Knowledge, attitude and practice toward anemia among mothers of adolescent girls in Puducherry, South India: a community-based cross-sectional study

INTRODUCTION

Anemia is a major public health problem worldwide, disproportionately affecting adolescent girls and women of reproductive age, particularly in low and middle-income countries.¹ In India, the burden of anemia remains substantial, with prevalence estimates of 67.1% among children aged 6-59 months and 57.0% among women aged 15-49 years, as reported in the National Family Health Survey-5 (NFHS-5).^1,2 This concern is especially pronounced during adolescence, a critical developmental period characterized by rapid physical growth, increased nutritional requirements, and the onset of menstruation, all of which increase susceptibility to iron deficiency anemia.³

The consequences of anemia during adolescence extend beyond immediate hematological impairment. Persistent anemia at this stage is associated with delayed physical growth, reduced cognitive performance, and increased vulnerability to infections, with long-term implications for educational attainment, productivity, and future maternal health outcomes.^4-6 Despite the implementation of national nutrition and supplementation programs, micronutrient deficiencies, particularly iron deficiency anemia, continue to be highly prevalent among Indian adolescents.⁷

Limited awareness and understanding of anemia remain key barriers to its prevention. Adolescent girls, especially those who have not been exposed to pregnancy or motherhood related health education, often lack adequate knowledge regarding the causes, consequences, and preventive measures for anemia.⁸ Inadequate awareness of iron-rich foods and appropriate dietary practices further exacerbates this problem, underscoring the need for targeted, context-specific educational strategies.⁹ Addressing these gaps requires engagement with adolescents as well as influential household members.

Mothers play a pivotal role in shaping dietary behaviors, health-seeking practices, and adherence to preventive interventions among adolescent girls. Maternal knowledge, attitudes, and practices related to anemia influence food choices, dietary diversity, and compliance with iron supplementation.^10,11 Evidence indicates that inadequate parental understanding of anemia and its long-term consequences contribute to poor adherence to iron supplementation programs among adolescent girls.^12,13 Therefore, strengthening maternal awareness and practices is critical for improving anemia prevention and management at the community level.

Although several studies in India have examined anemia among adolescents, evidence focusing specifically on maternal knowledge, attitudes, and practices in community settings remains limited. Puducherry, a union territory in south India with a mixed urban-rural population, represents a setting where localized community-based data are essential to inform culturally appropriate public health interventions. In this context, assessing maternal knowledge, attitudes, and practices regarding anemia, along with their association with selected demographic characteristics, can provide valuable insights into strengthening community-based and public health strategies aimed at preventing anemia among adolescent girls.

METHODS

A quantitative research approach with a community-based descriptive cross-sectional design was employed to assess the knowledge, attitudes, and practices regarding anemia among mothers of adolescent girls. The study was conducted in selected community areas of Puducherry, a Union Territory in South India, between September 2025 and December 2025. The study population comprised mothers of adolescent girls residing in the selected communities. A total of 160 mothers who met the eligibility criteria and were available during the data collection period were included using a convenience sampling technique.

Data were collected using data collection tools. Socio-demographic information was obtained using a questionnaire that included the mother’s age, educational qualification, type of family, monthly family income, place of residence, number of family members, food habits, history of menstrual disorders in the adolescent daughter, and occupation.

Maternal knowledge of anemia was assessed using a 20-item knowledge questionnaire, with each correct response scored as 1 and incorrect responses scored as 0. Knowledge scores ranged from 0 to 20 and were categorized as poor (<7), moderate (7-14), and adequate (>14). Maternal attitude toward anemia was assessed using a 5-point Likert scale comprising 10 statements, with response options ranging from strongly disagree (1) to strongly agree (5). Total attitude scores ranged from 10 to 50 and were classified as negative (<16), neutral (17-32), and positive (>33). Maternal practices related to anemia prevention were evaluated using a 10-item checklist with yes/no responses to the questions. Each appropriate practice was scored as one and inappropriate practice as zero, with total practice scores categorized as poor (<4), moderate (4-7), or good (>7).

