INTRODUCTION Anaemia remains one of the most significant public health problems affecting adolescents worldwide, particularly in low- and middle-income countries. Adolescence is a critical period of rapid physical growth, hormonal changes, and cognitive development, during which the demand for iron and other micronutrients increases substantially. Inadequate dietary intake, menstrual blood loss, recurrent infections, poor sanitation, and nutritional deficiencies contribute to the high burden of anaemia among adolescent girls. The World Health Organization (WHO) defines anaemia in adolescents as a haemoglobin concentration below the age- and sex-specific cut-off values and recognizes it as an important contributor to impaired physical capacity, reduced academic performance, decreased immunity, and poor reproductive health outcomes (1). Globally, anaemia affects nearly one-third of the world's population, with adolescent girls constituting one of the most vulnerable groups. According to the WHO, iron deficiency remains the leading cause of anaemia, although deficiencies of folate, vitamin B12, vitamin A, chronic infections, inherited haemoglobin disorders, and parasitic infestations also contribute significantly. Persistent anaemia during adolescence adversely affects growth, school performance, work productivity, and future maternal and neonatal health, making early identification and intervention a public health priority (2). India bears one of the highest burdens of anaemia worldwide. The National Family Health Survey-5 (NFHS-5) reported that approximately 59.1% of adolescent girls aged 15–19 years are anaemic, indicating that the burden has increased compared with previous surveys despite the implementation of several national nutrition programmes. This high prevalence reflects the continuing challenges related to inadequate dietary diversity, poor compliance with iron-folic acid supplementation, menstrual blood loss, recurrent infections, and socioeconomic disparities (3). Anaemia among adolescent girls is a multifactorial condition influenced by biological, nutritional, socioeconomic, behavioural, and environmental determinants. Factors such as low dietary iron intake, poor dietary diversity, undernutrition, menstrual abnormalities, low parental education, poverty, early marriage, inadequate sanitation, and limited awareness regarding nutrition have been consistently associated with anaemia. Understanding these determinants is essential for designing effective interventions tailored to local community needs (4,5). The Government of India has implemented several initiatives to reduce the burden of anaemia, including the Anemia Mukt Bharat (AMB) Strategy, Weekly Iron and Folic Acid Supplementation (WIFS), school health programmes, deworming campaigns, and nutrition education through the POSHAN Abhiyaan. These programmes aim to improve haemoglobin levels among adolescents through a life-cycle approach; however, the prevalence of anaemia remains unacceptably high in many regions, indicating gaps in programme implementation and utilization (6). While quantitative studies estimate the prevalence and associated risk factors of anaemia, they often fail to capture the perceptions, beliefs, practices, and barriers influencing nutritional behaviour and utilization of preventive services. A mixed-methods approach combines quantitative assessment with qualitative exploration, thereby providing a comprehensive understanding of both the magnitude of anaemia and the contextual determinants influencing its occurrence. Such an approach enables policymakers to design culturally appropriate and evidence-based interventions (7). Gujarat has shown improvements in several maternal and child health indicators; however, anaemia among adolescent girls continues to remain a major concern. Rural populations often face additional challenges related to dietary inadequacy, socioeconomic inequalities, limited health awareness, and poor compliance with iron supplementation programmes. District-level evidence regarding the prevalence and determinants of anaemia among adolescent girls is limited, particularly in Patan district, where local epidemiological data are scarce (8). Identifying the prevalence of anaemia and its determinants among adolescent girls in Patan district is essential for strengthening school health services, adolescent-friendly health programmes, and community-based nutrition interventions. Furthermore, understanding the perceptions of adolescents, parents, teachers, and healthcare providers regarding anaemia prevention and iron supplementation can facilitate better programme implementation and improve compliance with existing national initiatives (9). Therefore, the present mixed-method study was undertaken to estimate the prevalence of anaemia among adolescent girls in Patan district and to identify the nutritional, socioeconomic, behavioural, and health-related determinants associated with anaemia. The qualitative component aimed to explore the knowledge, attitudes, practices, and perceived barriers related to anaemia prevention and iron-folic acid supplementation, thereby generating evidence to support targeted public health interventions and strengthen adolescent health programmes (10). The specific objectives were to estimate the prevalence and severity of anaemia, assess the socio-demographic, nutritional, menstrual, behavioural, and socioeconomic factors associated with anaemia, evaluate the knowledge, attitudes, and practices regarding anaemia and iron-folic acid supplementation, and explore the perceived barriers and facilitators influencing the prevention and management of anaemia through qualitative interviews. The study is justified because anaemia remains one of the most prevalent nutritional disorders among adolescent girls in India despite the implementation of several national programmes such as Anemia Mukt Bharat and Weekly Iron and Folic Acid Supplementation (WIFS). Local evidence regarding the burden and determinants of anaemia in Patan district is limited, making it essential to generate region-specific data for effective planning and implementation of public health interventions. The findings of this study are expected to provide reliable estimates of the prevalence of anaemia, identify modifiable risk factors and contextual barriers, strengthen school and community-based nutrition programmes, improve compliance with iron-folic acid supplementation, support targeted health education and behavioural change interventions, and assist policymakers and healthcare providers in developing evidence-based strategies to reduce anaemia and improve the nutritional and overall health status of adolescent girls in the region.

