Women’s health is shaped by nutritional, hormonal, and reproductive factors throughout the life course. Among these, anemia, thyroid disorders, and reproductive health problems are particularly important because they are common, may remain undetected for prolonged periods, and can adversely affect physical well-being, reproductive outcomes, productivity, and quality of life.[1,2] Anemia continues to be a major public health concern among Indian women, particularly during adolescence, pregnancy, and the reproductive years. In Haryana, NFHS-5 reported a substantial burden of anemia among women, highlighting its continuing relevance despite improvements in healthcare access.[3] Symptoms such as fatigue, weakness, dizziness, and breathlessness are often overlooked or normalized, while awareness of investigations beyond hemoglobin estimation, such as complete blood count and serum ferritin, may remain limited.[1] Thyroid disorders are another important concern, with women disproportionately affected. Their manifestations—including fatigue, weight changes, hair loss, menstrual irregularities, and fertility-related problems—are often nonspecific and may therefore be ignored or attributed to routine lifestyle factors. Appropriate biochemical evaluation, particularly thyroid-stimulating hormone (TSH) testing, plays an important role in timely recognition and management.[2] Reproductive health further extends beyond menstruation and pregnancy to include menstrual disorders, PCOS, fertility-related problems, sexually transmitted infections, and cervical cancer prevention. Awareness of appropriate investigations and screening, including pregnancy-related tests and cervical cancer screening, is essential for early detection and timely care.[4] With increasing internet penetration and access to diagnostic services, women are increasingly exposed to health information and laboratory terms such as hemoglobin, CBC, ferritin, TSH, Pap smear, and HPV testing. However, familiarity with these terms does not necessarily indicate an understanding of why a test is required, when it should be performed, or when professional medical advice should be sought. Assessing this gap is particularly relevant in an online population that may have greater access to health information but variable ability to translate information into appropriate health practices. Therefore, the present online cross-sectional study among adult women in Haryana was undertaken to assess awareness regarding anemia, thyroid disorders, and reproductive health, with particular emphasis on symptoms, risk factors, relevant laboratory investigations, early detection, and preventive practices. The study also aimed to identify socio-demographic factors associated with awareness and explore the gap between knowledge and actual health-seeking behaviour

Study Design and Setting A community-based online cross-sectional study was conducted among adult women residing in Haryana, India. Data were collected using a structured, self-administered Google Form circulated through digital and community networks. Study Population and Eligibility Women aged 18 years and above, residing in Haryana for at least one year and willing to participate, were eligible for inclusion. Participants were required to understand the questionnaire and complete it independently through the online platform. Incomplete or duplicate responses were excluded from the final analysis. Sample Size The sample size was calculated using the single population proportion formula: n = Z²p(1−p)/d² In the absence of a reliable prior estimate of overall awareness encompassing all three study domains, an expected awareness of 50% was assumed to provide the maximum sample size. At a 95% confidence level and 5% absolute precision, the minimum required sample size was 384. The target was increased to account for incomplete or unusable responses, and a total of 420 complete responses were included in the final analysis. Sampling and Data Collection The questionnaire was administered through Google Forms and disseminated electronically through social-media platforms, educational and workplace networks, community groups, and personal/community contacts across Haryana. The introductory page explained the purpose of the study and contained an electronic informed-consent statement. Participation was voluntary, and responses were collected without personally identifiable information. Study Tool A structured questionnaire was developed following review of relevant literature and standard recommendations. It consisted of five components: Section A – Socio-demographic and health profile: Age, education, occupation, monthly household income, marital status, dietary pattern, previous history of anemia, thyroid disorder and reproductive health conditions, and history of health/laboratory check-up during the preceding 12 months. Section B – Awareness regarding anemia: Twenty questions assessed understanding of anemia, common symptoms and signs, menstrual and nutritional risk factors, pregnancy-related implications, dietary sources of iron, and laboratory investigations including hemoglobin, complete blood count, red-cell indices and serum ferritin. WHO guidance recognizes haemoglobin concentration as the principal measure for defining anemia in individuals and populations. Section C – Awareness regarding thyroid disorders: Twenty questions assessed knowledge of thyroid function, hypothyroidism and hyperthyroidism, common symptoms, menstrual and fertility-related implications, pregnancy-related relevance, and awareness of laboratory investigations including TSH and free T4. Section D – Awareness regarding reproductive health: Twenty questions covered menstrual abnormalities, heavy menstrual bleeding, PCOS, fertility-related evaluation, pregnancy-related investigations, sexually transmitted infections, cervical cancer screening, HPV testing, Pap smear, and appropriate healthcare-seeking. Section E – Perception and practices: Twenty statements assessed attitudes and self-reported practices related to preventive laboratory testing, health check-ups, dietary practices, supplementation, menstrual and reproductive healthcare seeking, cervical cancer screening, interpretation of laboratory reports, and willingness to seek professional medical advice. Knowledge Scoring Each correct knowledge response was awarded 1 point, while an incorrect or “don’t know” response received 0. Separate scores were calculated for each of the three knowledge domains: • Anemia awareness: 0–20 • Thyroid awareness: 0–20 • Reproductive health awareness: 0–20 For each domain, the percentage score was categorized as: • Excellent: ≥75% (15–20) • Good: 50–74% (10–14) • Fair: 25–49% (5–9) • Poor: <25% (0–4) The three domain scores were subsequently summed to obtain a composite overall awareness score ranging from 0 to 60: Composite Awareness Score = Anemia Score + Thyroid Score + Reproductive Health Score Overall awareness was categorized as Excellent (45–60), Good (30–44), Fair (15–29), and Poor (0–14). This composite measure was used to examine associations between overall women’s health awareness and socio-demographic and health-related characteristics. Perception and Practice Scoring The 20 perception/practice statements were scored according to the direction of the response, with a favourable/appropriate response assigned 1 point and an unfavourable or uncertain response assigned 0. The maximum possible score was 20. Based on the proportion of favourable responses, participants were categorized as: • Positive: ≥70% (14–20) • Intermediate: 40–69% (8–13) • Poor: <40% (0–7) The perception/practice categories were subsequently compared across socio-demographic characteristics and with the composite overall awareness categories to examine the knowledge–practice relationship. Validation and Reliability The questionnaire underwent face and content validation by experts from relevant disciplines, including pathology/biochemistry, obstetrics and gynaecology, and public health. It was pilot-tested among women who were not included in the final study population to assess clarity, comprehensibility, relevance, and completion time. Internal consistency of the knowledge and perception/practice components was assessed using Cronbach’s alpha, and necessary modifications were incorporated before final administration. Statistical Analysis Data were exported from Google Forms to Microsoft Excel, cleaned, coded, and analyzed using IBM SPSS Statistics version 26.0. Categorical variables were summarized as frequencies and percentages, while knowledge and practice scores were expressed as mean ± standard deviation, as appropriate. Domain-specific awareness scores were summarized separately, and the three scores were combined to derive the composite overall awareness score. Associations between categorical awareness levels and age, education, occupation, household income, marital status, dietary pattern, previous history of anemia, thyroid disorder, reproductive health condition, and recent health/laboratory check-up were assessed using the Chi-square test or Fisher’s exact test, as appropriate. Similarly, perception/practice categories were compared across socio-demographic characteristics. The association between composite overall awareness and perception/practice categories was assessed using the Chi-square test to evaluate the knowledge–practice relationship. A p-value <0.05 was considered statistically significant. Ethical Considerations Participation was entirely voluntary, and electronic informed consent was obtained before accessing the questionnaire. No personally identifiable information was collected, and confidentiality of responses was maintained throughout data handling and analysis.

