
T
h
e
s
o
lu
tio
n
s
p
r
o
p
o
s
ed
in
th
i
s
p
ap
er
in
clu
d
e
Hea
lth
ed
u
ca
tio
n
to
p
r
e
p
ar
e
ad
o
lescen
ts
f
o
r
p
h
y
s
ical
m
atu
r
ity
in
th
e
f
o
r
m
o
f
ed
u
ca
t
io
n
an
d
awa
r
en
ess
r
aisi
n
g
o
n
t
h
e
d
an
g
e
r
s
o
f
ea
r
l
y
m
ar
r
ia
g
e
o
n
p
h
y
s
ical
h
ea
lth
,
esp
ec
ially
th
e
r
is
k
o
f
an
em
ia.
Nu
tr
itio
n
in
ter
v
en
tio
n
p
r
o
g
r
am
s
an
d
ir
o
n
s
u
p
p
lem
en
ts
f
o
r
ad
o
lescen
t
g
ir
ls
.
Ph
y
s
ical
m
atu
r
atio
n
is
an
im
p
o
r
tan
t a
s
p
ec
t th
at
n
ee
d
s
to
b
e
co
n
s
id
er
ed
in
m
ain
tain
in
g
ad
o
lescen
t r
ep
r
o
d
u
ctiv
e
h
ea
lth
,
esp
ec
ially
f
o
r
th
o
s
e
wh
o
m
ar
r
y
at
a
y
o
u
n
g
ag
e
[
1
4
]
.
Ad
o
lescen
ts
wh
o
h
av
e
n
o
t
r
ea
ch
ed
o
p
tim
al
p
h
y
s
ical
m
atu
r
ity
ar
e
at
r
is
k
o
f
e
x
p
er
ien
ci
n
g
v
ar
io
u
s
c
o
m
p
licatio
n
s
o
f
p
r
eg
n
an
cy
an
d
ch
ild
b
i
r
th
,
s
u
ch
as
an
em
ia,
p
r
e
m
atu
r
e
b
ir
th
,
a
n
d
th
e
r
is
k
o
f
m
ater
n
al
a
n
d
in
f
an
t
d
ea
th
.
T
h
er
ef
o
r
e,
e
n
s
u
r
in
g
th
at
ad
o
lescen
ts
ac
h
iev
e
s
u
f
f
icien
t
p
h
y
s
ical
m
atu
r
ity
b
ef
o
r
e
m
ar
r
iag
e
an
d
p
r
eg
n
a
n
cy
is
v
er
y
im
p
o
r
tan
t
to
s
u
p
p
o
r
t
o
p
tim
al
r
ep
r
o
d
u
ctiv
e
h
ea
lth
an
d
a
h
ea
l
th
ier
f
u
tu
r
e
[
1
5
]
.
L
ac
k
o
f
h
ea
lth
ed
u
ca
tio
n
f
o
r
ad
o
lescen
ts
ca
u
s
es
th
em
to
b
e
u
n
awa
r
e
o
f
ce
r
tain
s
y
m
p
to
m
s
s
u
ch
as
f
atig
u
e
an
d
d
izzin
ess
,
as
well
as
th
e
s
y
m
p
to
m
s
o
f
an
em
ia.
T
h
er
ef
o
r
e
,
ad
o
lescen
ts
ar
e
n
o
t
a
war
e
o
f
th
e
n
ee
d
t
o
s
ee
k
tr
ea
tm
en
t
o
r
p
ay
atten
ti
o
n
to
h
ea
lth
ie
r
ea
tin
g
p
atter
n
s
[
1
6
]
.
Ad
o
lescen
ts
f
ac
e
a
ce
r
tain
p
r
o
ce
s
s
wh
ich
in
clu
d
es
s
ig
n
if
ican
t
p
h
y
s
ical
an
d
h
o
r
m
o
n
al
c
h
an
g
es,
wh
ic
h
m
ay
af
f
ec
t
n
u
tr
itio
n
al
n
ee
d
s
,
in
clu
d
in
g
ir
o
n
,
wh
ich
is
v
er
y
im
p
o
r
ta
n
t
f
o
r
p
r
ev
en
tin
g
a
n
em
ia
[
1
7
]
.
T
h
e
p
h
y
s
ical
m
atu
r
atio
n
e
-
m
o
d
u
le
in
v
o
lv
es
ed
u
ca
tio
n
o
n
n
u
tr
itio
n
al
b
alan
ce
,
r
o
u
tin
e
h
ea
lth
ch
ec
k
s
f
o
r
r
eg
u
lar
h
em
o
g
lo
b
in
an
d
b
l
o
o
d
ch
ec
k
s
,
Fe
an
d
Vitam
in
B
1
2
tab
lets
,
r
est
an
d
s
leep
co
v
er
ag
e,
ex
er
cise,
ir
o
n
s
u
p
p
lem
e
n
ts
,
r
ep
r
o
d
u
ctiv
e
h
ea
lth
ed
u
ca
tio
n
,
an
d
s
tr
ess
m
an
ag
em
en
t
[
1
8
]
.
T
h
is
p
ap
er
also
clea
r
ly
ex
p
lai
n
s
th
e
o
b
s
er
v
atio
n
s
o
f
p
r
ev
io
u
s
s
tu
d
ies
th
at
h
av
e
b
ee
n
co
n
d
u
cted
o
n
s
im
ilar
to
p
ics.
A
n
u
m
b
er
o
f
p
r
ev
io
u
s
s
tu
d
ies
h
a
v
e
s
h
o
wn
th
at
m
ar
r
iag
e
an
d
p
r
eg
n
an
cy
at
a
y
o
u
n
g
a
g
e
ar
e
clo
s
ely
r
elate
d
to
th
e
h
ig
h
r
is
k
o
f
an
em
ia,
as
a
r
esu
lt
o
f
n
o
t
ac
h
iev
in
g
a
b
io
lo
g
ically
m
atu
r
e
p
h
y
s
ical
co
n
d
itio
n
,
in
clu
d
in
g
n
u
tr
itio
n
al
s
tatu
s
an
d
r
ep
r
o
d
u
ctiv
e
d
e
v
elo
p
m
en
t
s
y
s
t
em
s
[
1
9
]
.
Ho
wev
er
,
th
er
e
is
s
till
lim
ited
r
esear
ch
th
at
s
p
ec
if
ically
ex
am
in
es p
h
y
s
ical
m
atu
r
ity
v
ar
iab
les with
th
e
in
cid
en
ce
o
f
an
em
ia
in
g
r
o
u
p
s
Evaluation Warning : The document was created with Spire.PDF for Python.
I
n
t J Pu
b
lic
Hea
lth
Sci
I
SS
N:
2252
-
8
8
0
6
P
h
ysica
l
-
ma
tu
r
a
tio
n
w
ith
h
ea
l
th
ed
u
ca
tio
n
o
n
th
e
in
cid
e
n
ce
o
f a
n
emia
a
m
o
n
g
…
(
Desta
A
yu
C
a
h
ya
R
o
s
yid
a
)
779
o
f
y
o
u
n
g
m
ar
r
ied
a
d
o
lescen
ts
,
s
o
th
is
s
tu
d
y
is
ex
p
ec
ted
to
f
ill
th
is
g
ap
an
d
p
r
o
v
id
e
a
d
ee
p
er
s
cien
tific
co
n
tr
i
b
u
tio
n
[
2
0
]
.
