European Journal of Cardiovascular Medicine

Anaemia remains a significant global public health challenge, impacting individuals across all age groups and genders. It is characterized by a reduction in red blood cells or their oxygen-carrying capacity, failing to meet the body’s physiological demands [1]. Affecting more than two billion people worldwide, anaemia is particularly widespread in developing nations, often stemming from deficiencies in iron, folate, and vitamin B12 [2,3]. Globally, adolescents constitute 16% of the population, numbering 1.3 billion, with India alone home to 253 million adolescents, representing one of the largest such cohorts globally [4,5]. Adolescence, spanning ages 10 to 19, is a pivotal phase of human development, laying the foundation for long-term health and well-being [6]. However, this group is highly susceptible to anaemia due to rapid growth and development, which escalates iron requirements. When dietary iron intake fails to meet these heightened needs, iron deficiency anaemia becomes a prevalent concern [7,8]. Adolescents often exhibit suboptimal nutritional practices, including meal skipping, reliance on unhealthy snacks, irregular eating patterns, and the influence of peer pressure and independent lifestyles. Compounding this, risky behaviours such as tobacco, alcohol, or drug use can impair nutrient absorption, further exacerbating the risk of anaemia [9]. Beyond diet, personal hygiene plays a critical role in maintaining health. Poor hygiene practices, such as inadequate handwashing or oral care, can lead to infections and gastrointestinal disorders like diarrhoea, which disrupt nutrient absorption and digestion. This creates a vicious cycle, worsening the risk of anaemia in adolescents with already compromised dietary habits [10,11]. Thus, promoting proper hygiene is essential not only for overall health but also for preventing and managing anaemia during this critical developmental stage. Recognizing the urgency of addressing anaemia among adolescents, initiatives like the Intensified National Iron Plus Initiative (I-NIPI) have been implemented. This program aims to combat anaemia through iron and folic acid supplementation, biannual deworming, and targeted awareness campaigns, striving to improve the nutritional status of adolescents and reduce anaemia prevalence [12]. This study focuses on the Gaya district of Bihar, aiming to bridge knowledge gaps and evaluate dietary practices contributing to anaemia among adolescents. It explores factors such as awareness of anaemia, understanding of its causes and prevention, dietary choices, and the implementation of health programs. By shedding light on these aspects, the research provides a comprehensive understanding of the nutritional and health status of adolescents in the region. The findings can inform targeted interventions to enhance anaemia-related awareness and dietary behaviours, contributing to the achievement of Sustainable Development Goals (SDGs). Specifically, the study aligns with SDG 3 (good health and well-being) by addressing knowledge gaps and dietary habits related to anaemia. It also supports SDG 2 (zero hunger and improved nutrition) by emphasizing the importance of iron-rich diets, while promoting health education and gender-inclusive interventions aligns with SDG 4 (quality education) and SDG 5 (gender equality). Furthermore, by highlighting gaps in healthcare program implementation, the study underscores the need for collaborative efforts, aligning with SDG 17 (partnerships for the goals) [13].

Existing literature predominantly focuses on school-going girls, with limited research encompassing both boys and girls in specific geographic regions [14-19]. This study aims to fill this gap by examining anaemia-related knowledge and dietary practices among adolescents in public schools in the Gaya district, Bihar. By assessing students’ awareness of anaemia, dietary habits, and hygiene practices, the study seeks to identify areas for educational interventions and promote healthier lifestyles. The geographic specificity of the research offers valuable insights for local policy-making and targeted interventions, ultimately contributing to improved adolescent well-being and sustainable development.

A cross-sectional study was conducted among 300 school-going adolescents aged 14 to 17 years from five villages in the Gaya district of Bihar at the Department of Community Medicine, Anugrah Narayan Magadh Medical College and Hospital, Gaya, Bihar (India). Prior to the study, written consent was obtained from parents, and assent forms were collected from the participating students. Five villages with higher secondary schools offering education from grades 7 to 12 were selected using a purposive sampling technique.

Inclusion and Exclusion Criteria: Students enrolled in grades 7 to 12 who were willing to participate and provided consent were included in the study. Those absent on the day of data collection were excluded. Initially, 710 participants were identified across the five schools. Of these, 300 school-going adolescents aged 14 to 17 years who consented to participate were included, while 410 were excluded due to absence, unwillingness to participate, or failure to provide consent.