Data collection was carried out through direct interaction with participants after explaining the purpose of the study and obtaining informed consent. Ethical approval was obtained from the institutional ethics committee, and confidentiality and anonymity were ensured throughout the study period. Data were coded, entered, and analyzed using the Statistical Package for the Social Sciences (SPSS). Descriptive statistics were used to summarize demographic characteristics and KAP scores, and the chi-square test was applied to examine associations between selected demographic variables and levels of knowledge, attitude, and practice regarding anemia. Statistical significance was set at p<0.05.

RESULTS

Socio-demographic characteristics of the participants

A total of 160 mothers of adolescent girls participated in the study. Half of the mothers (50.0%) were aged 40-45 years, while 21.3% were aged 35-40 years and 28.7% were above 45 years. Nearly half of the adolescent girls (48.8%) were aged 15-19 years. With regard to educational status, 41.3% of mothers had primary education, 32.5% had higher education, and 26.3% were illiterate.

More than half of the participants belonged to nuclear families (52.5%), and the majority reported a monthly family income between INR 1,000 and 5,000 (48.8%). A greater proportion of mothers resided in semi-urban areas (40.0%), followed by rural (32.5%) and urban areas (27.5%). Almost half of the families (46.3%) had more than three family members. Most mothers followed non-vegetarian food habits (90.0%). One-quarter of the adolescent girls (25.0%) had a history of menstrual disorders. Regarding occupation, 46.3% of mothers were workers and 43.8% were homemakers (Table 1).

Knowledge, attitude, and practice regarding anemia

The distribution of knowledge, attitude, and practice levels regarding anemia and the corresponding summary statistics are presented in Tables 2 and 3. With respect to knowledge, 42.5% of mothers demonstrated adequate knowledge, while 38.8% had moderate knowledge and 18.7% had poor knowledge. The mean knowledge score was 12.22±4.60, indicating an overall moderate level of knowledge.

Assessment of attitude revealed that the majority of mothers (83.8%) exhibited a positive attitude toward anemia prevention and management. Neutral and negative attitudes were observed in 13.7% and 2.5% of mothers, respectively. The mean attitude score was 36.02±6.90, reflecting a predominantly positive attitudinal orientation.

In terms of practice, most mothers (68.8%) demonstrated moderate practices related to anemia prevention, followed by 25.0% who reported good practices and 6.2% who exhibited poor practices. The mean practice score was 6.22±1.71, suggesting that the translation of knowledge and attitude into optimal preventive practices remained limited.

Association between demographic variables and knowledge, attitude, and practice levels

Associations between selected demographic variables and levels of knowledge, attitude, and practice regarding anemia were examined using the Chi-square test (Table 4). A statistically significant association was observed between the age of the mother and knowledge level (χ²=12.52, p=0.014) as well as practice level (χ²=17.54, p=0.010). Educational level showed a highly significant association with both knowledge level (χ²=68.36, p<0.001) and practice level (χ²=27.97, p<0.001).

Practice level was also significantly associated with monthly family income (χ²=18.62, p=0.016) and place of residence (χ²=13.07, p=0.036). No statistically significant association was found between any of the demographic variables and attitude level (p>0.05).

Other demographic variables, including age of the daughter, type of family, number of family members, food habits, history of menstrual disorders, and occupation, did not show statistically significant associations with knowledge, attitude, or practice levels (p>0.05).