T
h
is
s
tu
d
y
o
f
f
er
s
a
n
ew
ap
p
r
o
ac
h
b
y
co
m
b
in
in
g
p
h
y
s
ical
m
atu
r
ity
f
ac
to
r
s
with
th
e
in
cid
en
ce
o
f
an
em
ia
in
ad
o
lescen
ts
wh
o
m
a
r
r
y
y
o
u
n
g
.
T
h
i
n
g
s
th
at
ar
e
n
o
v
el
ab
o
u
t
th
is
s
tu
d
y
I
n
teg
r
ativ
e
ap
p
r
o
ac
h
b
etwe
en
p
h
y
s
ical
m
atu
r
ity
an
d
ea
r
ly
m
ar
r
iag
e.
T
h
is
s
tu
d
y
d
o
es
n
o
t
o
n
ly
lo
o
k
at
asp
ec
ts
o
f
p
r
eg
n
an
cy
o
r
n
u
tr
itio
n
,
b
u
t
ex
am
in
es
h
o
w
th
e
lev
el
o
f
b
io
lo
g
ical
m
atu
r
ity
(
e.
g
.
,
ag
e
o
f
m
en
a
r
ch
e,
b
o
d
y
d
e
v
elo
p
m
en
t)
af
f
ec
ts
s
u
s
ce
p
tib
ilit
y
to
an
em
ia
i
n
t
h
e
co
n
te
x
t
o
f
ea
r
ly
m
ar
r
iag
e
.
Pre
v
io
u
s
s
tu
d
ies
g
en
er
ally
d
is
cu
s
s
an
em
ia
in
ad
o
lescen
ts
in
g
en
er
al.
T
h
is
s
tu
d
y
tar
g
ets
a
m
o
r
e
s
p
ec
if
ic
s
u
b
g
r
o
u
p
,
n
a
m
ely
a
d
o
lescen
ts
wh
o
h
a
v
e
b
ee
n
m
ar
r
ied
,
w
h
o
f
ac
e
d
o
u
b
le
r
is
k
s
d
u
e
to
s
u
b
o
p
tim
al
m
atu
r
ity
a
n
d
th
e
b
io
lo
g
ical
d
em
an
d
s
o
f
m
ar
r
iag
e/p
r
e
g
n
an
c
y
.
W
ith
a
n
ew
u
n
d
e
r
s
tan
d
in
g
o
f
th
e
r
e
latio
n
s
h
ip
b
etwe
en
p
h
y
s
ical
m
atu
r
ity
an
d
an
em
ia
in
th
e
co
n
tex
t
o
f
ea
r
l
y
m
ar
r
ia
g
e
,
th
e
r
esu
lts
o
f
th
is
s
tu
d
y
ca
n
p
r
o
v
i
d
e
a
s
cien
tific
b
asis
f
o
r
ad
o
lescen
t
h
ea
lth
in
ter
v
en
tio
n
s
an
d
ea
r
ly
m
ar
r
ia
g
e
p
o
licies.
E
ar
ly
m
ar
r
ia
g
e
o
r
teen
ag
e
m
a
r
r
iag
e
o
f
ten
p
u
ts
ad
o
les
ce
n
ts
at
h
ig
h
er
h
ea
lth
r
is
k
s
,
in
clu
d
i
n
g
an
em
ia
wh
ich
ca
n
e
x
ac
er
b
ate
th
eir
p
h
y
s
ical
an
d
m
e
n
tal
co
n
d
itio
n
s
.
T
h
er
ef
o
r
e,
ed
u
ca
tio
n
al
in
te
r
v
en
tio
n
th
r
o
u
g
h
e
-
m
o
d
u
le
b
ased
o
n
an
u
n
d
e
r
s
tan
d
in
g
o
f
p
h
y
s
ical
m
atu
r
atio
n
is
v
er
y
im
p
o
r
tan
t
to
d
ec
r
ea
s
e
th
e
in
cid
en
ce
o
f
a
n
em
ia
am
o
n
g
ad
o
lescen
ts
wh
o
m
ar
r
y
at
a
y
o
u
n
g
ag
e.
P
h
y
s
ical
m
atu
r
atio
n
o
r
th
e
p
h
y
s
ical
r
ea
d
in
ess
o
f
ad
o
lescen
ts
p
lay
s
an
im
p
o
r
ta
n
t
r
o
le
in
p
r
ev
e
n
tin
g
an
em
ia.
B
ased
o
n
th
e
b
ac
k
g
r
o
u
n
d
ab
o
v
e,
th
e
r
esear
ch
er
s
ar
e
in
ter
ested
in
co
n
d
u
ctin
g
a
s
tu
d
y
en
titl
ed
"Ph
y
s
i
cal
m
atu
r
atio
n
u
s
in
g
e
-
m
o
d
u
le
o
n
t
h
e
in
cid
en
ce
o
f
a
n
em
ia
am
o
n
g
ad
o
lescen
ts
wh
o
m
ar
r
i
ed
at
a
y
o
u
n
g
ag
e.
"
T
h
is
is
c
o
n
s
id
er
ed
as
a
s
o
lu
tio
n
to
a
v
o
id
ad
v
e
r
s
e
im
p
ac
ts
an
d
im
p
r
o
v
e
t
h
e
h
ea
lth
o
f
wo
m
en
an
d
ch
ild
r
e
n
d
u
e
to
ea
r
l
y
m
ar
r
iag
e
o
r
teen
a
g
e
m
ar
r
iag
e
b
y
p
r
ep
ar
in
g
f
o
r
a
q
u
ality
p
r
eg
n
an
cy
.
T
h
is
r
esear
ch
also
m
ak
es
a
s
ig
n
if
ican
t
c
o
n
tr
ib
u
tio
n
to
th
e
d
e
v
elo
p
m
e
n
t
o
f
h
ea
lth
p
o
licies
an
d
th
e
ac
h
iev
em
e
n
t
o
f
th
e
Su
s
tain
ab
le
Dev
elo
p
m
en
t
Go
als
(
SDGs
)
.
E
f
f
o
r
ts
to
p
r
ev
e
n
t
an
em
ia
i
n
y
o
u
n
g
m
ar
r
ied
ad
o
lescen
ts
s
u
p
p
o
r
t
SDG
3
(
g
o
o
d
h
ea
lth
an
d
well
-
b
ein
g
)
,
s
p
ec
if
ically
in
r
e
d
u
cin
g
an
em
ia
r
ates,
im
p
r
o
v
in
g
m
ater
n
al
h
ea
lth
,
an
d
p
r
ev
e
n
tin
g
p
r
e
g
n
an
c
y
co
m
p
licatio
n
s
at
a
y
o
u
n
g
ag
e
.
Fu
r
th
er
m
o
r
e,
th
is
r
esear
ch
s
u
p
p
o
r
ts
SDG
4
(
q
u
a
lity
ed
u
ca
tio
n
)
b
y
s
tr
en
g
th
en
i
n
g
r
e
p
r
o
d
u
ctiv
e
h
ea
lth
a
n
d
n
u
t
r
itio
n
ed
u
ca
ti
o
n
f
o
r
ad
o
lescen
ts
,
an
d
SDG
5
(
g
e
n
d
er
eq
u
ality
)
b
y
p
r
o
m
o
tin
g
wo
m
en
'
s
h
ea
lth
p
r
o
tectio
n
an
d
p
r
ev
en
tin
g
th
e
n
eg
ativ
e
im
p
ac
ts
o
f
ea
r
ly
m
a
r
r
iag
e.