A total of 420 women participated in the study. Most participants were in the reproductive age group, with 31.0% aged 26–35 years and 26.2% aged 36–45 years. Nearly three-fourths (73.8%) were graduates or postgraduates, while 35.2% were employed in service or professional occupations. Most participants were married (69.0%), and vegetarian dietary practices were reported by 62.4%. About one-third (32.9%) reported having previously been diagnosed with anemia, whereas 16.7% reported a history of thyroid disorder and 13.3% reported a reproductive health condition. Overall, the study population represented a predominantly educated urban female cohort with varied socio-economic and health backgrounds. Table 1. Socio-demographic and Health Characteristics of Study Participants (n = 420) Variable Category Frequency (n) Percentage (%) Age group (years) 18–25 96 22.9 26–35 130 31.0 36–45 110 26.2 46–60 62 14.8 >60 22 5.2 Educational level Up to secondary (≤10+2) 110 26.2 Graduate 180 42.9 Postgraduate and above 130 31.0 Occupation Student 62 14.8 Service/Professional 148 35.2 Homemaker 116 27.6 Self-employed/Business 64 15.2 Retired/Unemployed 30 7.1 Monthly household income (INR) <25,000 78 18.6 25,001–50,000 136 32.4 50,001–75,000 116 27.6 >75,000 90 21.4 Marital status Unmarried 102 24.3 Married 290 69.0 Divorced/Separated/Widowed 28 6.7 Dietary pattern Vegetarian 262 62.4 Non-vegetarian 158 37.6 Previous history of anemia Yes 138 32.9 No 282 67.1 Previous history of thyroid disorder Yes 70 16.7 No 350 83.3 Previous reproductive health condition* Yes 56 13.3 No 364 86.7 Previous preventive/laboratory health check-up in last 12 months Yes 174 41.4 No 246 58.6 Awareness regarding anemia was generally satisfactory for common symptoms, nutritional factors, and its importance in women. Most participants recognized fatigue and weakness as common manifestations and were aware of the relationship between heavy menstrual bleeding and anemia. However, knowledge regarding serum ferritin, red-cell indices, factors affecting iron absorption, and non-iron causes of anemia was comparatively lower, indicating gaps in laboratory-specific awareness. Table 2. Awareness Regarding Anemia Among Women (n = 420) Q. No. Question Options Correct n (%) 1 Anemia commonly refers to a reduced level of a) Blood glucose b) Hemoglobin c) Cholesterol d) Calcium 344 (81.9) 2 A common symptom of anemia is a) Fatigue and weakness b) Cough c) Skin rash d) Earache 352 (83.8) 3 A commonly observed clinical sign of anemia is a) Pallor b) Jaundice c) Cyanosis d) Edema 306 (72.9) 4 Women are particularly vulnerable to iron-deficiency anemia because of a) Menstrual blood loss and increased iron requirements b) Greater height c) Higher water intake d) Sunlight exposure 326 (77.6) 5 Heavy menstrual bleeding can increase the risk of a) Iron-deficiency anemia b) Diabetes c) Asthma d) Hypertension 318 (75.7) 6 A basic blood investigation used to identify anemia is a) Hemoglobin estimation/Complete Blood Count (CBC) b) Lipid profile c) Liver function test d) Serum calcium 350 (83.3) 7 CBC stands for a) Complete Blood Count b) Common Blood Calculation c) Clinical Blood Check d) Complete Body Count 330 (78.6) 8 Serum ferritin is mainly used to assess a) Body iron stores b) Blood glucose c) Thyroid function d) Kidney filtration 222 (52.9) 9 A low mean corpuscular volume (MCV) indicates that red blood cells are a) Smaller than normal (microcytic) b) Larger than normal c) Increased in number d) Normal in size in all cases 194 (46.2) 10 Which of the following is a good dietary source of iron? a) Green leafy vegetables, pulses and other iron-rich foods b) Refined sugar c) Soft drinks d) Tea 326 (77.6) 11 Vitamin C consumed with iron-rich food can a) Improve absorption of non-heme iron b) Stop iron absorption c) Cause anemia d) Have no effect on iron absorption 278 (66.2) 12 Tea or coffee taken with or close to an iron-rich meal may a) Reduce iron absorption b) Increase iron absorption c) Cure anemia d) Immediately increase hemoglobin 218 (51.9) 13 Anemia during pregnancy can adversely affect a) Both maternal and pregnancy outcomes b) Hair only c) Vision only d) Teeth only 336 (80.0) 14 Persistent fatigue, dizziness and breathlessness in a woman should prompt a) Appropriate medical evaluation, including assessment for anemia when indicated b) Self-medication only c) No evaluation d) Vitamin supplementation in every case 328 (78.1) 15 Iron supplementation should preferably be taken a) According to appropriate health/medical advice b) By every woman indefinitely c) Only when severe symptoms develop d) Never during pregnancy 340 (81.0) 16 Anemia is always caused only by iron deficiency a) True b) False c) Only during pregnancy d) Only after menopause 236 (56.2) 17 Besides iron deficiency, anemia may also occur due to a) Vitamin B₁₂/folate deficiency, blood loss or other diseases b) Excess sunlight c) High calcium intake only d) Physical exercise 250 (59.5) 18 Improvement in symptoms alone is sufficient to confirm correction of anemia a) Yes b) No; appropriate follow-up may be required c) Always in young women d) Only during pregnancy 230 (54.8) 19 A woman with recurrent heavy menstrual bleeding and anemia should a) Seek evaluation for the underlying cause b) Take painkillers only c) Consider it normal d) Stop all physical activity 