Study Procedure: Data were collected using a structured interview schedule. A pilot study was conducted with ten participants, who were retained in the final sample as no modifications to the questionnaire were required. This research is part of a student dissertation project, and its limitations are acknowledged.

The questionnaire was divided into four sections:

1. Demographics of respondents(6 questions),
2. Knowledge about anaemia(10 questions),
3. Health practices related to anaemia(8 questions), and
4. Food frequency questionnaire(9 food groups), a validated tool adapted from the National Family Health Survey (NFHS-4) Diet Questionnaire [14,19-23].

Data Collection Process: Permission was first obtained from the principals of the five selected public schools. Two visits were planned for each school, coordinated with the schedule of the Medical Mobile Unit (MMU) vans. During the first visit, a session was held to explain the study’s purpose and the content of the consent and assent forms. Students were given one day to return signed consent forms from their parents or guardians. Data collection took place during the second visit, where one-on-one interviews were conducted using the structured questionnaire.

Statistical Analysis:

The collected data were systematically organized in a Microsoft Excel worksheet, followed by a thorough data cleaning process. Subsequently, the cleaned data were imported into SPSS software for statistical analysis. The following analytical methods were employed:

Descriptive Statistics: These were used to summarize the demographic characteristics of participants, their knowledge about anaemia, health practices, health-seeking behaviour, and responses to the Food Frequency Questionnaire (FFQ). Continuous variables were summarized using mean and standard deviation, while categorical variables were presented as counts and percentages.

Chi-square Test: This test was applied to examine associations between categorical variables, with statistical significance set at a p-value of <0.05. The independent variables included demographic factors such as age, gender, and education level, while the dependent variables encompassed knowledge about anaemia, health practices, and health-seeking behaviour related to anaemia.

Demographic profile of the participants: In the present study, we observed that the majority of the participants (81%) were aged between 14 and 16 years, while a smaller portion (19%) were aged 16 years and above. There was a higher number of female participants (65%) compared to male participants (35%). Half of the participants (50.33%) were studying in classes 9 to 10, while 30% were in classes 7 to 8, and 19.67% were in classes 11 to 12. Most participants (64%) came from nuclear families, while 36% came from joint families. Additionally, the data on parents' education levels indicate that nearly half of the participants' mothers (48.33%) had a secondary level of education, 41% had a primary level of education, and 10.67% were not educated. In contrast, a significant majority of the participants' fathers (68.33%) had a secondary level of education, 30% had a primary level, and only 1.67% were not educated (Table 1).

Table 1: Showing the demographic profile of the participants.

Knowledge about anaemia: A majority of participants (61%) reported that they have heard of anaemia, while 39% have not. When asked if they believe anaemia is a health problem, 48% agreed and 52% disagreed. Regarding contributing factors, 22% identified a decreased number of red blood cells (RBCs), 13% cited an increased number of RBCs, and 27% mentioned a decrease in white blood cells (WBCs). Additionally, 38% of participants expressed uncertainty about this. Participants identified several causes of anaemia, including poor diet (31%), severe blood loss (15%), intestinal worm infections (16%), and a combination of all these factors (10.33%), while 39% were unsure. The recognized signs and symptoms of anaemia included tiredness and fatigue (53%), vomiting (21%), and pale skin, nails, and eyes (27%). For treatment options, 43% suggested iron supplementation, 16% mentioned vitamin supplementation, 28% identified deworming as a treatment, and 16% chose all options. To prevent anaemia, 52% recommended increasing dietary iron intake, 28% suggested an increase in vitamins C, B12, and folate, 2% advised avoiding tea and coffee after meals, 32% emphasized the importance of personal hygiene, and 29% selected all options.

Table 2: Showing the knowledge about anaemia among adolescents.

The observation presented in Table 3 indicates that none of the participants were aware of the Intensified National Iron Plus Initiative (I-NIPI) program. Additionally, while the majority of the participants’ schools provided biannual deworming tablets (85%), none offered Weekly Iron-Folic Acid (WIFA) tablets. These findings highlight a significant lack of implementation of the I-NIPI program in public schools.