The present study was conducted as a community-based mixed-method study in the field practice area of the Medical College,Patan, Gujarat. The study was carried out over a period of one month and included both quantitative and qualitative components to comprehensively assess the prevalence of anaemia and its determinants among adolescent girls. Prior to the commencement of the study, ethical approval was obtained from the Institutional Ethics Committee (IEC). Written informed consent was obtained from all participants (and assent with parental/guardian consent for participants below 18 years of age, wherever applicable). Confidentiality and anonymity of the participants were maintained throughout the study, and participation was entirely voluntary. The study was conducted in accordance with the ethical principles of the Declaration of Helsinki. The quantitative component included 90 adolescent girls aged 10–19 years residing in the study area who were selected by simple random sampling from the eligible population. Adolescent girls who were permanent residents of the study area and willing to participate were included in the study. Girls with known haematological disorders, severe chronic illnesses, or those who declined to participate were excluded. Data were collected using a pretested, semi-structured questionnaire administered through face-to-face interviews. Information regarding socio-demographic characteristics, educational status, socioeconomic status (modified B.G. Prasad classification), dietary habits, menstrual history, personal hygiene, history of deworming, iron and folic acid supplementation, morbidity profile, and knowledge regarding anaemia was obtained. Anthropometric measurements, including height and weight, were recorded using standard techniques, and body mass index (BMI) was calculated according to WHO recommendations. Haemoglobin estimation was performed using a portable digital haemoglobinometer (HemoCue® system) under aseptic precautions. Anaemia was classified according to the World Health Organization (WHO) haemoglobin cut-off values for adolescent girls into mild, moderate, and severe anaemia. The qualitative component consisted of focus group discussions (FGDs) with adolescent girls and key informant interviews (KIIs) with Accredited Social Health Activists (ASHAs), Anganwadi Workers (AWWs), school teachers, and Auxiliary Nurse Midwives (ANMs) to explore perceptions regarding anaemia, dietary practices, menstrual health, compliance with iron-folic acid supplementation, barriers to treatment, and suggestions for improving adolescent nutrition. The discussions were conducted using a predesigned interview guide, audio-recorded after obtaining permission, transcribed verbatim, and analyzed using thematic content analysis. The collected data were entered into Microsoft Excel and analyzed using Statistical Package for the Social Sciences (SPSS) version 26.0. Descriptive statistics were expressed as frequencies, percentages, means, and standard deviations. The prevalence of anaemia was estimated with a 95% confidence interval. Associations between anaemia and selected socio-demographic, nutritional, menstrual, and behavioural variables were assessed using the Chi-square test or Fisher's exact test, as appropriate. Variables showing statistical significance in univariate analysis were included in a multivariable logistic regression model to identify independent determinants of anaemia. The results were expressed as adjusted odds ratios (AORs) with 95% confidence intervals, and a p-value <0.05 was considered statistically significant. The qualitative findings were triangulated with the quantitative results to provide a comprehensive understanding of the determinants of anaemia among adolescent girls.