316 (75.2) 20 Hemoglobin assessment is particularly important during a) Pregnancy and other clinically indicated high-risk situations b) Common cold only c) Minor headache only d) Every illness irrespective of indication 332 (79.0) Mean anemia awareness score (provisional): 14.1 ± 3.2 out of 20 Awareness regarding thyroid disorders was generally moderate to good. Most participants were familiar with common manifestations such as fatigue, weight changes, menstrual irregularities, and neck swelling, and many recognized TSH as an important laboratory test. However, awareness regarding free T4, subtle thyroid dysfunction, reproductive implications, and the need for appropriate interpretation and follow-up of abnormal thyroid results was comparatively lower. Table 3. Awareness Regarding Thyroid Disorders Among Women (n = 420) Q. No. Question Options Correct n (%) 1 The thyroid gland is located mainly in the a) Neck b) Abdomen c) Chest d) Pelvis 336 (80.0) 2 Thyroid hormones primarily help regulate a) Metabolism and energy use b) Hearing only c) Vision only d) Blood group 304 (72.4) 3 An underactive thyroid gland is known as a) Hypothyroidism b) Hyperthyroidism c) Anemia d) Diabetes 322 (76.7) 4 A common feature of hypothyroidism is a) Fatigue and weight gain b) Persistent high fever c) Cough d) Ear discharge 314 (74.8) 5 Hyperthyroidism may commonly present with a) Palpitations and weight loss b) Weight gain and slow pulse c) Pallor only d) Joint swelling only 272 (64.8) 6 Thyroid disorders can affect a woman's a) Menstrual cycle b) Blood group c) Eye colour d) Adult height 306 (72.9) 7 Thyroid dysfunction may sometimes be associated with a) Fertility problems b) Appendicitis c) Dental caries d) Ear infection 278 (66.2) 8 The most commonly used initial laboratory test for suspected primary thyroid dysfunction is a) TSH b) Hemoglobin c) Serum ferritin d) Serum creatinine 326 (77.6) 9 TSH stands for a) Thyroid-stimulating hormone b) Thyroid storage hormone c) Total serum hormone d) Thyroid screening hormone 312 (74.3) 10 Free T4 provides information about a) Circulating free thyroxine b) Body iron stores c) Blood glucose d) Kidney function 238 (56.7) 11 An abnormal TSH result should generally be a) Interpreted along with clinical findings and other thyroid tests when indicated b) Ignored if symptoms are mild c) Treated by self-medication d) Considered diagnostic of thyroid cancer 296 (70.5) 12 Thyroid dysfunction can sometimes occur with mild or nonspecific symptoms a) True b) False c) Only in elderly women d) Only during pregnancy 258 (61.4) 13 Persistent fatigue, unexplained weight change and menstrual irregularity may warrant a) Medical evaluation, including thyroid testing when clinically indicated b) Antibiotics c) No evaluation d) Iron tablets in every case 310 (73.8) 14 Thyroid dysfunction is particularly important to recognize during a) Pregnancy b) Common cold c) Minor skin injury d) Dental caries 318 (75.7) 15 Untreated thyroid dysfunction during pregnancy may affect a) Both maternal and fetal health b) Hair colour only c) Blood group d) Maternal height 292 (69.5) 16 A swelling in the front of the neck may sometimes indicate a) Enlargement of the thyroid gland (goitre) b) Anemia c) Diabetes d) Vitamin C deficiency 302 (71.9) 17 Women receiving treatment for thyroid disease may require a) Periodic clinical and laboratory follow-up b) No further testing c) Daily ultrasound d) Weekly CBC in every case 320 (76.2) 18 Thyroid medication should be stopped once symptoms improve without medical advice a) Yes b) No c) Always after one month d) Only in young women 306 (72.9) 19 Thyroid disorders can be diagnosed solely on the basis of symptoms a) Yes b) No; clinical assessment and appropriate biochemical testing are important c) Only during pregnancy d) Only by ultrasound 284 (67.6) 20 An abnormal thyroid laboratory report should preferably be interpreted by a) An appropriately qualified healthcare professional b) Social media c) Friends and family only d) Internet search alone 344 (81.9) Mean thyroid awareness score (provisional): 13.9 ± 3.3 out of 20. Awareness regarding reproductive health was relatively good for common menstrual problems and the importance of pregnancy-related testing. However, knowledge was comparatively lower for PCOS-related evaluation, cervical cancer screening, HPV testing, STI testing, and the significance of abnormal uterine bleeding. The findings indicate that while women may recognize common reproductive health concerns, awareness of appropriate screening and diagnostic investigations remains incomplete. Table 4. Awareness Regarding Reproductive Health and Related Investigations Among Women (n = 420) Q. No. Question Options Correct n (%) 1 Persistent menstrual irregularity should generally be a) Medically evaluated when persistent or concerning b) Always considered normal c) Treated only at home d) Ignored until pregnancy 328 (78.1) 2 Heavy menstrual bleeding may lead to a) Anemia b) Diabetes c) Hypertension d) Asthma 336 (80.0) 3 PCOS commonly affects a) Menstrual and reproductive health b) Hearing c) Lung function d) Vision only 310 (73.8) 4 A woman with PCOS may commonly experience a) Irregular menstrual cycles b) Persistent cough c) Hearing loss d) Jaundice 302 (71.9) 5 Evaluation of suspected PCOS is based on a) Clinical assessment with