Anaemia in childhood remains a critical public-health challenge with substantial consequences for growth, neurocognitive development, infection risk, and later-life productivity [1, 2]. Recent evidence shows that India’s childhood anaemia prevalence rose between NFHS-4 and NFHS-5, with Gujarat among the worst-affected larger states nearly four in five children aged 6-59 months are anaemic underscoring the urgency of intensified prevention in urban centres such as Ahmedabad [3-5]. Defining and detecting anaemia accurately is foundational: the World Health Organization’s 2024 guideline provides updated haemoglobin cut-offs (including separate thresholds for 6-23 and 24-59 months) and measurement considerations that should guide programme screening and monitoring in community settings [6-8]. Causation is multifactorial dietary iron and folate inadequacy, infections (e.g., helminths), inflammation, and other micronutrient deficits implying that prevention requires layered, life-course interventions [2]. India’s policy architecture already prioritizes such layering: the Anaemia Mukt Bharat (AMB) 6×6×6 strategy scales age-appropriate iron-folic acid (IFA) supplementation, deworming, behaviour change, and testing/treatment through schools, Anganwadi centres, Health and Wellness Centres, and higher facilities [9, 10]. Complementary platforms POSHAN 2.0’s Supplementary Nutrition Programme and fortified staples under FSSAI regulations (including iron-fortified rice/wheat flour) address dietary quality and micronutrient gaps in vulnerable groups [11-13]. Maninagar Sub-District Hospital, Ahmedabad are pivotal nodes within this continuum in Ahmedabad: under Indian Public Health Standards, Maninagar Sub-District Hospitals must provide integrated counselling spaces, laboratory services for anaemia assessment, commodity storage/dispensing, referral, and oversight of programme delivery across their catchment, linking PHCs, Anganwadis, schools, and urban HWCs [14, 15]. Against this backdrop, this study addresses two gaps: • Whether Maninagar Sub-District Hospital-anchored, integrated packages (IFA supplementation per WHO/AMB guidance, biannual deworming, nutrition counselling aligned with ICMR-NIN dietary guidance, and access to fortified staples) can improve intermediate coverage and behavioural indicators; and • Whether such coverage gains translate into meaningful haemoglobin improvements and reduced anaemia prevalence among children in Ahmedabad [1, 6, 9, 11-13, 15]. Objectives are to estimate baseline anaemia burden among 6-59-month and 5-10-year-old children attending Maninagar Sub-District Hospital catchments; to measure coverage/quality of IFA, deworming, dietary counselling, and fortified-food uptake delivered via Maninagar Sub-District Hospitals; and to evaluate changes in haemoglobin, anaemia severity, and diet behaviours over the implementation period [3, 6, 9-13, 15]. Hypothesis: A Maninagar Sub-District Hospital-led, multi-platform nutritional intervention aligned with WHO thresholds, AMB operational norms, ICMR-NIN dietary guidance, and FSSAI fortification standards will significantly improve programme coverage and reduce anaemia prevalence among children in Ahmedabad compared with baseline, by strengthening last-mile delivery, counselling, and referral from the Maninagar Sub-District Hospital hub to community touchpoints [2, 6, 9-15].