A total of 90 adolescent girls were included in the study, with a mean age of 15.3 ± 2.1 years. The majority of participants belonged to the 14–16 years age group (44.4%), were studying in secondary school (44.4%), and belonged to socioeconomic class III (37.8%). The overall prevalence of anaemia was 60.0%, while 40.0% of the participants had normal haemoglobin levels. Among the anaemic girls, mild anaemia was the most common (51.9%), followed by moderate anaemia (40.7%) and severe anaemia (7.4%). The mean haemoglobin concentration of the study population was 11.2 ± 1.4 g/dL. Analysis of determinants revealed that inadequate dietary diversity, irregular consumption of iron and folic acid (IFA) tablets, heavy menstrual bleeding, underweight nutritional status (BMI <18.5 kg/m²), maternal illiteracy, and lack of deworming were significantly associated with anaemia (p <0.05). Inadequate dietary diversity (72.2% vs. 33.3%; χ²=12.81, p<0.001) and irregular IFA consumption (66.7% vs. 27.8%; χ²=13.54, p<0.001) showed the strongest associations with anaemia. Knowledge regarding anaemia and its prevention was found to be suboptimal, with less than half of the participants aware of iron deficiency as the cause of anaemia and only 37.8% reporting regular IFA tablet consumption. Qualitative findings from focus group discussions and key informant interviews further highlighted poor dietary practices, inadequate awareness, fear of side effects of IFA tablets, and limited nutrition counselling as important barriers to anaemia prevention. Overall, the study demonstrated a high burden of anaemia among adolescent girls, with nutritional, behavioural, and socioeconomic factors playing a significant role in its occurrence, emphasizing the need for strengthened nutrition education, improved IFA compliance, regular deworming, and community-based interventions. Table 1. Socio-demographic Characteristics of Adolescent Girls (N = 90) Variable Frequency (n) Percentage (%) Age Group (years) 10–13 22 24.4 14–16 40 44.4 17–19 28 31.1 Religion Hindu 76 84.4 Muslim 12 13.3 Others 2 2.2 Educational Status Middle School 24 26.7 Secondary School 40 44.4 Higher Secondary 26 28.9 Socioeconomic Status Class II 16 17.8 Class III 34 37.8 Class IV 28 31.1 Class V 12 13.3 Mean Age = 15.3 ± 2.1 years Table 2. Prevalence and Severity of Anaemia among Adolescent Girls (N = 90) Variable Frequency (n) Percentage (%) Anaemia Status Anaemic 54 60.0 Non-anaemic 36 40.0 Severity of Anaemia (n=54) Mild 28 51.9 Moderate 22 40.7 Severe 4 7.4 Mean Haemoglobin = 11.2 ± 1.4 g/dL Table 3. Determinants of Anaemia among Adolescent Girls (N = 90) Variable Anaemic n (%) Non-anaemic n (%) χ² p-value Inadequate Dietary Diversity 39 (72.2) 12 (33.3) 12.81 <0.001* Irregular IFA Consumption 36 (66.7) 10 (27.8) 13.54 <0.001* Heavy Menstrual Bleeding 20 (37.0) 5 (13.9) 5.89 0.015* Underweight (BMI <18.5 kg/m²) 24 (44.4) 8 (22.2) 4.78 0.029* Mother Illiterate 21 (38.9) 6 (16.7) 5.36 0.021* Deworming Not Received 26 (48.1) 9 (25.0) 4.96 0.026* Table 4. Knowledge, Practices and Qualitative Findings Related to Anaemia (N = 90) Quantitative Findings Variable Frequency (n) Percentage (%) Aware that Iron Deficiency Causes Anaemia 41 45.6 Regular IFA Tablet Consumption 34 37.8 Consumed Green Leafy Vegetables ≥3 times/week 39 43.3 Dewormed in Last 6 Months 55 61.1 Received Nutrition Education 48 53.3 Major Themes Identified during FGDs/KIIs Theme Key Findings Awareness Limited knowledge regarding symptoms and prevention of anaemia Dietary Practices Poor intake of iron-rich foods due to food preferences and affordability IFA Compliance Fear of side effects and forgetfulness reduced compliance Menstrual Health Heavy menstrual bleeding perceived as a major cause of weakness Health Services Regular school distribution of IFA tablets appreciated, but counselling was inadequate Suggestions Nutrition education, parental involvement, improved counselling, and regular screening were recommended

The present study found an overall anaemia prevalence of 60.0% among adolescent girls, indicating that anaemia remains a severe public health problem in the study area. This finding is comparable with the pooled prevalence reported by Daniel et al., who observed a prevalence of 65.7% among Indian adolescent girls in their systematic review and meta-analysis, emphasizing the persistent burden of anaemia despite ongoing national nutrition programmes (11). Among the anaemic participants, mild anaemia (51.9%) was the most common, followed by moderate (40.7%) and severe anaemia (7.4%). Similar observations have been reported by Kaur et al., who found mild anaemia to be the predominant form among Indian adolescent girls, suggesting that early identification through routine screening offers an opportunity for timely intervention before progression to severe disease (12). The present study demonstrated that inadequate dietary diversity and irregular iron-folic acid (IFA) tablet consumption were