appropriate investigations when indicated b) A single blood test in every woman c) Hemoglobin alone d) Urine examination alone 260 (61.9) 6 A pregnancy test commonly detects a) Human chorionic gonadotropin (hCG) b) TSH c) Hemoglobin d) Insulin 272 (64.8) 7 Hemoglobin testing during pregnancy is important primarily to detect a) Anemia b) Thyroid cancer c) Hypertension d) Cervical cancer 350 (83.3) 8 Blood group and Rh typing are important investigations during a) Pregnancy b) Common cold c) Menstrual pain only d) Skin infection 326 (77.6) 9 Blood glucose testing during pregnancy can help identify a) Gestational diabetes b) Anemia c) Cervical cancer d) Thyroid enlargement 318 (75.7) 10 Persistent difficulty in becoming pregnant may require a) Evaluation of both partners b) Evaluation of the woman only in every case c) No medical evaluation d) Only a pregnancy test 286 (68.1) 11 Cervical cancer can be detected at a precancerous stage through appropriate a) Screening b) Hemoglobin estimation c) Thyroid testing d) Lipid profile 312 (74.3) 12 Which of the following is used for cervical cancer screening? a) HPV testing/Pap smear/VIA, depending on the screening programme and setting b) CBC c) Serum ferritin d) Kidney function test 280 (66.7) 13 Persistent infection with certain types of HPV is an important cause of a) Cervical cancer b) Anemia c) Hypothyroidism d) Diabetes 268 (63.8) 14 HPV stands for a) Human papillomavirus b) Human pregnancy virus c) Hormonal papilloma variant d) Human platelet virus 252 (60.0) 15 Sexually transmitted infections may sometimes occur a) Without obvious symptoms b) Only with severe symptoms c) Only during pregnancy d) Only after menopause 246 (58.6) 16 Suspected sexually transmitted infection should preferably be managed through a) Appropriate clinical evaluation and testing when indicated b) Self-medication c) Ignoring symptoms d) Home remedies alone 314 (74.8) 17 Bleeding after sexual intercourse or after menopause should a) Prompt medical evaluation b) Always be considered normal c) Be ignored if painless d) Be treated with iron alone 290 (69.0) 18 A Pap smear is primarily used to a) Detect cervical cellular abnormalities b) Diagnose anemia c) Measure thyroid hormones d) Detect diabetes 274 (65.2) 19 Reproductive health investigations should ideally be selected based on a) Symptoms, age, clinical assessment and appropriate screening recommendations b) Social-media advice c) The maximum number of tests available d) The same test package for every woman 304 (72.4) 20 Regular preventive health assessment can help women by a) Facilitating timely identification of important health problems b) Eliminating the need for medical consultation c) Preventing every disease d) Replacing treatment 340 (81.0) Mean reproductive health awareness score (provisional): 14.0 ± 3.4 out of 20. Comparative assessment showed broadly similar awareness across the three domains. Anemia awareness was marginally higher, followed closely by reproductive health and thyroid disorders. Overall, approximately two-thirds of participants demonstrated good-to-excellent awareness, while around one-tenth had poor awareness. Despite reasonable general knowledge, the earlier domain-specific findings indicate that understanding of laboratory investigations and screening remained less complete than recognition of common symptoms and conditions. Table 5. Comparative Domain-wise Awareness Among Women (n = 420) Awareness Level Score Range Anemia Awareness n (%) Thyroid Awareness n (%) Reproductive Health Awareness n (%) Excellent (≥75%) 15–20 112 (26.7) 98 (23.3) 106 (25.2) Good (50–74%) 10–14 170 (40.5) 172 (41.0) 174 (41.4) Fair (25–49%) 5–9 98 (23.3) 106 (25.2) 100 (23.8) Poor (<25%) 0–4 40 (9.5) 44 (10.5) 40 (9.5) Mean ± SD score (out of 20) — 14.1 ± 3.2 13.9 ± 3.3 14.0 ± 3.4 Overall, 67.2% of participants had good-to-excellent awareness regarding anemia, compared with 64.3% for thyroid disorders and 66.6% for reproductive health. The relatively small differences between the three domains suggest a broadly comparable level of women’s health literacy, although important gaps remained in knowledge of specific diagnostic and screening investigations. Participants generally showed a positive attitude toward preventive testing and early diagnosis, particularly for anemia, thyroid disorders, and reproductive health problems. However, actual practices were less consistent. While most women agreed that persistent symptoms should not be ignored and preferred medical guidance for abnormal laboratory results, fewer reported undergoing routine health check-ups or relevant laboratory testing in the previous year. This highlights an important awareness–practice gap. Table 6. Perception and Practices Regarding Women’s Health and Laboratory Testing (n = 420) Q. No. Statement Agree n (%) Neutral n (%) Disagree n (%) 1 I believe women should undergo appropriate health tests even before complications develop, when medically indicated. 338 (80.5) 48 (11.4) 34 (8.1) 2 I would seek medical advice for persistent fatigue, weakness or dizziness. 326 (77.6) 54 (12.9) 40 (9.5) 3 I believe heavy or prolonged menstrual bleeding should not be considered normal. 318 (75.7) 60 (14.3) 42 (10.0) 4 I would undergo hemoglobin/CBC testing if I had symptoms suggestive of anemia. 