Tabel 4.7 Analysis results of Ferritin level in the control group and intervention group (N=30)

Based on table 4.7, the results of bivariate analysis were as follows:

There was no significant difference in the level of ferritin hormone before treatment between the intervention group and the control group with p value >0.05

Characteristics of groups based on women age showed that the majority of samples in the control group were 27 years with the lowest age of 25 years and the highest age of 32 years. The majority of samples in the intervention group were 26.6 years with the lowest age of 25 years and the highest age of 30 years.

Common limits used by women of chilbearing age is 19-49 years, both for women who are married, widowed and unmarried. This age is the reproductive age of a woman associated with pregnancy, birth and the health of reproductive organs.[10] In the life cycle, women's health is affected by biological, cultural, behavioral and social factors. Biological factors are the most influential factor.

Adequate nutrition, a fundamental basis for the health of each individual, is very important for women because inadequate nutrition leads to chaos not only for women's health but also for the health of their children later.[11]

The educational characteristic of the respondents in the control group and the intervention group showed that high school (SHS) education level was dominant, with the lowest education of junior high school (JHS) and the highest education was higher education.

Education is one of the factors that can support the ease of a person to receive information and she can be motivated better, so that it is expected that the higher the level of education of a woman, the better motivation to make decisions for her nutritional needs.

One's education affects her nutritional condition because it is expected that with a higher level of education, the knowledge or nutritional information owned will be better. Nutritional problems often arise due to ignorance or lack of information about adequate nutrition. A person with low education is not necessarily less able to prepare foods that meet nutritional requirements compared to other people with higher education. If the person is diligent in listening or searching information on nutrition, it is not impossible that her nutritional knowledge will be better.

It should be considered that the level of education also determines whether or not someone to easily gain and understand the knowledge on nutrition obtained. In the interests of family nutrition, education is needed so that a person is more responsive to nutritional problems within the family and can take quick action.[11]

Education distribution of anemic women in the work area of ​​Bergas CHC between the intervention group and the control group showed the same value between secondary Senior High School and higher education.

Menstruation is a natural cycle that occurs in a woman's body. This cycle will generally appear every about 4 weeks, starting from the first day of menstruation until the first day of the next menstrual period.[12]

However, not all women experience the same cycle. The menstrual cycle can sometimes come faster or slower with differences ranging from 21 to 35 days. During menstruation, women will experience bleeding from the vagina for about 2 days to one week with an average blood volume of 30-70 milliliters. But there are some women who bleed more. The highest volume of bleeding during menstruation usually occurs on the first and second days.[12]

Chronic blood loss can also lead to anemia. In women, there is a natural blood loss every month. If the blood that comes out during menstruation is very much there will be iron deficiency anemia. Women do not have sufficient iron supplies and low iron absorption into the body so they cannot replace iron lost during menstruation.[12]

The study results on Hemoglobin levels using the Mann Whitney test showed the value before treatment of 0.148 (p >0.05) which meant that there was no significant difference in Hb levels before treatment between the intervention group and the control group. P value after being given 14 days treatment was 0.016 (p <0.05) and p value after 30 days of treatment was 0.002 (p <0.05), it can be concluded that there were significant differences in Hb levels after 14 and 30 days of treatment between the intervention group and the control group. During the 30 days there was an increase of 0.52 gr% in the intervention group and 0.15gr% in the control group.

This study is not in accordance with the study conducted by Sumiati Aiba (2016) that coconut haustorium in the treatment group had no effect on increasing hemoglobin in the first, second, third and fourth weeks with p = >0.05, but providinf coconut haustorium it did not lead to blood deficiency symptoms until anemia.[9]

The formation of hemoglobin in the blood is affected by the availability of other nutrients such as protein and iron. The consumption of nutrients from food is expected to have a balanced nutritional content, so that the metabolic process in the body will work optimally. Women of chilbearing age who have less nutritional status are likely to experience anemia. A person who has a good nutritional status will also have a good food reserves in the body. Nutrition among women of chilbearing age must be considered, given their function and role as housewives who will naturally experience pregnancy, delivery and labor and lactation.

Therefore women of chilbearing must have sufficient food reserves in the body so that they can carry out their role both as housewives and workers well.

The increase in hemoglobin levels among women of chilbearing is not only affected by Fe supplement alone but is also supported by consumption of foods containing substances needed in hemoglobin synthesis.

Coconut haustorium is one alternative to meet iron requirement as a nonheme iron source, it contains iron as much as 1.01 mg/100 grams. Adding iron content from Coconut haustorium plays a role for the formation of hemoglobin. Coconut haustorium contains nutrients in the form of proteins that play a role in the composition blood that is rich in iron, and flavonoid compounds that can maintain blood vessel health.[9]

A healthy human body contains ±3.5 grams of Fe which is almost entirely in the form of complex bonds with proteins. Approximately 70% of Fe in the body is functional or essential, and 30% is non-essential which in the form of 66% hemoglobin and 3% myoglobin and the rest is in the form of certain enzymes. Non-essential iron is available as a reserve in the forms of ferritin and hemosiderin as much as 25% and in the tissue perenchyma of approximately 5%. If these needs are not met, the Fe reserved in the body will be used and the reserve site will eventually be empty. As a result, Fe deficiency anemia will occur.[13]