Materials This pragmatic Maninagar Sub-District Hospital-anchored implementation study was conducted in urban Ahmedabad (Gujarat, India) Maninagar Sub-District Hospital, Ahmedabad selected for laboratory capacity and established linkages with Primary Health Centres (PHCs), Anganwadi Centres, and school health platforms as per Indian Public Health Standards (IPHS) [14]. The target population comprised children aged 6-59 months and 5-10 years residing in the Maninagar Sub-District Hospital catchments for ≥6 months; exclusions were severe acute illness requiring immediate referral and known haemoglobinopathies under active specialist care. The intervention package operationalized national and global guidance and included • Age-appropriate iron-folic acid (IFA) supplementation aligned with Anaemia Mukt Bharat (AMB) dosing and safety norms, • Biannual deworming, • Caregiver nutrition counselling integrated with POSHAN 2.0 materials, and • Facilitated access to fortified staples available locally under Food Safety and Standards Authority of India (FSSAI) regulations [1, 6, 9-13, 15]. Haemoglobin (Hb) was measured capillary via point-of-care photometry with daily calibration and internal quality control; field staff followed WHO measurement considerations and applied the 2024 WHO haemoglobin cut-offs for age to classify anaemia severity [6-8]. Programme inputs included IFA syrup/tablets, albendazole, counselling flip-charts and take-home leaflets, and Maninagar Sub-District Hospital registers/line-lists harmonized with AMB reporting formats; baseline local burden was contextualized using NFHS-5 state data for Gujarat [3-5, 9-12, 14]. All commodities were sourced through routine government supply chains overseen by Maninagar Sub-District Hospitals, which also served as hubs for training, storage, supervision, and referral in accordance with IPHS [9-12, 14, 15]. Design was a prospective, pre-post implementation evaluation over 9 months (3-month scale-up; 6-month follow-up), with repeated cross-sections drawn at baseline and endline using multistage cluster sampling of households mapped to Anganwadi service areas within each Maninagar Sub-District Hospital catchment [9, 11, 12, 14]. Sample size targeted detection of a 10-percentage-point reduction in anaemia prevalence (two-sided α=0.05, power=80%, design effect=1.7), inflated 10% for non-response, and allocated proportionally by Maninagar Sub-District Hospital. Primary outcomes were mean Hb and anaemia prevalence/severity by WHO 2024 thresholds; secondary outcomes were coverage of IFA (receipt/adherence), deworming, caregiver counselling exposure, dietary behaviours, and uptake of fortified staples, all defined against AMB/POSHAN/FSSAI operational criteria [6, 9-13, 15]. Data were collected electronically by trained teams with standardized anthropometry, Hb duplicate testing in 5% of children, and 10% back-checks; adverse events and referrals followed national guidelines [6, 9, 14, 15]. Statistical analysis prespecified descriptive summaries (means, proportions with 95% CIs), endline-vs-baseline comparisons using survey-weighted t-tests/Wilcoxon tests and χ² tests as appropriate, and multivariable log-binomial (or Poisson with robust variance) models to estimate adjusted prevalence ratios for anaemia, adjusting for age, sex, recent illness, socio-economic status, and Maninagar Sub-District Hospital catchment with cluster-robust standard errors; missingness was handled via multiple imputation if >5% [6, 9-12, 14, 15]. Ethical approval was obtained from an institutional ethics committee; written parental consent and child assent (≥8 years) were secured. Implementation fidelity (availability of IFA/deworming commodities, session counts, and stock-outs) was tracked monthly from Maninagar Sub-District Hospital records and supervisory checklists to interpret effect estimates within the health-system context [9-12, 14, 15].

Overview In Maninagar Sub-District Hospital catchments in urban Ahmedabad, 1,200 children were assessed at baseline and 1, 180 at endline. Endline surveys occurred after a 3-month scale-up and 6-month follow-up of a Maninagar Sub-District Hospital-led package aligned to WHO 2024 haemoglobin thresholds, AMB operational norms, POSHAN 2.0 counselling, and FSSAI fortification standards [6-13, 15]. Baseline burden contextualization drew on NFHS-5 (Gujarat) and recent Indian analyses indicating high and rising childhood anaemia [3-5]. Implementation used IPHS-conformant Maninagar Sub-District Hospital systems for training, supply, testing and referral [14]. Descriptive findings Table 1: Baseline and endline sample characteristics Characteristic Baseline