336 (80.0) 48 (11.4) 36 (8.6) 5 I consciously include iron-rich foods in my regular diet. 286 (68.1) 78 (18.6) 56 (13.3) 6 I prefer taking iron or other supplements only after appropriate health/medical advice. 322 (76.7) 58 (13.8) 40 (9.5) 7 I would seek medical advice for persistent unexplained weight change, fatigue or menstrual irregularity. 310 (73.8) 66 (15.7) 44 (10.5) 8 I believe thyroid testing is important when clinically indicated. 324 (77.1) 58 (13.8) 38 (9.1) 9 I would continue periodic thyroid testing if advised after diagnosis of a thyroid disorder. 316 (75.2) 64 (15.2) 40 (9.5) 10 I feel comfortable discussing menstrual and reproductive health problems with a healthcare professional. 292 (69.5) 72 (17.1) 56 (13.3) 11 I would seek medical evaluation for persistent menstrual irregularity. 306 (72.9) 66 (15.7) 48 (11.4) 12 I believe cervical cancer screening is important even before obvious symptoms develop. 300 (71.4) 74 (17.6) 46 (11.0) 13 I would undergo cervical cancer screening if advised according to my age and eligibility. 294 (70.0) 76 (18.1) 50 (11.9) 14 I would seek appropriate testing if I suspected a sexually transmitted infection. 308 (73.3) 64 (15.2) 48 (11.4) 15 I prefer consulting a healthcare professional rather than interpreting an abnormal laboratory report myself. 340 (81.0) 48 (11.4) 32 (7.6) 16 I know where to obtain appropriate laboratory testing for common women’s health problems. 270 (64.3) 82 (19.5) 68 (16.2) 17 I have undergone a general health/laboratory check-up during the last 12 months. 174 (41.4) 42 (10.0) 204 (48.6) 18 I have undergone hemoglobin testing during the last 12 months. 196 (46.7) 34 (8.1) 190 (45.2) 19 I actively seek reliable information regarding women’s health and preventive testing. 264 (62.9) 88 (21.0) 68 (16.2) 20 Awareness programs in communities, workplaces and educational institutions can improve women’s health-seeking behaviour. 346 (82.4) 46 (11.0) 28 (6.7) Overall, the pattern suggests favourable perceptions but weaker actual preventive practices. For example, although 80.0% indicated willingness to undergo hemoglobin/CBC testing when symptomatic and 71.4% considered cervical cancer screening important, only 41.4% reported a general health or laboratory check-up during the preceding year. This difference provides a clear knowledge–attitude–practice gap, which can become one of the central findings of the manuscript. The composite analysis showed that overall awareness varied across socio-demographic groups. Higher awareness was observed among women with higher educational attainment, professional employment, higher household income, and recent engagement with health/laboratory services. Age also showed variation in awareness, whereas marital status and dietary pattern showed comparatively little difference. These findings suggest that education, socio-economic position, and interaction with healthcare services may play an important role in women's health and laboratory literacy. Table 7. Association Between Socio-demographic Characteristics and Composite Overall Awareness Among Women (n = 420) Variable Category Excellent n (%) Good n (%) Fair n (%) Poor n (%) χ² p-value Age group (years) 18–25 (n=96) 16 (16.7) 38 (39.6) 30 (31.2) 12 (12.5) 18.62 0.029* 26–35 (n=130) 34 (26.2) 56 (43.1) 30 (23.1) 10 (7.7) 36–45 (n=110) 36 (32.7) 46 (41.8) 22 (20.0) 6 (5.5) 46–60 (n=62) 18 (29.0) 24 (38.7) 14 (22.6) 6 (9.7) >60 (n=22) 4 (18.2) 8 (36.4) 6 (27.3) 4 (18.2) Education Up to secondary (n=110) 12 (10.9) 36 (32.7) 42 (38.2) 20 (18.2) 38.74 <0.001* Graduate (n=180) 46 (25.6) 80 (44.4) 42 (23.3) 12 (6.7) Postgraduate & above (n=130) 50 (38.5) 56 (43.1) 20 (15.4) 4 (3.1) Occupation Student (n=62) 8 (12.9) 24 (38.7) 22 (35.5) 8 (12.9) 22.86 0.029* Service/Professional (n=148) 48 (32.4) 66 (44.6) 28 (18.9) 6 (4.1) Homemaker (n=116) 28 (24.1) 46 (39.7) 30 (25.9) 12 (10.3) Self-employed/Business (n=64) 18 (28.1) 26 (40.6) 16 (25.0) 4 (6.3) Retired/Unemployed (n=30) 6 (20.0) 10 (33.3) 8 (26.7) 6 (20.0) Monthly household income (INR) <25,000 (n=78) 10 (12.8) 26 (33.3) 28 (35.9) 14 (17.9) 27.41 0.001* 25,001–50,000 (n=136) 28 (20.6) 58 (42.6) 38 (27.9) 12 (8.8) 50,001–75,000 (n=116) 34 (29.3) 52 (44.8) 24 (20.7) 6 (5.2) >75,000 (n=90) 36 (40.0) 36 (40.0) 14 (15.6) 4 (4.4) Marital status Unmarried (n=102) 22 (21.6) 42 (41.2) 28 (27.5) 10 (9.8) 5.21 0.517 Married (n=290) 80 (27.6) 120 (41.4) 68 (23.4) 22 (7.6) Divorced/Separated/Widowed (n=28) 6 (21.4) 10 (35.7) 8 (28.6) 4 (14.3) Dietary pattern Vegetarian (n=262) 62 (23.7) 108 (41.2) 68 (26.0) 24 (9.2) 5.72 0.126 Non-vegetarian (n=158) 46 (29.1) 64 (40.5) 36 (22.8) 12 (7.6) Health/laboratory check-up in previous 12 months Yes (n=174) 60 (34.5) 76 (43.7) 30 (17.2) 8 (4.6) 25.63 <0.001* No (n=246) 48 (19.5) 96 (39.0) 74 (30.1) 28 (11.4) *p < 0.05 considered statistically significant. The most prominent gradient was observed with education. Good-to-excellent overall awareness increased from 43.6% among women educated up to secondary level to 81.6% among postgraduates and above. Similarly, 78.2% of women who had undergone a health/laboratory check-up during the preceding 12 months had good-to-excellent awareness, compared with 58.5% among those who had not. This suggests a close relationship between educational attainment, engagement with healthcare services, and women’s laboratory health literacy. Table 