2.
M
E
T
H
O
D
T
h
is
was
a
q
u
an
titativ
e
s
tu
d
y
u
s
in
g
a
q
u
asi
-
ex
p
e
r
im
en
tal
d
esig
n
an
d
p
r
e
-
p
o
s
t
test
d
esig
n
with
a
co
n
tr
o
l
g
r
o
u
p
.
T
h
is
s
tu
d
y
i
n
v
o
lv
ed
two
g
r
o
u
p
s
o
f
s
u
b
jec
ts
[
2
1
]
.
Pre
-
test
f
o
r
th
e
i
n
ter
v
en
tio
n
g
r
o
u
p
was
co
n
d
u
cte
d
b
y
ch
ec
k
in
g
Hb
l
ev
els,
wh
ich
was
f
o
llo
wed
b
y
tr
ea
tm
en
t
in
th
e
f
o
r
m
o
f
p
r
o
v
id
in
g
p
h
y
s
ical
-
m
atu
r
atio
n
h
ea
lth
ed
u
ca
ti
o
n
u
s
in
g
e
-
m
o
d
u
le
with
a
tech
n
o
lo
g
y
-
b
ased
ap
p
r
o
ac
h
.
I
t
is
ex
p
ec
ted
th
at
ad
o
lescen
ts
wo
u
ld
b
e
m
o
r
e
u
n
d
er
s
tan
d
in
g
ab
o
u
t
th
e
im
p
o
r
ta
n
ce
o
f
d
iet
o
r
n
u
tr
itio
n
,
Fe
tab
lets
,
th
e
p
r
ev
en
tio
n
o
f
an
e
m
ia
an
d
th
e
im
p
o
r
tan
ce
o
f
h
ea
lth
m
o
n
ito
r
in
g
d
u
r
i
n
g
p
r
ep
ar
atio
n
f
o
r
p
r
eg
n
an
cy
an
d
d
u
r
in
g
p
r
e
g
n
an
c
y
[
2
2
]
.
E
d
u
ca
tio
n
an
d
ass
is
tan
ce
wer
e
p
r
o
v
id
ed
f
o
r
o
n
e
m
o
n
th
,
an
d
th
en
a
p
o
s
t
-
test
was
p
er
f
o
r
m
ed
b
y
ch
ec
k
i
n
g
Hb
lev
els.
R
esp
o
n
d
en
ts
in
th
e
co
n
tr
o
l g
r
o
u
p
wer
e
o
n
ly
g
i
v
en
co
u
n
s
elin
g
o
n
Fe
tab
lets
.
T
h
e
p
o
p
u
latio
n
in
v
o
lv
ed
all
a
d
o
lescen
ts
wh
o
m
a
r
r
ied
at
a
y
o
u
n
g
ag
e
in
B
an
g
k
alan
Dis
tr
ict,
Ma
d
u
r
a
in
Sep
tem
b
er
-
No
v
em
b
er
2
0
2
4
as
m
an
y
as
5
4
p
eo
p
le.
T
h
e
s
am
p
le
s
ize
was
d
eter
m
in
e
d
u
s
in
g
th
e
Slo
v
in
f
o
r
m
u
la,
an
d
th
e
ca
lcu
latio
n
r
esu
lted
in
4
4
r
esp
o
n
d
e
n
ts
.
T
h
e
s
tu
d
y
s
am
p
les
wer
e
s
elec
ted
th
r
o
u
g
h
ac
cid
en
tal
s
am
p
lin
g
tech
n
i
q
u
e.
4
4
r
esp
o
n
d
en
ts
wer
e
ass
ig
n
ed
in
to
tw
o
g
r
o
u
p
s
,
n
am
ely
th
e
in
ter
v
e
n
tio
n
g
r
o
u
p
a
n
d
th
e
co
n
tr
o
l g
r
o
u
p
,
wh
ich
co
n
s
is
ted
o
f
2
2
r
esp
o
n
d
e
n
ts
,
r
esp
ec
tiv
ely
.
T
h
e
s
tu
d
y
v
ar
iab
les
co
n
s
is
ted
o
f
th
e
i
n
d
ep
e
n
d
en
t
v
ar
iab
le
o
f
p
h
y
s
ical
m
atu
r
ati
o
n
an
d
th
e
d
ep
en
d
e
n
t
v
ar
iab
le
o
f
a
n
em
ia.
T
h
e
d
ata
co
llectio
n
in
s
tr
u
m
en
t
u
s
ed
h
er
e
was
th
e
p
h
y
s
ical
m
atu
r
atio
n
q
u
esti
o
n
n
air
e
.
Fu
r
th
er
m
o
r
e
,
an
e
m
ia
was
ass
ess
ed
th
r
o
u
g
h
Hem
o
g
lo
b
i
n
le
v
els.
T
h
e
r
esear
ch
in
s
tr
u
m
en
t
u
s
ed
in
th
e
s
tu
d
y
,
"Ph
y
s
ical
m
atu
r
atio
n
with
h
ea
lth
ed
u
ca
tio
n
o
n
th
e
in
cid
en
ce
o
f
a
n
em
ia
am
o
n
g
ad
o
lescen
ts
wh
o
m
ar
r
ied
at
a
y
o
u
n
g
ag
e
,
"
c
o
n
s
is
ted
o
f
a
q
u
esti
o
n
n
air
e
co
v
er
i
n
g
r
esp
o
n
d
e
n
t
ch
ar
ac
ter
is
tics
,
r
ep
r
o
d
u
ctiv
e
h
ea
lth
k
n
o
wled
g
e,
p
h
y
s
ical
m
atu
r
atio
n
,
an
e
m
ia
p
r
ev
en
tio
n
b
e
h
av
io
r
,
an
d
h
ea
lth
ed
u
ca
tio
n
.
B
ef
o
r
e
b
e
in
g
u
s
ed
in
th
e
m
ain
s
tu
d
y
,
th
e
q
u
esti
o
n
n
air
e
u
n
d
er
wen
t
v
alid
ity
an
d
r
eliab
ilit
y
test
in
g
t
o
en
s
u
r
e
th
at
it
m
e
asu
r
ed
v
ar
i
ab
les
ac
cu
r
ately
a
n
d
co
n
s
is
ten
tly
.
Data
wer
e
an
aly
ze
d
u
s
in
g
u
n
iv
ar
iate
an
d
b
i
v
ar
iate
an
aly
s
is
th
r
o
u
g
h
th
e
I
B
M
SP
SS
s
o
f
twar
e.
Un
iv
ar
iate
an
aly
s
is
was
ap
p
lied
to
d
eter
m
in
e
f
r
eq
u
en
cy
d
is
tr
ib
u
tio
n
,
wh
ile
b
iv
ar
iate
an
aly
s
is
ap
p
lied
th
e
C
h
i
-
s
q
u
ar
e
test
.
Dif
f
er
en
ce
s
in
th
e
m
ea
n
h
em
o
g
l
o
b
in
le
v
els
in
f
em
ale
ad
o
lescen
ts
b
ef
o
r
e
a
n
d
af
ter
i
n
ter
v
en
tio
n
was a
n
aly
ze
d
u
s
in
g
th
e
p
air
ed
t
-
test
(
n
o
r
m
al
d
ata
d
is
tr
ib
u
tio
n
)
b
etwe
en
g
r
o
u
p
s
[
2
3
]
.