the strongest determinants of anaemia, with statistically significant associations (p<0.001). These findings agree with those of Patel et al., who reported poor dietary intake, inadequate consumption of iron-rich foods, and poor compliance with IFA supplementation as important predictors of anaemia among adolescent girls (13). Similar conclusions have also been drawn in recent Indian systematic reviews, which identified nutritional inadequacy and suboptimal adherence to supplementation programmes as consistent risk factors. Heavy menstrual bleeding, low body mass index, maternal illiteracy, and failure to receive regular deworming were also significantly associated with anaemia in the present study. These observations are consistent with the findings of Chaudhary et al., who reported that menstrual blood loss, undernutrition, poor maternal education, and inadequate dietary diversity significantly increased the risk of anaemia among adolescent girls in Gujarat (14). The qualitative component of the study revealed inadequate awareness regarding anaemia, fear of side effects of IFA tablets, poor dietary practices, and insufficient nutrition counselling as important barriers to anaemia prevention. Similar barriers have been highlighted by Duggirala et al., who emphasized that strengthening school-based nutrition education, improving adherence to iron supplementation, and integrating behaviour change communication with regular screening are essential for reducing the burden of anaemia among adolescent girls (15). Overall, the findings of the present study indicate that anaemia among adolescent girls is influenced by multiple nutritional, behavioural, and socioeconomic factors. Strengthening nutrition education, improving dietary diversity, ensuring regular iron-folic acid supplementation, promoting deworming, and enhancing community awareness through school and community-based programmes are likely to contribute substantially to reducing the burden of anaemia in this vulnerable population.

The present mixed-method study demonstrated that anaemia remains a major public health problem among adolescent girls, with an overall prevalence of 60.0%. Mild anaemia constituted the largest proportion of cases, although a considerable number of participants also had moderate and severe anaemia. Inadequate dietary diversity, irregular consumption of iron and folic acid tablets, heavy menstrual bleeding, undernutrition, maternal illiteracy, and lack of deworming were identified as significant determinants of anaemia. The qualitative findings further revealed inadequate awareness regarding anaemia, poor dietary practices, fear of side effects of iron supplementation, and insufficient nutrition counselling as important barriers to prevention and treatment. These findings highlight the need for integrated nutritional, educational, and community-based interventions to improve the health and nutritional status of adolescent girls. Limitations of the Study The present study had certain limitations. Being conducted in the RHTC field practice area of a single tertiary care institution, the findings may not be generalizable to all adolescent girls in Patan district or other regions. The sample size was relatively small (90 participants), which may have limited the precision of estimates and the ability to detect weaker associations. The cross-sectional quantitative component precluded establishing causal relationships between anaemia and its determinants. Dietary intake, menstrual history, and compliance with iron-folic acid supplementation were based on self-reported information and were therefore susceptible to recall and reporting bias. Biochemical investigations to identify specific causes of anaemia, such as serum ferritin, vitamin B12, or folate levels, were not performed because of resource constraints. Recommendations Based on the study findings, regular haemoglobin screening of adolescent girls should be strengthened through school health services and community outreach programmes to facilitate early detection and timely management of anaemia. Nutrition education should focus on promoting dietary diversity and increased consumption of iron-rich foods, while reinforcing the importance of regular iron-folic acid supplementation under the Anemia Mukt Bharat and Weekly Iron and Folic Acid Supplementation (WIFS) programmes. Health education addressing menstrual hygiene, deworming, and prevention of nutritional deficiencies should be integrated into adolescent health initiatives. Parents, teachers, ASHAs, Anganwadi workers, and healthcare providers should be actively involved in counselling adolescents to improve awareness and treatment adherence. Larger community-based longitudinal studies with comprehensive biochemical assessment are recommended to better understand the determinants of anaemia and evaluate the effectiveness of targeted intervention strategies.

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