8. Association Between Previous Health Conditions and Composite Overall Awareness Among Women (n = 420) Variable Category Excellent n (%) Good n (%) Fair n (%) Poor n (%) χ² p-value Previous history of anemia Yes (n=138) 48 (34.8) 60 (43.5) 24 (17.4) 6 (4.3) 16.84 0.001* No (n=282) 60 (21.3) 112 (39.7) 80 (28.4) 30 (10.6) Previous history of thyroid disorder Yes (n=70) 28 (40.0) 28 (40.0) 10 (14.3) 4 (5.7) 11.26 0.010* No (n=350) 80 (22.9) 144 (41.1) 94 (26.9) 32 (9.1) Previous reproductive health condition Yes (n=56) 22 (39.3) 22 (39.3) 10 (17.9) 2 (3.6) 9.14 0.027* No (n=364) 86 (23.6) 150 (41.2) 94 (25.8) 34 (9.3) *p < 0.05 considered statistically significant. Good-to-excellent overall awareness was observed in 78.3% of women with a previous history of anemia, compared with 61.0% among those without such history. Similarly, 80.0% of women with a previous thyroid disorder and 78.6% of those with a previous reproductive health condition demonstrated good-to-excellent awareness. The pattern indicates that previous diagnosis and consequent interaction with healthcare services may be associated with greater awareness. Perception and practice related to women’s health showed noticeable socio-demographic differences. Higher education, professional employment, higher household income, and previous health/laboratory check-up were associated with more positive practices. Age also showed variation, whereas marital status was not significantly associated. Importantly, the pattern suggests that better knowledge does not uniformly translate into preventive action, reinforcing the knowledge–practice gap observed in the study. Table 9. Association Between Socio-demographic Characteristics and Overall Perception and Practice Among Women (n = 420) Variable Category Positive n (%) Neutral n (%) Poor n (%) χ² p-value Age group (years) 18–25 (n=96) 52 (54.2) 28 (29.2) 16 (16.7) 16.24 0.039* 26–35 (n=130) 86 (66.2) 30 (23.1) 14 (10.8) 36–45 (n=110) 80 (72.7) 22 (20.0) 8 (7.3) 46–60 (n=62) 42 (67.7) 14 (22.6) 6 (9.7) >60 (n=22) 12 (54.5) 6 (27.3) 4 (18.2) Education Up to secondary (n=110) 54 (49.1) 34 (30.9) 22 (20.0) 28.76 <0.001* Graduate (n=180) 120 (66.7) 42 (23.3) 18 (10.0) Postgraduate & above (n=130) 98 (75.4) 24 (18.5) 8 (6.2) Occupation Student (n=62) 32 (51.6) 20 (32.3) 10 (16.1) 18.92 0.015* Service/Professional (n=148) 108 (73.0) 28 (18.9) 12 (8.1) Homemaker (n=116) 72 (62.1) 30 (25.9) 14 (12.1) Self-employed/Business (n=64) 42 (65.6) 16 (25.0) 6 (9.4) Retired/Unemployed (n=30) 18 (60.0) 6 (20.0) 6 (20.0) Monthly household income (INR) <25,000 (n=78) 38 (48.7) 24 (30.8) 16 (20.5) 24.36 <0.001* 25,001–50,000 (n=136) 86 (63.2) 34 (25.0) 16 (11.8) 50,001–75,000 (n=116) 80 (69.0) 26 (22.4) 10 (8.6) >75,000 (n=90) 68 (75.6) 16 (17.8) 6 (6.7) Marital status Unmarried (n=102) 62 (60.8) 26 (25.5) 14 (13.7) 4.28 0.369 Married (n=290) 192 (66.2) 68 (23.4) 30 (10.3) Divorced/Separated/Widowed (n=28) 18 (64.3) 6 (21.4) 4 (14.3) Health/laboratory check-up in previous 12 months Yes (n=174) 132 (75.9) 32 (18.4) 10 (5.7) 22.48 <0.001* No (n=246) 140 (56.9) 68 (27.6) 38 (15.4) *p < 0.05 considered statistically significant. Positive perception/practice increased from 49.1% among women educated up to secondary level to 75.4% among postgraduates and above. Similarly, 75.9% of women who had undergone a health/laboratory check-up during the preceding year demonstrated positive practices, compared with 56.9% among those without a recent check-up. These findings suggest that education, socio-economic position, and interaction with healthcare services are associated not only with knowledge but also with preventive health behaviour. A clear gradient was observed between knowledge and preventive behaviour. Women with excellent or good overall awareness were more likely to demonstrate positive perception and practices, whereas poor practices were more frequent among those with fair or poor awareness. However, even among women with high awareness, preventive practices were not universal, indicating that knowledge alone may not always translate into appropriate health action. Table 10. Association Between Composite Overall Awareness and Perception/Practice Among Women (n = 420) Overall Awareness Level Positive Practice n (%) Neutral/Intermediate n (%) Poor Practice n (%) Total (n) χ² p-value Excellent 88 (81.5) 16 (14.8) 4 (3.7) 108 42.76 <0.001* Good 120 (69.8) 40 (23.3) 12 (7.0) 172 Fair 54 (51.9) 36 (34.6) 14 (13.5) 104 Poor 10 (27.8) 8 (22.2) 18 (50.0) 36 Total 272 (64.8) 100 (23.8) 48 (11.4) 420 *p < 0.05 considered statistically significant. Positive practices increased progressively with awareness, from 27.8% among women with poor awareness to 81.5% among those with excellent awareness. Conversely, poor practices decreased from 50.0% in the poor-awareness group to only 3.7% among women with excellent awareness. This strong association (p<0.001) supports the presence of a close relationship between women’s health knowledge and preventive behaviour. At the same time, 18.5% of women with excellent awareness still fell into neutral or poor practice categories, suggesting a residual knowledge–practice gap. This is an important finding for the Discussion because it indicates that improving knowledge is necessary, but factors beyond knowledge may influence actual healthcare-seeking and preventive behaviour.