3.
RE
SU
L
T
S AN
D
D
I
SCU
SS
I
O
N
T
ab
le
1
s
h
o
ws
th
e
d
e
m
o
g
r
ap
h
ic
an
d
b
io
lo
g
ical
ch
a
r
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o
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e
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y
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I
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Sep
tem
b
er
20
26
:
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780
d
is
tr
ib
u
tio
n
b
etwe
en
th
e
co
n
tr
o
l a
n
d
in
ter
v
en
tio
n
g
r
o
u
p
s
[
2
4
]
.
Mo
s
t r
esp
o
n
d
en
ts
h
ad
a
f
in
a
l e
d
u
ca
tio
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o
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h
ig
h
s
ch
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in
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icatin
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th
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m
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ts
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th
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a
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leted
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ig
h
s
ch
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o
l
ed
u
ca
tio
n
wh
e
n
th
e
y
m
ar
r
ied
[
2
5
]
.
I
n
ter
m
s
o
f
ag
e
o
f
m
a
r
r
iag
e,
m
o
r
e
th
an
h
alf
o
f
th
e
r
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o
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d
en
ts
m
ar
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ied
at
th
e
ag
e
o
f
1
5
–
1
7
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e
ar
s
(
5
6
.
8
%),
wh
ich
is
co
n
s
id
er
ed
an
ea
r
ly
m
ar
r
ia
g
e
ag
e.
On
l
y
2
7
.
3
% m
ar
r
ie
d
at
th
e
ag
e
o
f
≥
1
8
y
ea
r
s
,
in
ac
co
r
d
an
ce
with
th
e
ag
e
lim
it
f
o
r
m
ar
r
iag
e
r
ec
o
m
m
en
d
e
d
b
y
la
w
in
I
n
d
o
n
esia
[
2
6
]
.
An
em
ia
s
tatu
s
s
h
o
wed
a
s
tr
ik
in
g
d
if
f
er
en
ce
b
etwe
en
g
r
o
u
p
s
.
I
n
th
e
c
o
n
tr
o
l
g
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p
,
th
e
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r
o
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o
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tio
n
o
f
ad
o
lescen
ts
with
an
em
ia
r
ea
c
h
ed
5
9
.
1
%,
wh
ile
in
th
e
in
te
r
v
en
tio
n
g
r
o
u
p
it
was
o
n
ly
3
1
.
8
%.
T
h
is
co
u
ld
in
d
icate
th
e
in
f
l
u
en
ce
o
f
th
e
in
ter
v
en
tio
n
o
n
th
e
in
cid
e
n
ce
o
f
an
e
m
ia.
T
h
is
f
in
d
in
g
i
s
in
li
n
e
with
th
e
h
y
p
o
th
esis
th
at
in
ter
v
en
tio
n
s
r
elate
d
to
p
h
y
s
ical
m
atu
r
atio
n
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d
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r
ly
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R
eg
ar
d
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g
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h
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ical
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atu
r
atio
n
s
ig
n
s
,
m
o
s
t
r
esp
o
n
d
en
ts
ex
p
er
ien
ce
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m
en
ar
c
h
e
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ag
e
≥
1
2
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r
s
(
7
0
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5
%).
Ho
we
v
e
r
,
ar
o
u
n
d
2
9
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5
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ad
ex
p
er
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ce
d
m
en
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r
ch
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ef
o
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ag
e
1
2
,
wh
ich
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ld
b
e
an
in
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icato
r
o
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ly
m
atu
r
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d
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elate
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ch
as
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m
ia
[
1
5
]
.
All
b
aselin
e
ch
ar
ac
ter
is
tic
v
ar
iab
les
s
h
o
wed
p
-
v
alu
es
>
0
.
0
5
,
wh
ic
h
m
ea
n
s
th
at
b
o
th
g
r
o
u
p
s
(
co
n
tr
o
l
an
d
in
ter
v
e
n
tio
n
)
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e
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o
m
o
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eo
u
s
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ter
m
s
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e
d
u
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tio
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lev
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g
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o
f
m
ar
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a
n
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ia
s
tatu
s
,
an
d
s
ig
n
s
o
f
p
h
y
s
ical
m
atu
r
atio
n
.
T
ab
le
1
.
C
h
ar
ac
ter
is
tics
o
f
r
es
ea
r
ch
r
esp
o
n
d
en
ts
(n
=
4
4
)
C
h
a
r
a
c
t
e
r
i
s
t
i
c
s
C
o
n
t
r
o
l
g
r
o
u
p
(n
=
22)
I
n
t
e
r
v
e
n
t
i
o
n
g
r
o
u
p
(n
=
2
2
)
To
t
a
l
(n
=
44)
p
-
v
a
l
u
e
A
g
e
15
–
1
6
y
e
a
r
s
6
(
2
7
.
3
%)
4
(
1
8
.
2
%)
1
0
(
2
2
.
7
%)
0
.
8
5
17
–
1
8
y
e
a
r
s
1
0
(
4
5
.
4
%)
1
2
(
5
4
.
5
%)
2
2
(
5
0
%)
19
–
2
0
y
e
a
r
s
6
(
2
7
.
3
%)
6
(
2
7
.
3
%)
1
2
(
2
7
.
3
%)
La
st
e
d
u
c
a
t
i
o
n
l
e
v
e
l
N
o
sc
h
o
o
l
2
(
9
.
1
%)
1
(
4
.
5
%)
3
(
6
.
8
%)
0
.
7
6
El
e
m
e
n
t
a
r
y
s
c
h
o
o
l
/
e
q
u
i
v
a
l
e
n
t
5
(
2
2
.
7
%)
3
(
1
3
.
6
%)
8
(
1
8
.
2
%)
Ju
n
i
o
r
h
i
g
h
sc
h
o
o
l
/
e
q
u
i
v
a
l
e
n
t
1
0
(
4
5
.
4
%)
1
1
(
5
0
%)
2
1
(
4
7
.
7
%)
H
i
g
h
sc
h
o
o
l
/
e
q
u
i
v
a
l
e
n
t
5
(
2
2
.
7
%)
7
(
3
1
.
8
%)
1
2
(
2
7
.
3
%)
A
g
e
a
t
marr
i
a
g
e
<
1
5
y
e
a
r
s
4
(
1
8
.
2
%)
3
(
1
3
.
6
%)
7
(
1
5
.
9
%)
0
.
9
1
15
–
1
7
y
e
a
r
s
1
2
(
5
4
.
5
%)
1
3
(
5
9
.
1
%)
2
5
(
5
6
.
8
%)
≥
1
8
y
e
a
r
s
6
(
2
7
.
3
%)
6
(
2
7
.
3
%)
1
2
(
2
7
.
3
%)
A
n
e
m
i
c
s
t
a
t
u
s
A
n
e
m
i
c
1
3
(
5
9
.
1
%)
7
(
3
1
.
8
%)
2
0
(
4
5
.
5
%)
0
.
7
7
N
o
t
a
n
e
mi
c
9
(
4
0
.
9
%)
1
5
(
6
8
.
2
%)
2
4
(
5
4
.
5
%)
S
i
g
n
s
o
f
p
h
y
si
c
a
l
mat
u
r
a
t
i
o
n
M
e
n
a
r
c
h
e
<
1
2
y
e
a
r
s
8
(
3
6
.
4
%)
5
(
2
2
.