Table 3: Implementation of the Intensified National Iron Plus Initiative (I-NIPI)

Health Practices Related to Anaemia: This study highlights varying health practices associated with anaemia among participants. A striking 97% of respondents reported using soap to wash their hands after defecation, indicating good hygiene habits in this aspect, while only 52% washed their hands with soap before meals. Nail-trimming practices were followed by 68%, showcasing moderate attention to personal cleanliness. However, only 35% of individuals brushed their teeth twice daily. Outdoor exposure by walking barefoot was reported by 68%, potentially increasing the risk of infections and parasitic diseases. Moreover, 34% had checked their hemoglobin levels in the past year, suggesting limited awareness or access to diagnostic facilities. Preventive health practices were notably low, with only 11% taking Iron and Folic Acid (IFA) tablets in the past year and 72% having taken a deworming tablet within six months.

Table 4: Health practices associated with anaemia.

Dietary Pattern of Adolescents: The Food Frequency Questionnaire (FFQ) findings indicated that adolescents were not sufficiently integrating iron-rich foods into their daily diets. While the majority of adolescents reported consuming roti or rice daily (98%), their intake of pulses (51%) and dark green leafy vegetables (DGLV) (59%) was limited to a weekly basis. Ideally, both pulses and DGLV, recognized as vital sources of iron, should be consumed on a daily basis [24,25]. Furthermore, fruits, which are excellent sources of Vitamin C and play a crucial role in enhancing iron absorption, were primarily consumed on a weekly (48%) and occasional (37%) basis. Non-vegetarian foods, rich in heme-iron and recommended for weekly consumption, were instead consumed occasionally by most participants. Additionally, a considerable number of adolescents exhibited unhealthy eating habits by frequently consuming fried foods and aerated beverages on a daily or weekly basis [Table 5].  

Table 5: Dietary pattern of adolescents.

Table 6 demonstrates the relationship between participants' demographic characteristics and their knowledge about anaemia. A statistically significant association (p < 0.05) was found between participants' education level and their understanding of anaemia, with students in grades 9–10 exhibiting greater knowledge compared to those in grades 7–8. Additionally, significant associations (p < 0.05) were observed between participants' age, education level, and the availability of deworming tablets in their schools. These findings underscore the effectiveness of initiatives like the National Iron Plus Initiative (NIPI), as reflected in the distribution of deworming tablets to students.

Table 6: Showing the association between demographic profile and knowledge about anaemia.

The relationship between the demographic characteristics of participants and their health practices concerning anaemia is summarized in Table 7. A statistically significant association (p < 0.05) was observed between participants' gender and the frequency of nail trimming. Specifically, 71.43% of boys trimmed their nails more frequently compared to 28.57% of girls. When asked about the preference for longer nails, girls shared that they find it aesthetically pleasing and attractive. Conversely, some boys explained their frequent nail trimming was influenced by their work in Kirana shops, as shorter nails facilitate tasks like cutting paper and removing stapler pins. Another notable association (p < 0.05) was identified between gender and the consumption of Iron and Folic Acid (IFA) tablets over the past year, with females reporting higher rates of consumption than males. Furthermore, age and education level demonstrated a significant correlation (p < 0.05) with the use of deworming tablets within the last six months. Despite the availability of these tablets to school students, it was alarming to discover that 29.8% of students from grades 7 to 12 had not consumed them. Upon investigation, students revealed concerns over potential side effects such as loose motions, while a few indicated that their parents had advised against taking the tablets.

Table 7: Showing the association between demographic profile and health practices related to anaemia.