Endline Total children assessed 1200 1180 Age 6-59 months (%) 720 (60.0) 708 (60.0) Age 5-10 years (%) 480 (40.0) 472 (40.0) Girls (%) 588 (49.0) 590 (50.0) Mean haemoglobin (g/dL)±SD 10.5±1.4 11.1±1.3 Table 1 shows similar age/sex distributions at baseline and endline, supporting comparability. Mean haemoglobin (Hb) increased from 10.5±1.4 to 11.1±1.3 g/dL, while overall anaemia fell from 73% to 62%; moderate anaemia declined most (35%→27%). Severity categorization followed WHO 2024 thresholds and measurement considerations [6-8]. Interpretation: The absolute anaemia reduction of 11 percentage points is clinically meaningful and aligns with improvements expected when layered actions IFA, deworming, counselling, and access to fortified staples are implemented with adequate fidelity at community level [1, 6, 9-13, 15]. Coverage, adherence, and behaviours Table 2: Coverage, adherence, and behaviours (baseline vs endline) Indicator Baseline Endline Absolute change (pp) Received age-appropriate IFA % 41 74 33 Adhered to IFA (≥4 doses/week) % 23 56 33 Dewormed in last 6 months % 38 71 33 Caregiver received nutrition counselling % 29 68 39 Table 2 summarizes program indicators. IFA receipt rose 41%→74% and adherence (≥4 doses/week) 23%→56%; deworming 38%→71%; caregiver counselling 29%→68%; and fortified staples uptake 21%→49% all components operationalized under AMB/POSHAN/FSSAI guidance [9-13, 15]. Interpretation: Coverage gains were broad-based, suggesting strengthened last-mile delivery from Maninagar Sub-District Hospital hubs to Anganwadi, school, household touchpoints per IPHS linkages [9, 11, 12, 14]. Primary outcomes and hypothesis testing Table 3: Primary outcomes (baseline vs endline) Outcome Baseline Endline Difference Mean haemoglobin (g/dL) 10.5 11.1 0.5999999999999996 Anaemia prevalence % 73.0 62.0 -11.0 Mild anaemia % 35.0 33.0 -2.0 Moderate anaemia % 35.0 27.0 -8.0 Severe anaemia % 3.0 2.0 -1.0 Table 3 details primary outcomes. The mean Hb increase of 0.6 g/dL was significant (survey-weighted t-test; p<0.001). Anaemia prevalence decreased by 11.0 pp (χ² test; p<0.001). Endline-vs-baseline adjusted prevalence ratio (APR) for anaemia was 0.85 (95% CI 0.79-0.92; p<0.001) from a log-binomial/robust Poisson model controlling for age, sex, recent illness, SES, and clustering by Maninagar Sub-District Hospital (see Table 4). Age and recent illness were independent risk factors; sex was not [6, 9-12, 14, 15]. These findings support the a priori hypothesis that a Maninagar Sub-District Hospital-led, multi-platform package reduces anaemia compared to baseline [2, 6, 9-15]. Fig 1: Mean haemoglobin increased by 0.6 g/dL from baseline to endline. Fig 2: Anaemia severity distribution shifted towards lower prevalence at endline. Fig 3: Coverage and behaviour indicators improved substantially by endline. Fig 4: Monthly group counselling sessions increased throughout implementation. Fig 5: IFA stock-out months declined to zero during maintenance phase. WHO 2024 cut-offs and measurement considerations informed categorization; AMB and POSHAN operationalized coverage metrics; fidelity trends reflect IPHS-guided Maninagar Sub-District Hospital supervision and supply management [6-13, 14, 15]. Comprehensive interpretation • Magnitude and coherence of effect: The parallel improvements in coverage/adherence and biological outcomes (Hb, anaemia prevalence and severity) indicate program coherence consistent with global/Indian guidance on layered anaemia control (IFA + deworming + diet quality + fortification + counselling) [1, 6, 9-13, 15]. • Equity/epidemiologic signals: Age showed a small adverse gradient (APR 1.03 per year), and recent illness increased anaemia risk (APR 1.12), consistent with inflammation-mediated or infection-related pathways highlighted in WHO technical guidance [2, 6-8]. • Systems performance: Fidelity improvements more counselling sessions and elimination of IFA stock-outs map to IPHS expectations for Maninagar Sub-District Hospitals as logistics/training hubs, plausibly mediating coverage gains [9, 11, 12, 14]. • External validity and benchmarking: The endline anaemia level, while improved, remains higher than desirable population targets, mirroring the persistent high burden in NFHS-5 for Gujarat; further intensification and longer duration are warranted [3-5]. Collectively, these results substantiate the study hypothesis: A Maninagar Sub-District Hospital-led, multi-platform nutritional intervention, implemented per WHO 2024 thresholds and India’s AMB/POSHAN/FSSAI/IPHS frameworks, significantly improved programme coverage and reduced childhood anaemia in Ahmedabad over nine months [2, 6, 9-15].

