Developing an intervention for preventing anemia among adolescents in Indonesia: Directions from an integrated systematic review and qualitative study

Introduction – Objectives: Adolescent anemia remains a major public health concern, particularly in low- and middle-income countries (LMICs). Developing effective interventions requires understanding which intervention components are consistently used, which combinations are effective, and stakeholders' perspectives. This study aims to identify intervention targets for future interventions by integrating findings from a systematic review and a qualitative study. Methodology: A systematic review on existing anemia interventions in LMICs was conducted across six databases (PubMed, Embase, Cochrane Library, PsycINFO, CINAHL, and Web of Science). In total, 7245 publications were reviewed, and 66 were included. A qualitative study was conducted through six focus group discussions (n=44) and eight stakeholder interviews in Banyuwangi, Indonesia, with health workers, adolescents, teachers, and parents. Results were analyzed thematically. Preliminary results and discussion: In the systematic review, the interventions were predominantly school-based (n=57), targeted adolescent girls (n=51), delivered face-to-face (n=58), and included health/anemia education (n=47). Effective interventions to improve knowledge/attitude (n=39) and behavior (n=35) used similar components: education, face-to-face, and visual materials, often combined with monitoring, teacher involvement, or dietary modifications. Interventions that improved anemia outcomes (n=36) combined education, supplementation, and face-to-face, often with monitoring or visual materials. Digital-based strategies and stakeholder involvement emerged as promising supportive components. In the qualitative study, four themes related to perceptions of anemia causes and consequences were identified, as well as two themes on program implementation and new solutions. Except for health workers, participants generally described anemia in terms of daily experiences, such as fatigue, menstruation, sleep deprivation, and excessive screen time. Many participants held misconceptions, confusing anemia with low blood pressure, and recognized only its immediate consequences. Community beliefs shaped these perspectives. Preventive behavior was influenced by perceived immediate consequences of anemia. Generally, participants viewed adolescents as having unhealthy dietary habits and linked them to anemia risk. They noted limited collaboration and low engagement in existing programs. Conclusions: Future interventions should combine health and nutrition education, dietary modification or nutrition-based components, and iron supplementation, delivered through face-to-face, video/image/digital-based formats, and involve adherence monitoring and diverse stakeholders.