This study sought to assess the knowledge, dietary patterns, and personal hygiene behaviors of adolescents regarding anaemia in the Gaya district of Bihar, India. This investigation involved 300 adolescents aged predominantly between 14 to 16 years (81%), with females constituting 65% of the sample. The demographic profile revealed that most participants belonged to nuclear families (64%) and had parents with significant educational achievements, as nearly half of the mothers (48.33%) and over two-thirds of the fathers (68.33%) had completed secondary education. These socio-demographic characteristics provide essential context for understanding adolescents' knowledge and behaviors, highlighting the need for tailored interventions that factor in familial and educational influences on adolescent development and health. The findings underscore a substantial knowledge gap regarding anaemia among adolescents. Although a majority (61%) had heard the term “anaemia,” only 22% demonstrated awareness of its underlying physiological cause, namely the reduced production of red blood cells. This lack of understanding aligns with other studies, including those by Pareek P and Hafiz A, Angadi N and Ranjitha A, and Singh M et al., which collectively illustrate that while adolescents may recognize anaemia as a health issue, knowledge about its causes, symptoms, and prevention remains limited [22, 23, 14]. The contrasting international study in Saudi Arabia highlights global disparities in anaemia-related knowledge, with adolescent girls exhibiting greater awareness but still lacking understanding of its critical aspects [15]. These insights underline the pressing need for comprehensive health education programs aimed at equipping adolescents with fundamental knowledge about anaemia. A concerning observation was the complete lack of awareness regarding the National Iron Plus Initiative (NIPI) among participants. The poor implementation of the I-NIPI program in public schools in the Gaya district—evident from the absence of Weekly Iron and Folic Acid (WIFA) tablet distribution—raises alarms about system inefficiencies [24]. The findings of Ahmad K et al. further shed light on supply chain bottlenecks and operational challenges in delivering IFA supplementation nationwide. The study identified issues such as inadequate transportation, the absence of fixed distribution schedules, and ineffective management as critical barriers contributing to the poor distribution of IFA tablets [25, 26]. These systemic shortcomings highlight the need for robust management strategies, improved logistics, and widespread awareness campaigns to address these barriers and ensure the effective rollout of government health initiatives aimed at combating anaemia. In terms of hygiene practices, the study revealed encouraging trends, such as handwashing with soap after defecation (97%) and before meals (52%). However, other practices like regular nail trimming (68%), brushing teeth twice daily (35%), and avoiding barefoot exposure outside homes (68%) showed mixed adherence. Additionally, health-seeking behaviors were notably inadequate, as only 34% of adolescents reported checking their hemoglobin (Hb) levels in the previous year, and just 11% had taken Iron and Folic Acid tablets. These findings resonate with previous studies, such as those by Singh M et al., which demonstrated similar adherence patterns, and Pal J and Pal AK, which found even lower compliance with hygiene practices among adolescents in West Bengal [14, 10]. Enhancing adolescent awareness of the importance of regular health screenings and promoting accessibility to preventive resources are essential for fostering healthier habits. The dietary patterns reported by adolescents further highlight critical gaps in nutritional practices. Consumption of iron-rich foods like pulses (51%), dark green leafy vegetables (59%), and fruits (48%) was limited to weekly intake, contrary to daily recommendations [27]. Additionally, the prevalence of unhealthy dietary habits, including frequent consumption of fried foods and aerated drinks, presents significant challenges for addressing nutritional deficiencies. These patterns align with findings from Pareek P and Hafiz A, Alam N et al., and Hariyanto N et al., which revealed correlations between inadequate dietary practices and anaemia prevalence [22, 28, 29]. It is imperative to emphasize the inclusion of iron-rich food sources in daily meals and discourage the consumption of unhealthy foods through nutritional counseling and community-based interventions. The inclusion of both boys and girls in this study provides valuable insights into gendered differences in anaemia-related knowledge and practices. While previous research has predominantly focused on adolescent girls due to their heightened vulnerability to anaemia, this study advocates for expanding investigations to include boys, thereby bridging the knowledge gap and developing gender-inclusive strategies for anaemia prevention and management. Overall, the study's findings have significant clinical implications, highlighting the necessity for multifaceted interventions encompassing health education, dietary improvements, hygiene promotion, and systemic reforms in public health programs. Addressing these factors holistically can pave the way for reducing anaemia prevalence and enhancing the overall health and well-being of adolescents in the Gaya district and beyond.

This study highlights critical gaps in anaemia-related knowledge and dietary practices among school-going adolescents in Gaya district. While hygiene practices were satisfactory, awareness of anaemia causes, symptoms, and screenings remained low, alongside concerns about I-NIPI program implementation. Gender-sensitive interventions are essential, including enhanced anaemia education, improved dietary habits, and regular nutrition sessions. Integrating anaemia awareness into school curricula and strengthening health campaigns can significantly reduce anaemia prevalence and improve adolescent health in the region. Proactive, targeted measures are vital for sustainable impact.

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