7
%)
1
3
(
2
9
.
5
%)
0
.
7
9
M
e
n
a
r
c
h
e
≥
1
2
y
e
a
r
s
1
4
(
6
3
.
6
%)
1
7
(
7
7
.
3
%)
3
1
(
7
0
.
5
%)
S
o
u
r
c
e
:
P
r
i
mar
y
D
a
t
a
2
0
2
4
3
.
1
.
Resul
t
s
o
f
t
he
ind
epend
ent
t
-
t
est
bet
wee
n phy
s
ica
l m
a
t
ura
t
i
o
n a
nd
a
nem
ia
in
a
do
lescent
s
who
m
a
rr
ied a
t
a
y
o
un
g
a
g
e
B
ased
o
n
th
e
r
esu
lts
o
f
th
e
in
d
ep
en
d
e
n
t
t
-
test
in
T
ab
le
2
,
it
was
f
o
u
n
d
th
at
all
p
h
y
s
ical
m
atu
r
atio
n
in
d
icato
r
s
h
ad
a
s
ig
n
if
ican
t
r
elatio
n
s
h
ip
to
an
em
ia
s
tatu
s
in
ad
o
lescen
ts
wh
o
m
ar
r
ied
at
a
y
o
u
n
g
ag
e.
T
h
e
av
er
ag
e
h
e
m
o
g
lo
b
in
(
Hb
)
lev
el
in
th
e
i
n
ter
v
en
tio
n
g
r
o
u
p
was
h
ig
h
er
(
1
1
.
4
g
/
d
L
)
c
o
m
p
ar
ed
to
th
e
co
n
tr
o
l
g
r
o
u
p
(
1
0
.
5
g
/d
L
)
,
with
a
p
-
v
a
lu
e
o
f
0
.
0
0
8
,
in
d
icatin
g
a
s
ig
n
if
ican
t
d
if
f
er
en
ce
.
Var
iab
les
s
u
ch
as
r
ep
r
o
d
u
ctiv
e
o
r
g
an
d
ev
elo
p
m
en
t,
b
o
d
y
g
r
o
wth
,
ag
e
o
f
m
en
a
r
ch
e,
p
u
b
e
r
ty
s
tatu
s
,
an
d
n
u
tr
itio
n
al
s
tatu
s
s
h
o
wed
a
p
-
v
alu
e
<
0
.
0
5
,
in
d
icatin
g
th
at
th
er
e
wa
s
a
s
ig
n
if
ican
t
d
if
f
e
r
en
ce
b
et
wee
n
th
e
two
g
r
o
u
p
s
.
T
h
e
in
t
er
v
en
tio
n
g
r
o
u
p
th
at
h
ad
b
etter
p
h
y
s
ical
m
atu
r
ity
s
tatu
s
also
ten
d
ed
t
o
h
av
e
h
i
g
h
er
H
b
lev
els,
s
o
th
e
y
ex
p
er
ien
c
ed
less
an
em
ia.
T
h
ese
r
esu
lts
in
d
icate
th
at
p
h
y
s
ical
m
atu
r
ity
p
lay
s
a
n
im
p
o
r
tan
t
r
o
le
in
th
e
in
cid
en
ce
o
f
a
n
em
ia,
esp
ec
ially
in
ad
o
lescen
t
g
ir
ls
wh
o
m
ar
r
ied
y
o
u
n
g
[
2
4
]
.
B
o
d
y
co
n
d
itio
n
s
th
at
ar
e
n
o
t
y
et
o
p
tim
ally
m
atu
r
e
ca
n
in
cr
ea
s
e
th
e
r
is
k
o
f
h
ea
lth
p
r
o
b
lem
s
in
clu
d
in
g
an
em
ia,
b
ec
a
u
s
e
th
e
in
cr
ea
s
ed
n
ee
d
f
o
r
ir
o
n
is
n
o
t
b
al
an
ce
d
b
y
s
u
f
f
icien
t
b
o
d
y
r
eser
v
es [
1
5
]
.
T
ab
le
2
.
R
esu
lts
o
f
th
e
in
d
e
p
e
n
d
en
t t
-
test
b
etwe
en
p
h
y
s
ical
m
atu
r
atio
n
an
d
an
em
ia
in
ad
o
lescen
ts
wh
o
m
ar
r
ied
at
a
y
o
u
n
g
ag
e
(
n
=
4
4
)
P
h
y
s
i
c
a
l
mat
u
r
a
t
i
o
n
v
a
r
i
a
b
l
e
C
o
n
t
r
o
l
g
r
o
u
p
(
M
e
a
n
±
S
D
)
I
n
t
e
r
v
e
n
t
i
o
n
g
r
o
u
p
(
M
e
a
n
±
S
D
)
p
-
v
a
l
u
e
I
n
f
o
r
mat
i
o
n
R
e
p
r
o
d
u
c
t
i
v
e
o
r
g
a
n
d
e
v
e
l
o
p
me
n
t
(
o
b
s
e
r
v
a
t
i
o
n
sc
o
r
e
)
3
.
1
±
0
.
7
3
.
6
±
0
.
5
0
.
0
1
2
*
S
i
g
n
i
f
i
c
a
n
t
B
o
d
y
g
r
o
w
t
h
(
h
e
i
g
h
t
/
w
e
i
g
h
t
Z
-
sc
o
r
e
i
n
d
e
x
)
-
0
.
8
±
1
.
1
-
0
.
2
±
0
.
9
0
.
0
4
5
*
S
i
g
n
i
f
i
c
a
n
t
A
g
e
o
f
m
e
n
a
r
c
h
e
(
y
e
a
r
s)
1
1
.
8
±
0
.
9
1
2
.
3
±
0
.
8
0
.
0
4
1
*
S
i
g
n
i
f
i
c
a
n
t
P
u
b
e
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t
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l
s
t
a
t
u
s
(
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n
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sc
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)
2
.
9
±
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3
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±
0
.
7
0
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0
1
9
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it
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HB
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th
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tates th
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s
th
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b
en
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its
o
f
p
r
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n
tiv
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m
ea
s
u
r
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tak
en
.
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n
th
is
co
n
tex
t,
teen
ag
er
s
wh
o
r
ec
eiv
e
ed
u
ca
tio
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ab
o
u
t
th
e
im
p
o
r
tan
ce
o
f
p
h
y
s
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m
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ity
a
n
d
its
r
elatio
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s
h
ip
to
a
n
em
ia
ar
e
lik
ely
t
o
b
e
m
o
r
e
m
o
tiv
ated
t
o
im
p
r
o
v
e
t
h
eir
d
iet
[
2
7
]
.
T
h
ese
r
esu
lts
ar
e
in
lin
e
with
r
esear
ch
co
n
d
u
cted
b
y
L
estar
i
et
a
l.
[
2
8
]
,
w
h
ich
s
h
o
wed
t
h
at
p
r
o
v
id
i
n
g
d
ig
ital
m
ed
ia
-
b
ased
n
u
tr
itio
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ed
u
ca
tio
n
i
n
cr
ea
s
ed
t
h
e
k
n
o
wled
g
e
a
n
d
co
m
p
lia
n
ce
o
f
ad
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lescen
t
g
ir
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co
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s
u
m
in
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f
o
o
d
s
h
ig
h
in
ir
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n
,
wh
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h
ad
a
p
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s
itiv
e
im
p
ac
t o
n
in
cr
ea
s
in
g
h
em
o
g
lo
b
in
le
v
els
[
2
9
]
.