Iron is a useful part for oxygen binding in erythrocytes. This substance is needed by the body 15-30 mg per day. Adult women have about 2.1 g of Fe, with 1.6 grams of hemoglobin. Hemoglobin consists of four units, each unit contains one heme group and one protein chain. Iron is found in the liver, meat, eggs, nuts, cheese, fish, green vegetables, cereals, and fruits.[14]

Anemia is the largest public health problem in the world, especially for women of chilbearing group. High risk group for anemia is women of chilbearing group because they do not have sufficient iron intake or reserves for Fe need and loss. Anemia among women of chilbearing can cause fatigue, weak body, and decreased work productivity. For pregnant women, anemia contributes to an increase in the prevalence of maternal mortality and morbidity, and for infants it can increase the risk of infant morbidity and mortality, and low birth weight.[15]

Anemia is a clinical symptom where hemoglobin levels in red blood are less than normal. Decrease in hemoglobin concentration is due to disruption of the formation of red blood cells caused by reduced levels of iron in the blood. So, the blood cannot carry oxygen in the amount needed by the body, and this will cause anemia.[33]

Iron deficiency anemia is an anemia that occurs due to lack of iron (Fe) that the body needs in the formation of red blood cells. In addition, in the process of forming hemoglobin, iron plays a role in the storage and transport of oxygen. Iron deficiency in the body characterize that the body lacks hemoglobin and oxygen which will inhibit the formation of red blood cells. The occurrence of iron deficiency anemia is largely determined by the ability of iron absorption, iron-containing diets, increased iron requirements, amount of iron lost in the body, loss of blood during labor, menstruation, and chronic diseases such as tuberculosis and malaria.[28]

Iron deficiency generally causes symptoms such as pallor, dizziness, headache, nail epithelial changes, lethargy, shortness of breath, weakness, drowsiness, fatigue, decreased fitness, decreased work ability and wound healing disorders.[66]

The process of iron absorption in the intestine consists of three phases, namely the luminal phase, mucosal phase, and systemic or corporeal phase. during the luminal phase the iron bond from food ingredients is released/converted into dissolved form, then iron in the form of ferric (Fe +++) is reduced to ferro (Fe ++) so it is readily absorbed by the intestine. In this process, the gastric secretionand gastric acid play an important role.

The best absorption occurs in the duodenum and proximal jejunum. This is associated with the number of receptors on the intestinal surface and intestinal pH.[19] Factors that inhibit iron absorption are influenced by substances mostly found in foods derived from plants. The strongest inhibitors are polyphenol compounds such as tannin in tea. Tea can reduce absorption up to 80% as a result of the formation of iron-tannate complex.[18]

The results showed that there was no significant correlation between ferritin hormone levels in the intervention group and the control group before being treated with p >0.05. Ferritin level in the intervention group after 30 days of treatment was 17.22 ng/ml and p value = 0.003 (p <0.05) which meant that there was a significant difference in ferritin hormone level in the intervention group after 30 days of treatment. Ferritin level in the control group after 30 days of treatment was -11.3 ng/ml and p value = 0.003 (p <0.05), which meant that there was a significant difference in ferritin hormone level in the control group after 30 days of treatment.

In this study it can be seen that ferritin levels before treatment in the two groups were at normal levels, in the intervention group the initial ferritin level was 25.86 ng/ml while in the control group was 29.68 ng/ml. After being given treatment it can be seen that there were changes in ferritin levels in both groups. In the control group there was a decrease in ferritin levels to 18.42 ng/ml while in the intervention group there was an increase in ferritin level to 43.07 ng/ml.

The study results showed that ferritin levels between two groups were different and there was a decrease in ferritin level in the control group, this might be due to the fact that this study did not take into account other variables that could affect ferritin levels in women of childbearing age. Further studies with multivariate analysis to observe other causes are needed.

From the data above, the addition of coconut haustorium powder to Fe tablets would increase the ferritin level of the body. Changes in ferritin levels before and after the tested with paired t-test showed significant result in the intervention group.

This study used ferritin parameter which was measured to determine the ferritin level of respondents. Ferritin serum in addition to describes iron reserves in the body, is also an acute phase reactant which will increase not only when the body's iron reserves increase but also in acute or chronic inflammation, liver disease, alcoholic, hemolytic anemia, hemochromatosis and malignancy. Meanwwhile low serum ferritin levels usually show iron deficiency anemia, menstruation with heavy bleeding or chronic gastrointestinal bleeding. Normal serum ferritin level is about 10-120 ng/ml.[20]

This study proved that consuming coconut haustorium at a dose of 800 mg three times/day together with Fe 60 mg tablets per day could routinely increase ferritin level and hemoglobin level among women of childbearing age. This study used the same dose (providing Coconut haustorium) to each respondent, the time period of hemoglobin examination was performed 3 times, the first day was before the intervention, day 14, and the day 30 after intervention and the assessment of ferritin level was conducted before intervention and after 30 days of treatment.

The authors did not examine the levels of substances, other Coconut haustorium vitamins and side effects that might affect the changes in hemoglobin and ferritin levels. The authors did not monitor other factors that could affect iron absorption in the body, for example the way respondents drink coconut haustorium powder and Fe tablets by using tea or drinks that could inhibit the absorption of Fe and did not monitor the daily dietary patterns consumed by respondents. This study was conducted by providing coconut haustorium powder to the respondents, the authors did not perform a preference test on the coconut haustorium powder to be given to the respondents.