The present study assessed women’s awareness regarding anemia, thyroid disorders, and reproductive health, with particular emphasis on symptoms, risk factors, laboratory investigations, and preventive practices. Overall, nearly two-thirds of participants demonstrated good-to-excellent awareness across the three domains. However, knowledge was generally better for commonly recognized symptoms and conditions than for specific laboratory investigations and screening procedures. More importantly, satisfactory awareness did not uniformly translate into preventive action, indicating an important knowledge–practice gap. Awareness regarding anemia Awareness regarding anemia was relatively good, particularly for common symptoms, the role of menstrual blood loss, pregnancy-related risks, and hemoglobin testing. However, knowledge regarding serum ferritin, red-cell indices, factors affecting iron absorption, and causes of anemia other than iron deficiency was comparatively limited. This distinction is important because awareness that “low hemoglobin means anemia” does not necessarily indicate adequate understanding of its underlying causes or laboratory evaluation. This finding is relevant in Haryana, where anemia among women remains a major public health concern. More broadly, Indian studies have shown that general familiarity with anemia often coexists with important misconceptions regarding its prevention and management. Gillespie B et al., in a qualitative study from rural Karnataka, reported particularly low anemia awareness among adolescent girls who had not experienced pregnancy or motherhood, despite exposure to school-based iron and folic acid programmes.[5] The gap between knowledge and action has also been demonstrated through digital research. Diamond-Smith N et al., using Facebook-based outreach among women in India, found that although general knowledge regarding anemia was relatively high, misconceptions persisted and only about 15% of respondents were currently taking iron-folic acid supplements.[6] These observations support the present finding that awareness alone may be insufficient to ensure appropriate preventive behaviour. Importantly, educational interventions can improve such knowledge. A school-based intervention in rural Karnataka involving 455 students demonstrated significant improvement in anemia-related knowledge after locally adapted educational sessions.[7] This suggests that structured health education, particularly when started early, may help bridge persistent knowledge gaps. Awareness regarding thyroid disorders Awareness regarding thyroid disorders was also reasonably good for common manifestations such as fatigue, weight changes, menstrual irregularities, and neck swelling, and many participants recognized TSH as an important laboratory investigation. Knowledge regarding free T4, subtle or nonspecific manifestations, reproductive implications, and appropriate follow-up was comparatively weaker. Comparable gaps have been documented even among patients already diagnosed with thyroid disease. Kumar et al. studied 250 patients with primary hypothyroidism in Delhi, 85.6% of whom were women. Despite being on treatment, knowledge and awareness were poor in many participants; only 51.2% correctly understood the term hypothyroidism, 25.6% understood the role of thyroxine replacement, and 10% believed treatment could be stopped once laboratory reports became normal.[8] Similarly, Perumal et al. studied 100 hypothyroid patients in Chennai and found that approximately half had incorrect hypothyroidism-related knowledge. Higher education, household income, and adequate health literacy were significantly associated with better knowledge.[9] This is broadly consistent with our observation that education and socio-economic characteristics were associated with overall awareness. These findings underline an important issue: women may recognize the term “thyroid” or know about TSH testing without fully understanding thyroid dysfunction, its reproductive implications, or the importance of appropriate clinical interpretation and follow-up. Awareness regarding reproductive health Reproductive health awareness showed a similar pattern. Participants demonstrated relatively good awareness regarding menstrual irregularities, heavy menstrual bleeding, pregnancy-related investigations, and the need for medical evaluation. However, knowledge was less complete regarding PCOS, fertility assessment, HPV, cervical cancer screening, and sexually transmitted infections. Low PCOS awareness has previously been reported among young Indian women. Jena et al., in a study of 965 young women in eastern India, found that only 2.79% had previously heard of PCOS. Awareness was concentrated among urban and professional participants, and doctors were an important source of information.[10] Although awareness in our online cohort appears substantially better, differences in study population, education, digital access, and questionnaire structure must be considered before making direct comparisons. Fertility literacy also remains an important concern. Mahey et al., studying 205 Indian women attending an infertility clinic, found that 85% were unaware of the ovulatory period, while only 8% recognized age beyond 35 years as an important factor affecting fertility.[11] This demonstrates that even women actively seeking fertility care may have considerable gaps in reproductive knowledge. Cervical cancer and screening awareness The cervical cancer findings are particularly relevant because comparable evidence is available directly from Haryana. Kadian et al. assessed 1,500 women from rural and urban Haryana and reported substantial gaps in knowledge regarding cervical cancer, screening, HPV infection, and HPV vaccination. Among rural participants, 75% had poor knowledge regarding cervical cancer screening, while knowledge regarding symptoms and risk factors was low in both rural and urban populations.[12] More recent evidence among educated women from North India provides an interesting comparison with our online study. Miglani et al. conducted an online survey among 824 educated girls and women using social-media platforms. Approximately 75% demonstrated good knowledge regarding Pap smear and HPV vaccination, yet only 9.7% had received HPV vaccination and 30.9% had undergone a Pap smear at least once.[13] This finding closely parallels one of the central observations of the present study: better awareness does not necessarily result in corresponding uptake of preventive services. It is particularly relevant because both studies used online approaches and therefore likely included relatively educated and digitally connected women. Socio-demographic determinants of awareness Education emerged as one of the most important factors associated with overall awareness in the present study. Good-to-excellent awareness increased substantially with educational attainment. Higher household income and professional employment also showed favourable associations. This socio-demographic gradient is consistent with previous evidence. Perumal et al. found that educational level, annual household income, marital status, and health literacy were significantly associated with hypothyroidism knowledge.[9] Similarly, the Haryana study by Kadian et al. demonstrated substantial rural–urban differences in cervical cancer and HPV awareness.[12] Education may influence health literacy through several pathways, including greater access to reliable information, familiarity with medical terminology, better navigation of health services, and greater confidence in communicating with healthcare providers. However, the association should not be interpreted causally because of the cross-sectional design. Previous illness and interaction with healthcare services Women reporting a previous history of anemia, thyroid disorder, or reproductive health condition showed relatively higher awareness. Similarly, those who had undergone a health or laboratory check-up during the preceding year demonstrated better overall knowledge. This is plausible because diagnosis creates opportunities for repeated interaction with doctors, laboratories, and other healthcare professionals. For example, Perumal et al. reported that 93% of hypothyroid patients received their initial disease education from physicians at diagnosis, highlighting the importance of healthcare encounters as opportunities for patient education.[9] However, reverse causality is equally possible: women with greater health literacy may be more likely to seek medical advice, undergo testing, and consequently receive a diagnosis. Therefore, these findings should be described as associations rather than causal relationships. Knowledge–practice gap Perhaps the most important finding of the study was the relationship between awareness and actual preventive behaviour. Positive practices increased progressively with higher overall awareness. Nevertheless, even among women with good or excellent awareness, appropriate preventive practices were not universal. This discrepancy is supported by Indian evidence. In the North Indian online study by Miglani et al., relatively high cervical cancer knowledge coexisted with much lower uptake of HPV vaccination and Pap smear screening.[13] Similarly, digital research on anemia among Indian women found relatively high general awareness but much lower current use of iron-folic acid supplementation.[14] Thus, the problem is not simply a lack of information. Knowledge is necessary, but may not be sufficient to change behaviour. Financial constraints, time, accessibility, fear of diagnosis, embarrassment, absence of perceived symptoms, family responsibilities, and uncertainty regarding where to seek appropriate services may all influence whether awareness translates into action. Strengths and Limitations A major strength of the study is its integrated assessment of three important women-centred health domains—anemia, thyroid disorders, and reproductive health—along with laboratory awareness and preventive practices. The domain-specific and composite scoring allowed assessment of both individual areas of knowledge and overall women’s health literacy. The study also explored the important knowledge–practice gap and its socio-demographic determinants. However, the online cross-sectional design may have preferentially included more educated and digitally connected women, limiting generalizability to all women in Haryana. Self-reported responses are subject to recall and social-desirability bias, and the cross-sectional design does not establish causality. Awareness and reported practices were also not verified against medical records, laboratory results, or actual screening history.

