Introduction

Despite several decades of programming, anaemia continues to be a critical public health problem in India, affecting 59% adolescent girls and 31% boys aged 15-19 years.1 This is an increase from the 2015-16 estimates and has raised concerns regarding the effectiveness of anaemia prevention programs.2, 3In India, the prevalence of anaemia is highest in the early years, decreases until about 11 years of age and then increases again during adolescence, particularly in girls due to the start of menstruation and as a consequence of early marriage and teenage pregnancy.4-8 Nutritional anaemia due to lack of iron, folate, or vitamin B12 is the most prevalent form in this age group6 and has long term negative implications on growth and development, school performance and work productivity.8-12 Anaemia during adolescent pregnancy is associated with poor pregnancy outcomes such premature births, low birth weight, and perinatal and maternal mortality.8, 13, 14
The Government of India has highlighted the importance of improving the nutrition of adolescents by modifying schemes originally aimed at the welfare of pregnant women and children. The Scheme for Adolescent Girls (SAG), the Kishori Shakti Yojana , RMNCH+A initiative, Sneha Clinics, the National Iron Plus Initiative, the Anaemia Mukt Bharat (AMB, Anaemia free India) initiative and POSHAN Abhiyaan, all include special features for empowering and improving the health and nutrition of adolescents. The revamped AMB initiative, aimed to break the intergenerational cycle of anaemia, focuses on six groups likely to benefit, six institutional mechanisms and six interventions.15, 16 Several of these interventions such as weekly iron and folic acid (IFA) supplementation, anaemia testing and treatment, deworming and education, specifically target adolescent boys and girls.15
Regardless of these interventions, findings from our recent study in rural Karnataka and others studies as well, revealed gaps in community awareness of adolescent anaemia and its prevention, poor dietary behaviour, low compliance with regular IFA consumption and lack of adequate nutrition education in schools.17-21 Students and teachers described a vigilance-oriented approach i.e., supervised swallowing of IFA tablets, without any meaningful communication on what they were receiving, and why.22 In addition to addressing supply side barriers and careful programming, studies have continually highlighted a need to implement interventions to address demand-side barriers by improving awareness and changing behaviours surrounding diet and iron consumption.4, 16, 19, 23-27To this end, we conducted research to understand the extent to which adolescent awareness of and attitudes about anaemia can change through short, targeted nutritional messages delivered by teachers at school.