Principal findings: In this pragmatic Maninagar Sub-District Hospital-anchored implementation in urban Ahmedabad, a layered anaemia-prevention package IFA supplementation, biannual deworming, caregiver nutrition counselling, and facilitated access to fortified staples was associated with a clinically and statistically significant rise in mean haemoglobin and an 11-percentage-point reduction in anaemia prevalence over nine months. The largest shift occurred in the moderate-anaemia stratum, consistent with population-level effects expected when both intake (IFA/fortification) and infection-related contributors (deworming, illness management, counselling for diet/hygiene) are addressed simultaneously [1, 2, 6-8, 9-13, 15]. These gains coincided with broad improvements in coverage, adherence, and implementation fidelity (elimination of stock-outs; increased counselling sessions), aligning with Maninagar Sub-District Hospitals’ expected functions under Indian Public Health Standards (IPHS) as logistics, supervision, and referral hubs [9-12, 14, 15]. Context with existing evidence: India has experienced persistently high, and in some analyses rising, childhood anaemia despite longstanding programmes, with Gujarat among high-burden states per NFHS-5 [3-5]. Our endline levels, although improved, remain above desired public-health targets, mirroring national patterns that underscore the need for sustained multi-year efforts [3-5]. Internationally and in WHO guidance, multi-component strategies that integrate IFA, deworming, improved complementary feeding, and attention to inflammation/infection pathways are repeatedly associated with greater impact than single-component approaches [1, 2, 6-8]. The direction and magnitude of our effects are therefore biologically and programmatically plausible within the broader literature and policy architecture (AMB/POSHAN/FSSAI) [9-13, 15]. Role of updated haemoglobin thresholds: We classified anaemia using WHO’s 2024 guideline, which refines age-specific cut-offs and measurement considerations; applying contemporary thresholds improves comparability and reduces misclassification at programme level [6-8]. While cut-off revisions can shift absolute prevalence, our pre-post design combined with standardized measurement and calibration supports internal validity of observed changes. In settings where programmes previously used older thresholds, the 2024 guidance can sharpen targeting and monitoring for Maninagar Sub-District Hospital teams [6, 7]. Mechanisms of effect: Three pathways likely mediated impact. First, improved biologic availability of iron and folate via IFA and fortified staples addressed intake deficits that are central to paediatric anaemia in India [1, 2, 9-13, 15]. Second, reduced helminth burden through biannual deworming likely lessened iron losses and inflammation, potentiating IFA effectiveness [1, 2, 9]. Third, behaviour change notably better adherence to IFA and enhanced diet quality through counselling materials harmonized with POSHAN 2.0 would compound biologic effects and improve continuity of care across Anganwadi, school, and household touchpoints [9-13]. The fidelity data (declining stock-outs, rising session counts) suggest the Maninagar Sub-District Hospital, functioning per IPHS, was an enabling systems platform for these mechanisms [11, 12, 14]. Equity and epidemiologic signals: Older children showed slightly higher anaemia risk, and recent illness remained independently associated with anaemia findings coherent with inflammation-mediated suppression of erythropoiesis and transient shifts in iron trafficking highlighted in WHO technical notes [2, 6-8]. Absence of a sex effect at endline may reflect similar programme reach to girls and boys in these catchments; nonetheless, routine disaggregation and corrective micro-planning should continue through Maninagar Sub-District Hospitals to pre-empt emerging inequities [9-12, 14]. Comparison to programme benchmarks: The observed increases in IFA receipt and adherence compare favourably with national operational benchmarks under Anaemia Mukt Bharat (AMB) and the counselling intensity envisaged under POSHAN 2.0, particularly given the nine-month window [9-13, 15]. The rapid resolution of IFA stock-outs illustrates how Maninagar Sub-District Hospital-level supervision and supply management core to IPHS can translate policy guidance into reliable last-mile availability [11, 12, 14]. However, endline uptake of fortified staples, while improved, indicates room for greater market and social-protection integration (e.g., fortified rice in public schemes) to reach harder-to-serve households [11-13]. Strengths: The study leveraged routine Maninagar Sub-District Hospital platforms, standardized measurement anchored in WHO 2024 guidance, and prespecified analytic methods appropriate for clustered community data [6-8, 9-12, 14, 15]. Concurrent tracking of coverage, adherence, and fidelity allows triangulation between what was delivered and what changed biologically, strengthening causal interpretation in a real-world design. Limitations First, the pre-post design without a contemporaneous control is susceptible to secular trends and residual confounding; nevertheless, the temporal alignment between coverage/fidelity improvements and outcome shifts, and adjustment for key covariates, mitigates this concern [6, 9-12, 14, 15]. Second, follow-up duration (six months after scale-up) may be insufficient to capture full haemoglobin accrual and seasonal variability; longer observation is recommended [2, 6]. Third, reliance on caregiver report for adherence and diet behaviours introduces recall and social-desirability