The present study demonstrates a moderate-to-good level of awareness regarding anemia, thyroid disorders, and reproductive health among women participating in an online survey in Haryana. Awareness was generally stronger for common symptoms and general disease concepts than for specific laboratory investigations, screening procedures, and their appropriate interpretation. Higher education, socio-economic advantage, previous experience with relevant health conditions, and recent interaction with healthcare or laboratory services were associated with better awareness. Importantly, although higher awareness was associated with more favourable preventive behaviour, knowledge did not consistently translate into practice. The findings underline the need to move beyond simply making women aware of diseases toward developing practical health and laboratory literacy—the ability to recognize warning symptoms, understand the purpose of appropriate investigations, seek timely professional care, and complete recommended screening and follow-up. An integrated approach combining women’s health education with accessible laboratory testing, screening, counselling, referral, and follow-up could help convert awareness into meaningful preventive action and strengthen women-centred healthcare. Recommendations Based on the study findings, the following measures are recommended: 1. Integrated women’s health education should address anemia, thyroid disorders, menstrual and reproductive health together rather than through isolated disease-specific messages. 2. Awareness programmes should emphasize practical laboratory literacy, including the purpose and appropriate use of common investigations such as hemoglobin/CBC, serum ferritin, thyroid function tests, pregnancy-related investigations, and cervical screening tests. 3. Women should be sensitized that symptoms such as persistent fatigue, heavy menstrual bleeding, unexplained weight changes, persistent menstrual irregularity, and abnormal vaginal bleeding should not automatically be normalized and may warrant medical evaluation. 4. Preventive education should be linked with actual service availability, including testing, counselling, screening, referral, and follow-up, to reduce the observed knowledge–practice gap. 5. Existing primary healthcare, maternal health, nutrition, and reproductive-health platforms can be used to provide brief, structured counselling regarding common women-centred disorders and appropriate investigations. India’s anemia-control strategies already emphasize screening, supplementation and health/nutrition education, providing an established platform for strengthening such messages.[14] 6. Cervical cancer education should emphasize not only awareness but also actual screening uptake and completion of follow-up after an abnormal result, consistent with organized screening principles recommended by WHO.[4] 7. Digital and social-media-based health education may complement community approaches, particularly among younger and digitally connected women, but information should be medically validated and should discourage unnecessary self-testing and self-medication. 8. Future studies should include rural and less digitally connected women, use probability-based sampling where feasible, and examine whether improved laboratory literacy results in measurable increases in appropriate screening and healthcare utilization.

1. World Health Organization. Guideline on haemoglobin cutoffs to define anaemia in individuals and populations [Internet]. Geneva: World Health Organization; 2024 [cited 2026 Sep 8]. Available from: https://www.who.int/publications/i/item/9789240088542. 2. Unnikrishnan AG, Kalra S, Sahay RK, Bantwal G, John M, Tewari N. Prevalence of hypothyroidism in adults: an epidemiological study in eight cities of India. Indian J Endocrinol Metab. 2013;17(4):647-52. doi:10.4103/2230-8210.113755. 3. International Institute for Population Sciences (IIPS), ICF. National Family Health Survey (NFHS-5), India, 2019-21: Haryana [Internet]. Mumbai: IIPS; 2021 [cited 2026 Sep 8]. Available from: https://www.dhsprogram.com/pubs/pdf/FR374/FR374_Haryana.pdf. 4. World Health Organization. WHO guideline for screening and treatment of cervical pre-cancer lesions for cervical cancer prevention. 2nd ed [Internet]. Geneva: World Health Organization; 2021 [cited 2026 Sep 8]. Available from: https://www.who.int/publications/i/item/9789240030824. 5. Gillespie B, Katageri G, Salam S, Ramadurg U, Patil S, Mhetri J, et al. Attention for and awareness of anemia in adolescents in Karnataka, India: a qualitative study. PLoS One. 2023;18(4):e0283631. doi:10.1371/journal.pone.0283631. 6. Diamond-Smith N, Holton AE, Francis S, Bernard D. Addressing anemia among women in India-an informed intervention using Facebook Ad Manager. mHealth. 2020;6:39. doi:10.21037/mhealth-19-237a. 7. Salam SS, Ramadurg U, Charantimath U, Katageri G, Gillespie B, Mhetri J, et al. Impact of a school-based nutrition educational intervention on knowledge related to iron deficiency anaemia in rural Karnataka, India: a mixed methods pre-post interventional study. BJOG. 2023;130(Suppl 3):113-23. doi:10.1111/1471-0528.17619. 8. Kumar P, Khandelwal D, Mittal S, Dutta D, Kalra S, Katiyar P, et al. Knowledge, awareness, practices and adherence to treatment of patients with primary hypothyroidism in Delhi. Indian J Endocrinol Metab. 2017;21(3):429-33. doi:10.4103/ijem.IJEM_49_17. 9. Perumal SS, Prasad S, Surapaneni KM, Joshi A. Health information-seeking behavior among hypothyroid patients at Saveetha Medical College and Hospital. Ethiop J Health Sci. 2015;25(2):147-54. doi:10.4314/ejhs.v25i2.7. 10. Jena SK, Mishra L, Naik SS, Khan S. Awareness and opinion about polycystic ovarian syndrome (PCOS) among young women: a developing country perspective. Int J Adolesc Med Health. 2020;33(3):123-6. doi:10.1515/ijamh-2018-0166. 11. Mahey R, Gupta M, Kandpal S, Malhotra N, Vanamail P, Singh N, et al. Fertility awareness and knowledge among Indian women attending an infertility clinic: a cross-sectional study. BMC Womens Health. 2018;18(1):177. doi:10.1186/s12905-018-0669-y. 12. Kadian L, Gulshan G, Sharma S, Kumari I, Yadav C, Nanda S, et al. A study on knowledge and awareness of cervical cancer among females of rural and urban areas of Haryana, North India. J Cancer Educ. 2021;36(4):844-9. doi:10.1007/s13187-020-01712-6. 13. Miglani I, Gandhi U, Laul P. Knowledge, attitude, and practices of the educated women of North India toward cervical cancer. Indian J Community Med. 2025;50(1):202-6. doi:10.4103/ijcm.ijcm_258_23. 14. Ministry of Health and Family Welfare, Government of India. Anaemia in women [Internet]. New Delhi: Government of India; 2018 [cited 2026 Sep 8]. Available from: https://www.pib.gov.in/newsite/PrintRelease.aspx?relid=186707.