I
n
ad
d
itio
n
,
r
esear
ch
b
y
Sar
i
et
a
l.
[
3
0
]
al
s
o
f
o
u
n
d
th
at
th
e
u
s
e
o
f
tech
n
o
lo
g
y
-
b
ased
ed
u
ca
tio
n
al
m
e
d
ia
ca
n
in
cr
ea
s
e
th
e
ef
f
ec
tiv
en
ess
o
f
an
em
ia
p
r
ev
e
n
tio
n
p
r
o
g
r
a
m
s
am
o
n
g
s
tu
d
en
t
s
.
T
h
u
s
,
it
ca
n
b
e
co
n
clu
d
ed
t
h
at
h
ea
lth
ed
u
ca
tio
n
in
ter
v
e
n
tio
n
s
u
s
in
g
e
-
m
o
d
u
le
ar
e
an
ef
f
ec
tiv
e
s
tr
ateg
y
i
n
in
c
r
ea
s
in
g
h
em
o
g
l
o
b
in
lev
els
in
ad
o
lescen
ts
.
T
h
is
in
ter
v
en
tio
n
n
o
t
o
n
ly
in
cr
ea
s
es
k
n
o
wled
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e
b
u
t
also
en
co
u
r
a
g
es p
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s
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b
eh
a
v
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r
al
ch
an
g
es in
ter
m
s
o
f
n
u
tr
itio
n
al
in
tak
e
an
d
h
ea
lth
y
life
s
ty
les [
2
9
].
Hea
lth
ed
u
ca
tio
n
th
r
o
u
g
h
e
-
m
o
d
u
les
p
r
o
v
id
es
co
n
v
en
ie
n
c
e
f
o
r
r
esp
o
n
d
en
ts
in
r
ec
eiv
in
g
h
ea
lth
in
f
o
r
m
atio
n
in
a
m
o
r
e
f
lex
i
b
le
an
d
in
ter
ac
tiv
e
m
an
n
er
.
T
h
is
ap
p
r
o
ac
h
is
in
li
n
e
with
th
e
p
lan
n
ed
h
ea
lth
b
eh
av
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r
th
eo
r
y
,
wh
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e
x
p
lai
n
s
th
at
an
in
d
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id
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s
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ten
tio
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to
b
eh
av
e
h
ea
lth
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is
in
f
lu
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n
ce
d
b
y
th
r
ee
m
ain
co
n
s
tr
u
cts,
n
am
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attitu
d
es
to
war
d
b
eh
av
io
r
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s
u
b
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n
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m
s
,
an
d
p
er
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b
e
h
av
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r
al
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l
[
31
]
.
I
n
th
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co
n
tex
t
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f
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-
m
o
d
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les,
in
f
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m
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ac
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ap
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p
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itiv
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h
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n
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ter
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t
ca
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m
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p
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b
eh
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ex
am
p
les
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r
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m
th
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r
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e
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m
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h
u
s
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m
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m
e
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f
ec
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m
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s
h
ap
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alth
y
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te
n
tio
n
s
a
n
d
b
e
h
av
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r
s
in
ac
co
r
d
an
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th
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d
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lth
B
eh
av
io
r
th
eo
r
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l
f
r
am
ewo
r
k
[
3
2
]
.
3
.
3
.
Dif
f
e
r
ence
in t
he
increa
s
e
in hem
o
g
lo
bin
lev
els bet
w
ee
n t
he
t
wo
g
ro
up
s
T
h
e
r
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lts
p
r
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d
in
T
ab
le
4
r
e
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ti
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r
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test
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a
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f
0
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0
0
0
(
p
-
v
alu
e
<
α
=
0
.
0
5
)
.
I
t
was
f
o
u
n
d
th
at
th
er
e
was
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if
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e
r
en
c
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in
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m
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1
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4
5
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r
/
d
l.
T
h
u
s
,
it
ca
n
b
e
co
n
clu
d
ed
th
at
th
er
e
was
an
ef
f
ec
t
o
f
p
h
y
s
ical
m
atu
r
atio
n
u
s
in
g
e
-
m
o
d
u
le
o
n
th
e
in
cid
e
n
ce
o
f
an
e
m
ia
am
o
n
g
ad
o
lescen
t
s
wh
o
m
ar
r
ied
at
a
y
o
u
n
g
ag
e.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
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2
2
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I
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t J Pu
b
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lth
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l.
15
,
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.
3
,
Sep
tem
b
er
20
26
:
7
7
7
-
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8
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782
T
ab
le
4
.
Dif
f
e
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e
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h
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e
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h
em
o
g
lo
b
in
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els b
ef
o
r
e
an
d
af
ter
in
ter
v
en
tio
n
V
a
r
i
a
b
l
e
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n
t
e
r
v
e
n
t
i
o
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(
n
=
22)
C
o
n
t
r
o
l
(n
=
22)
p
-
v
a
l
u
e
M
e
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e
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g
l
o
b
i
n
l
e
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e
l
s
2
.
0
7
(
0
.
3
8
)
0
.
6
2
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.
8
2
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0
.
0
0
0
*
M
e
a
n
d
i
f
f
e
r
e
n
c
e
1
.
4
5
*
I
n
d
e
p
e
n
d
e
n
t
t
-
t
e
st
B
ased
o
n
th
e
r
esu
lts
o
f
s
tatis
ti
ca
l
test
s
u
s
in
g
an
i
n
d
ep
e
n
d
en
t
t
-
test
,
a
p
-
v
alu
e
o
f
0
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0
0
0
(
≤
α
0
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0
5
)
was
o
b
tain
ed
,
in
d
icatin
g
th
at
th
er
e
was
a
s
ig
n
if
ican
t
d
if
f
er
en
ce
b
etwe
en
th
e
in
ter
v
en
tio
n
g
r
o
u
p
an
d
th
e
co
n
tr
o
l
g
r
o
u
p
in
in
cr
ea
s
in
g
h
em
o
g
lo
b
in
lev
els.
T
h
e
av
er
ag
e
d
if
f
e
r
en
ce
in
in
cr
ea
s
in
g
h
em
o
g
lo
b
in
lev
els
was
1
.
4
5
g
r
/d
l
in
t
h
e
g
r
o
u
p
th
at
r
ec
eiv
e
d
in
ter
v
e
n
tio
n
th
r
o
u
g
h
e
-
m
o
d
u
les
o
n
p
h
y
s
ical
m
atu
r
atio
n
.
T
h
ese
r
esu
lts
in
d
icate
th
at
th
e
u
s
e
o
f
e
-
m
o
d
u
les
in
ed
u
ca
tio
n
o
n
p
h
y
s
ical
m
atu
r
a
tio
n
h
as
a
n
ef
f
e
ct
o
n
r
ed
u
cin
g
th
e
in
cid
en
ce
o
f
an
em
ia
in
ad
o
lescen
ts
wh
o
m
a
r
r
y
at
a
y
o
u
n
g
ag
e
.
Fu
r
th
er
m
o
r
e
,
h
ea
lth
e
d
u
ca
tio
n
s
er
v
es
as
a
cu
e
to
ac
tio
n
th
at
m
o
tiv
ates
ad
o
lescen
ts
to
c
h
an
g
e
th
eir
h
ea
lth
b
eh
a
v
io
r
s
.
