Relationship Between Adolescent Anemia and School Attendance Observed During a Nationally Representative Survey in India

Background Anemia has been suggested to be related with schooling outcomes in India. Less is known, however, about whether the observed relationship persists after accounting for all household-level factors which may confound the association between anemia and schooling.Methods Nationally representative data on adolescents aged 15-18 years with data on measured hemoglobin level and school attendance 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, while controlling for age and period effects. We assessed heterogeneity in the relationship between anemia and school attendance across anemia severity groups and socio-demographic characteristics.Results The proportion of adolescents with any anemia is 55.2% (95% CI: 55.0-55.5) among young women and 31.0% (95% CI: 30.6-31.5) among young men. In conventional (between-household) regression models, having any anemia is associated with a 2.5 percentage point reduction (95% CI: 2.1-2.8) in school attendance; however, in household fixed-effects models, anemia has qualitatively small and non-significant effects on school attendance. Our results are consistent using alternative model specifications as well as across anemia severity groups, genders, types of relationship to the household head, household wealth quintiles, and states and union territories in India.Conclusions This within-household analysis finds little evidence that anemia is associated with school attendance among adolescents in India. Observational studies likely overstate the connection between anemia and school attendance due to household factors that have not been accounted for. Anemia is a condition which leads to a decreased capacity to circulate oxygen in the body resulting in fatigue, weakness, dizziness, and shortness of breath among other symptoms. It has been proposed that having anemia can impact the education of adolescents. We undertook a large-scale study of the relationship between anemia and school attendance among adolescents in India. We found that household-level factors are linked with school attendance, and the direct relationship between anemia and attendance was less clear. This study highlights the need to consider all influences that can impact whether adolescents can access education. Thus, approaches that just target adolescents at risk of anemia may not be sufficient to considerably improve school attendance at the population level in India. De Neve et al. determine the relationship between anemia and school attendance among adolescents using a large national dataset from India. In this within-household analysis, the relationship between anemia and schooling is more muted compared to more conventional analyses which do not account for all household-level factors.