*Statistically significant at p<0.05 (Chi-square test)

DISCUSSION

This community-based cross-sectional study assessed the knowledge, attitudes, and practices regarding anemia among mothers of adolescent girls in selected areas of Puducherry and examined their association with selected demographic variables. The findings provide context-specific insights into maternal perspectives on anemia prevention and reveal a clear mismatch between awareness, favorable attitudes, and consistent adoption of preventive practices. Maternal knowledge of anemia was predominantly moderate, with fewer than half of the mothers demonstrating adequate knowledge. This pattern is consistent with earlier community-based studies from India and other low- and middle-income settings, which have reported partial awareness of anemia, accompanied by gaps in understanding its causes, dietary prevention, and long-term health consequences.^14,15 Although many mothers were aware of anemia as a health condition, limited knowledge regarding iron-rich foods, enhancers of iron absorption, and preventive strategies may restrict their ability to implement effective preventive measures for their adolescent daughters. Given the increased nutritional demands during adolescence, such gaps in knowledge may contribute to delayed or inadequate prevention.^16,17 Previous research has similarly reported low recognition of anemia symptoms and underestimation of its prevalence among children and adolescents.¹⁸

In contrast, the attitudes toward anemia prevention were overwhelmingly positive. Most mothers acknowledged the importance of preventing anemia, consistent with previous studies showing that caregivers often perceive anemia as a significant health concern, even when detailed knowledge is lacking.^19,20 However, these favorable attitudes did not proportionately translate into optimal preventive practices. This disconnect highlights a commonly observed gap between cognitive awareness and behavioral implementation, indicating that positive perceptions alone may be insufficient to drive sustained health-promoting behavior in the presence of contextual and structural constraints.

Preventive practices related to anemia were largely moderate, with only one-quarter of mothers reporting good practice. The gap between positive attitudes and suboptimal practices may be influenced by multiple interrelated factors, including limited dietary diversity, economic constraints, cultural food preferences, time limitations, and misconceptions about iron supplementation.^21,22 These findings suggest that interventions focusing solely on information dissemination may be inadequate. Addressing practical barriers at the household and community levels, such as promoting affordable iron-rich foods, correcting misconceptions, and reinforcing supplementation messages, may support better translation of knowledge and attitudes into practice.

Association analysis identified maternal education level as a key determinant of knowledge and practices related to anemia. Mothers with higher educational attainment demonstrated significantly better understanding and more appropriate preventive practices, reinforcing existing evidence that education enhances health literacy, access to information, and informed decision-making regarding nutrition and preventive care.^23-25 A significant association between maternal age and knowledge level was also observed, possibly reflecting accumulated life experience and repeated exposure to the health services. Together, maternal age and education appear to function as reinforcing determinants shaping both awareness and the ability to apply preventive measures effectively. Attitudes toward anemia prevention did not vary significantly across demographic groups, suggesting that positive perceptions may be relatively widespread, potentially reflecting the reach of national nutrition initiatives and public health messages.²⁶ The relative homogeneity of the study population may have limited the detection of nuanced differences across subgroups. Overall, the findings indicate that while mothers of adolescent girls in Puducherry generally hold positive attitudes toward anemia prevention, gaps in knowledge and inconsistent preventive practices persist in the community. Maternal education emerged as a critical factor influencing both understanding and behavior, underscoring the importance of educational empowerment in preventing anemia. The persistent gap between attitudes and practices highlights the need for community-level public health approaches that extend beyond awareness creation to address practical constraints and support sustained behavioral changes.

This study provides community-level evidence on maternal knowledge, attitudes, and practices regarding anemia among mothers of adolescent girls in Puducherry, where such data are limited. By focusing on mothers as key influencers of adolescent health behaviors, this study offers relevant insights into anemia prevention at the household level. However, the cross-sectional design limits the causal interpretation of these associations. Information on practices was self-reported and may be subject to recall or social desirability bias. In addition, as the study was conducted in selected community areas, the findings may not be generalizable to other settings with different sociocultural or health system contexts.

CONCLUSION

This study demonstrates that although mothers of adolescent girls exhibit favorable attitudes toward anemia prevention, their knowledge and preventive practices are only moderate. Maternal education emerged as a key determinant influencing both knowledge and practice, emphasizing its role in strengthening anemia prevention efforts in the future. Context-specific evidence, such as this, is essential for informing community-based and public health strategies aimed at reducing the burden of anemia among adolescent girls.

ACKNOWLEDGEMENTS

The authors sincerely thank all the mothers of adolescent girls who participated in this study for their time, cooperation, and valuable responses.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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