Ad
o
lescen
ts
wh
o
p
r
e
v
io
u
s
ly
co
n
s
id
er
ed
an
em
ia
a
co
m
m
o
n
co
n
d
i
tio
n
b
e
g
in
to
u
n
d
er
s
tan
d
its
im
p
ac
t
o
n
m
ater
n
al
an
d
f
etal
h
ea
lth
,
s
u
ch
as
ch
r
o
n
ic
f
atig
u
e,
p
r
eg
n
an
cy
co
m
p
licatio
n
s
,
p
r
eter
m
b
ir
th
,
a
n
d
s
tu
n
tin
g
in
ch
ild
r
e
n
.
T
h
u
s
,
h
ea
lth
ed
u
ca
tio
n
in
ter
v
en
tio
n
s
h
av
e
a
m
o
r
e
s
u
s
tain
ab
le
ef
f
ec
t
th
a
n
s
u
p
p
lem
en
tatio
n
alo
n
e,
as
th
e
y
ca
n
s
h
ap
e
h
ea
lth
awa
r
en
ess
,
attitu
d
es,
an
d
b
eh
a
v
io
r
s
in
ter
n
ally
[
1
4
]
.
T
h
e
r
esu
lts
o
f
th
is
s
tu
d
y
in
d
icate
th
at
p
h
y
s
ical
m
atu
r
atio
n
in
ter
v
en
tio
n
s
with
h
ea
lth
ed
u
ca
tio
n
co
n
tr
ib
u
te
to
a
r
ed
u
ctio
n
i
n
th
e
in
cid
en
ce
o
f
an
em
ia
i
n
ad
o
l
escen
ts
wh
o
m
ar
r
y
at
a
y
o
u
n
g
ag
e.
T
h
ese
f
in
d
in
g
s
in
d
icate
th
at
h
ea
lth
e
d
u
ca
tio
n
n
o
t
o
n
ly
i
n
cr
ea
s
es
k
n
o
wled
g
e
b
u
t
also
in
f
lu
en
ce
s
c
h
an
g
es
i
n
ad
o
lescen
ts
'
h
ea
lth
b
eh
av
io
r
s
b
y
r
aisi
n
g
awa
r
en
ess
o
f
th
e
im
p
o
r
ta
n
ce
o
f
b
i
o
lo
g
ical
r
ea
d
i
n
ess
an
d
n
u
t
r
itio
n
al
s
tatu
s
b
ef
o
r
e
p
r
eg
n
a
n
cy
.
I
n
ad
o
l
escen
ts
wh
o
m
ar
r
y
ea
r
ly
,
im
m
atu
r
ity
o
f
r
ep
r
o
d
u
ctiv
e
o
r
g
an
s
an
d
h
ig
h
ir
o
n
r
eq
u
ir
em
en
ts
d
u
r
in
g
g
r
o
wth
in
cr
ea
s
e
th
e
r
is
k
o
f
an
em
ia,
esp
ec
ially
wh
en
co
m
b
in
ed
with
in
ad
eq
u
ate
d
ietar
y
p
atter
n
s
an
d
lim
ited
ac
ce
s
s
to
r
ep
r
o
d
u
ctiv
e
h
ea
lth
in
f
o
r
m
atio
n
[
8
]
.
T
h
eo
r
etica
lly
,
ad
o
lescen
ce
is
an
im
p
o
r
tan
t
tr
an
s
itio
n
p
er
io
d
m
ar
k
ed
b
y
p
h
y
s
ical
g
r
o
wth
an
d
in
cr
ea
s
ed
n
u
tr
itio
n
al
n
ee
d
s
,
e
s
p
ec
ially
ir
o
n
,
w
h
ich
is
v
er
y
i
m
p
o
r
tan
t
i
n
th
e
f
o
r
m
atio
n
o
f
h
em
o
g
lo
b
in
.
W
h
en
ad
o
lescen
t
g
ir
ls
m
ar
r
y
a
n
d
b
e
co
m
e
p
r
e
g
n
an
t
at
a
y
o
u
n
g
ag
e,
th
e
n
ee
d
f
o
r
ir
o
n
b
ec
o
m
es
h
ig
h
er
,
a
n
d
if
n
o
t
b
alan
ce
d
with
ad
e
q
u
ate
ed
u
ca
t
io
n
an
d
u
n
d
er
s
tan
d
in
g
,
th
e
r
is
k
o
f
a
n
em
ia
in
cr
ea
s
es [
3
3
]
.
Pro
v
id
in
g
e
d
u
ca
tio
n
th
r
o
u
g
h
e
-
m
o
d
u
les
allo
ws
ad
o
lescen
ts
to
o
b
tain
i
n
f
o
r
m
atio
n
a
b
o
u
t
th
e
im
p
o
r
tan
ce
o
f
n
u
t
r
itio
n
al
in
ta
k
e,
h
em
o
g
lo
b
in
f
u
n
ctio
n
,
an
d
th
e
im
p
ac
t
o
f
an
e
m
ia,
in
an
in
ter
ac
tiv
e
an
d
ea
s
ily
ac
ce
s
s
ib
le
way
.
T
h
is
i
s
in
li
n
e
with
th
e
HB
M
th
eo
r
y
,
wh
ich
s
tates
th
at
in
cr
ea
s
ed
k
n
o
wled
g
e
an
d
r
is
k
p
er
ce
p
tio
n
ca
n
e
n
co
u
r
ag
e
i
n
d
i
v
id
u
als
to
c
h
an
g
e
th
eir
h
ea
lth
b
eh
av
io
r
.
E
-
m
o
d
u
les d
esig
n
ed
w
ith
th
is
ap
p
r
o
ac
h
ar
e
ab
le
to
in
cr
ea
s
e
ad
o
lesc
en
t
awa
r
en
ess
o
f
th
e
im
p
o
r
t
an
ce
o
f
p
h
y
s
ical
m
atu
r
atio
n
b
ef
o
r
e
m
ar
r
iag
e
o
r
p
r
eg
n
a
n
cy
,
as we
ll a
s
in
cr
ea
s
e
th
e
b
eh
a
v
io
r
o
f
co
n
s
u
m
in
g
n
u
tr
itio
u
s
f
o
o
d
s
an
d
ir
o
n
s
u
p
p
le
m
en
tatio
n
[
2
7
]
.
T
h
is
s
tu
d
y
is
s
u
p
p
o
r
te
d
b
y
f
in
d
in
g
s
f
r
o
m
p
r
e
v
io
u
s
s
tu
d
ies,
s
u
ch
as
a
s
tu
d
y
b
y
Nu
r
ain
i
an
d
An
d
r
ian
i
[
3
4
]
,
wh
ich
s
h
o
wed
t
h
at
d
ig
i
tal
-
b
ased
ed
u
ca
tio
n
al
in
ter
v
e
n
tio
n
s
ca
n
im
p
r
o
v
e
a
d
o
lescen
ts
'
k
n
o
wled
g
e
an
d
attitu
d
es
in
p
r
ev
en
tin
g
an
em
i
a.
An
o
th
er
s
tu
d
y
b
y
Sty
an
in
g
r
u
m
et
a
l.
[
3
5
]
also
f
o
u
n
d
t
h
at
ad
o
lescen
ts
wh
o
r
ec
eiv
ed
i
n
ten
s
iv
e
n
u
tr
itio
n
e
d
u
ca
tio
n
ex
p
e
r
ien
ce
d
a
s
ig
n
if
ican
t
in
cr
ea
s
e
in
h
e
m
o
g
lo
b
in
lev
els
co
m
p
ar
e
d
to
th
e
g
r
o
u
p
th
at
d
id
n
o
t
r
ec
ei
v
e
ed
u
ca
tio
n
[
2
9
]
.