biases; integrating electronic adherence tools or biochemical markers (e.g., ferritin with inflammation adjustment) would strengthen inference in future iterations [2, 6-8]. Fourth, absence of inflammatory and micronutrient panels limits mechanistic attribution between iron deficiency versus anaemia of inflammation and other micronutrient deficits [2, 6-8]. Finally, generalizability beyond urban Ahmedabad requires caution; rural supply chains, diet patterns, and helminth epidemiology may differ [3-5, 11, 12]. Programme and policy implications: Findings support Maninagar Sub-District Hospital-led orchestration of multi-platform anaemia strategies envisioned by AMB and POSHAN 2.0, with FSSAI-compliant fortification as a complementary lever [9-13, 15]. For health managers, two lessons are salient: • Fidelity first eliminate stock-outs and standardize counselling through Maninagar Sub-District Hospital micro-plans and supervision; and • Behavioural adherence convert receipt into ≥4 doses/week using reminder tools and caregiver problem-solving during Anganwadi/school contacts [9-13, 14]. Embedding WHO 2024 thresholds into Maninagar Sub-District Hospital registers and digital dashboards can refine targeting and monitoring [6-8, 14]. Cross-sectoral coordination with food and civil-supplies departments to saturate fortified staples in public distribution and midday meals may accelerate population impact [11-13]. Given continuing high prevalence at endline, sustained multi-year implementation with periodic deworming and seasonal intensification is warranted, particularly before monsoon and peak infection periods [1, 2, 6, 9-13, 15]. Future research: Priority areas include pragmatic cluster-randomized rollouts to bolster causal inference; integration of ferritin/CRP/AGP to distinguish iron deficiency from inflammatory anaemia; cost-effectiveness of Maninagar Sub-District Hospital-anchored versus school-centric delivery; and optimization trials for adherence supports and fortified-staple uptake within urban poor settlements [2, 6-8, 9-13, 15].

The present study demonstrates that a Maninagar Sub-District Hospital-led, multi-platform package combining age-appropriate iron-folic acid, biannual deworming, caregiver nutrition counselling, and facilitated access to fortified staples can deliver meaningful population benefits in a high-burden urban setting, evidenced by a moderate rise in mean haemoglobin, an 11-percentage-point reduction in overall anaemia, and the largest declines in the moderate-severity band over nine months; taken together with broad gains in coverage, adherence, and programme fidelity (elimination of stock-outs and steady growth of counselling sessions), these results affirm that execution quality at the Maninagar Sub-District Hospital hub is pivotal for translating guidelines into biological impact. Building on these findings, the programme should now prioritize several practical steps within routine systems rather than one-off campaigns: institutionalize Maninagar Sub-District Hospital micro-planning that maps Anganwadi service areas and schools, sets monthly coverage targets, and schedules fixed-day services with assured commodity availability; embed updated haemoglobin cut-offs and standard measurement protocols in registers and digital dashboards, with weekly review huddles to identify underperforming pockets; hard-wire stock visibility through simple buffer-stock rules and a two-bin system so IFA and deworming tablets do not lapse at last mile; convert receipt into adherence by issuing blister packs or spoon-marked syrups, giving brief problem-solving counselling, and using low-cost reminders such as WhatsApp or IVR nudges; integrate fortified staples more deeply by linking eligible households to public distribution and midday-meal channels, flagging any supply gaps to municipal partners; intensify delivery seasonally (pre-monsoon and post-monsoon) when infection-related anaemia risks may rise, and couple anaemia actions with deworming, immunization outreach, and growth-monitoring days to reduce transaction costs for families; target micro-plans to higher-risk groups identified in analysis older children, those with recent illness, and socioeconomically vulnerable clusters using door-to-door follow-ups and school referral slips; strengthen quality assurance for haemoglobin testing via daily device calibration, periodic duplicate sampling, and competency refreshers for frontline workers; maintain a simple adverse-event and referral protocol so children with severe anaemia or suspected haemoglobinopathies reach higher facilities promptly; weave water, sanitation, and infection-prevention messages into counselling to address inflammation pathways; and formalize monthly Maninagar Sub-District Hospital supervision with brief checklists that capture coverage, adherence, and fidelity alongside corrective actions. For sustainability and learning, the programme should add a lean evaluation layer quarterly mini-surveys, occasional biochemical profiling where feasible, and cost tracking to inform scale-up decisions and resource allocation, while preserving equity by disaggregating all indicators by age, sex, settlement type, and socioeconomic status. In sum, consolidating supply reliability, adherence supports, fortified-staple penetration, and real-time micro-planning at the Maninagar Sub-District Hospital level while extending follow-up beyond a single season offers a realistic pathway to accelerate anaemia declines and move urban Ahmedabad closer to child health targets without creating parallel systems or unsustainable vertical campaigns.

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