T
h
e
f
in
d
in
g
s
o
f
th
is
s
tu
d
y
also
s
h
o
w
th
at
ir
o
n
s
u
p
p
lem
en
tatio
n
with
o
u
t
s
tr
en
g
th
e
n
i
n
g
ed
u
ca
t
io
n
an
d
b
io
lo
g
ical
r
ea
d
in
ess
is
o
f
ten
in
ef
f
ec
tiv
e.
T
h
is
m
ay
o
cc
u
r
b
ec
au
s
e
ad
o
lescen
ts
d
o
n
o
t
y
et
u
n
d
er
s
tan
d
th
e
im
p
o
r
tan
ce
o
f
ad
h
er
en
ce
to
ir
o
n
s
u
p
p
lem
en
tatio
n
,
la
ck
awa
r
en
ess
o
f
th
e
r
is
k
s
o
f
a
n
em
ia,
a
n
d
ar
e
s
till
in
f
lu
en
ce
d
b
y
cu
ltu
r
al
an
d
s
o
cial
f
ac
to
r
s
r
elate
d
to
ea
r
ly
m
ar
r
iag
e.
T
h
er
ef
o
r
e,
in
teg
r
atin
g
r
ep
r
o
d
u
ctiv
e
h
ea
lt
h
ed
u
ca
tio
n
,
p
h
y
s
ical
d
e
v
elo
p
m
en
t,
a
n
d
n
u
tr
itio
n
al
i
n
ter
v
en
tio
n
s
is
a
m
o
r
e
co
m
p
r
eh
e
n
s
iv
e
ap
p
r
o
ac
h
t
o
p
r
ev
en
tin
g
a
n
em
ia
in
y
o
u
n
g
m
ar
r
ied
ad
o
lescen
ts
.
T
h
u
s
,
th
e
r
esu
lts
o
f
th
is
s
tu
d
y
s
u
p
p
o
r
t
t
h
e
u
s
e
o
f
lear
n
in
g
tech
n
o
lo
g
y
s
u
ch
as
e
-
m
o
d
u
les
as
an
ef
f
ec
tiv
e
ap
p
r
o
ac
h
i
n
an
em
ia
p
r
ev
en
tio
n
p
r
o
g
r
am
s
,
es
p
ec
ially
f
o
r
g
r
o
u
p
s
o
f
y
o
u
n
g
m
ar
r
ie
d
f
em
ale
ad
o
lescen
ts
.
T
h
is
ef
f
o
r
t
also
s
u
p
p
o
r
ts
th
e
ac
h
ie
v
em
en
t
o
f
SDGs
,
esp
ec
ially
in
ter
m
s
o
f
i
m
p
r
o
v
i
n
g
a
d
o
lescen
t
h
ea
lth
an
d
r
ed
u
cin
g
an
em
ia
r
a
tes.
4.
CO
NCLU
SI
O
N
I
t
ca
n
b
e
c
o
n
clu
d
e
d
th
at
th
e
r
e
was
an
ef
f
ec
t
o
f
p
h
y
s
ical
m
at
u
r
atio
n
u
s
in
g
e
-
m
o
d
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Evaluation Warning : The document was created with Spire.PDF for Python.
I
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Hea
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2252
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8
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.
DATA AV
AI
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AB
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.
RE
F
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R
E
NC
E
S
[
1
]
A.
-
C
.
P
e
c
h
e
r
,
S
.
B
a
c
h
,
J.
P
a
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.
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a
n
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.
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,
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A
n
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mi
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[
2
]
M
.
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[
3
]
C
.
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.
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e
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a
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d
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M
.
P
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w
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s,
“
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.
[
4
]
E.
F
e
b
r
i
a
n
a
,
“
P
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n
g
a
r
u
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k
o
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t
a
b
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m
b
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(
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TD
)
d
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k
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,
p
p
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3
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,
2
0
2
1
.
[
5
]
W
o
r
l
d
H
e
a
l
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O
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g
a
n
i
z
a
t
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o
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(
W
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O
)
,
“
W
H
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a
l
a
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d
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t
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o
n
.
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l
o
b
a
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mi
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e
st
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m
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s
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n
w
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f
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e
,
b
y
p
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g
n
a
n
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y
st
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t
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n
d
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n
a
g
e
d
6
–
5
9
mo
n
t
h
s
,
”
W
H
O
.
[
6
]
K
e
m
e
n
t
e
r
i
a
n
S
e
k
r
e
t
a
r
i
a
t
N
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g
a
r
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R
I
,
“
M
a
sa
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a
,
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,
2
0
2
5
,
[
O
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]
.
A
v
a
i
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a
b
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:
h
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s
:
/
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d
a
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b
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.
s
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.
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h
-
g
i
z
i
-
p
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b
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l
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/
[
7
]
M
a
n
i
s
h
a
N
i
t
i
n
G
o
r
e
,
M
a
d
e
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a
:
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-
sec
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4
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j
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s.
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3
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7
.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
SS
N
:
2
2
5
2
-
8
8
0
6
I
n
t J Pu
b
lic
Hea
lth
Sci
,
Vo
l.
15
,
No
.
3
,
Sep
tem
b
er
20
26
:
7
7
7
-
7
8
5
784
[
8
]
K
.
L.
I
.
S
a
mso
n
,
J
.
A
.
J.
F
i
sc
h
e
r
,
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n
d
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.
L.
R
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e
,
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o
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s,
a
n
e
m
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a
,
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r
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yu
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785
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h
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n
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ifery
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ls
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h
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re
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lt
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d
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m
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n
d
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c
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it
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h
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b
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sh
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n
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ti
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l
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n
d
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tern
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ti
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n
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l
sc
ien
ti
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ic
jo
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rn
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ls,
a
n
d
is
c
u
rre
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tl
y
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lso
a
c
ti
v
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in
w
r
it
in
g
b
o
o
k
s
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th
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f
ield
o
f
h
e
a
lt
h
.
S
h
e
c
a
n
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o
n
tac
ted
a
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m
a
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:
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in
a
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ik
m
a
h
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p
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sb
y
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a
c
.
i
d
.
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o
li
c
h
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tin
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lec
tu
re
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M
id
wife
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t
Un
i
v
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rsitas
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G
RI
Ad
i
Bu
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n
a
S
u
ra
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y
a
.
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r
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x
p
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rti
se
is
in
P
re
m
e
n
o
p
a
u
sa
l
re
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ro
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u
c
ti
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e
a
lt
h
.
S
h
e
h
a
s
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n
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d
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ti
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l
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c
k
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d
in
m
id
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n
d
h
e
a
lt
h
,
a
n
d
p
la
y
s
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ti
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le
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c
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m
ic
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t
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n
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n
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a
d
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h
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n
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l
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n
d
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ter
n
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t
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sc
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jo
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n
a
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n
d
is
c
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tl
y
a
ls
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a
c
ti
v
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writi
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k
s
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th
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fiel
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h
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lt
h
.
S
h
e
c
a
n
b
e
c
o
n
tac
ted
a
t
e
m
a
il
:
so
li
c
h
a
ti
n
@
u
n
i
p
a
sb
y
.
a
c
.
id
.
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