Defining AGYW in the Indian context

In India, the term AGYW encompasses a diverse and transitional population, ranging from school-going adolescents to married young women, young mothers, and recent migrants. These groups differ in their experiences of mobility, access to education, exposure to SRH information, and autonomy in sexual relationships. Our operational definition of AGYW (ages 16–24) reflects this heterogeneity and focuses on a critical life stage marked by sexual debut, relationship formation, and family pressures around marriage and reproduction. By examining these dynamics, we aim to understand who is vulnerable and how and why that vulnerability manifests across time and contexts.

Existing literature and gaps

There is moderate literature demonstrating that AGYW in India experience heightened risk for HIV and other STIs due to early marriage, limited SRH knowledge, gender-based violence, and restricted access to healthcare [3,4,5]. According to the National Family Health Survey (NFHS-5, 2019–21), nearly 23% of women in India are married before the legal age of 18, and 6.8% of adolescent girls have already experienced childbirth. Further, 7.7% of ever-married women aged 15–24 report having experienced sexual violence. Despite legal protections, social norms continue to inhibit agency, rendering AGYW particularly vulnerable in both marital and premarital contexts.

Much of the current research on AGYW vulnerability is fragmented. Quantitative studies often quantify prevalence without adequately capturing the processes through which risk is constructed and experienced [3,6]. While qualitative research offers greater depth, it has disproportionately focused on high-risk populations, such as female sex workers (FSWs) or trafficked girls [7,8], leaving a dearth of insight into the broader population of AGYW. Moreover, many studies analyze vulnerabilities in isolation, focusing on knowledge gaps, service availability, or individual behaviors without examining how these factors intersect to reinforce and sustain systemic risk.

Notably, few studies critically interrogate the institutional and structural stigma that shapes AGYW’s access to SRH services. Bhugra et al. [9] highlight the conservative sexual attitudes that inhibit SRH access but often do not explore how these norms manifest within institutions such as schools and clinics. Likewise, Dayal and Gundi [10] document service delivery failures at adolescent clinics yet stop short of connecting these gaps to underlying structural neglect, provider bias, or policy fragmentation.

In summary, previous qualitative research has primarily centered on high-risk populations—such as female sex workers or trafficked adolescents—thereby overlooking the broader population of AGYW whose vulnerabilities manifest within normative family and community settings. Moreover, prior studies have often treated determinants such as early marriage, SRH knowledge, or service access in isolation. Our study contributes to the literature by examining these factors as interlinked processes—what we term “pathways of vulnerability”—that evolve dynamically across social and institutional levels.

By combining voices of AGYW with those of service providers, NGO staff, and government implementers, this study also bridges the analytical gap between individual experiences and institutional practice. It thereby offers an integrated understanding of how policy intent, program delivery, and lived realities interact to shape AGYW’s vulnerability in urban India.

A pathways approach to vulnerability

This study advances the literature by focusing on the interconnected pathways of vulnerability—how overlapping and interacting determinants cumulatively shape AGYW’s experiences. We adopt a grounded theory approach [11] to analyze how individual, interpersonal, community, and structural factors influence one another across time and space. This perspective allows us to move beyond static listings of barriers to uncover the underlying dynamics and sequences that reinforce risk.

For example, an AGYW may be aware of safe sex practices but unable to apply this knowledge due to stigma from peers, fear of judgment from providers, or lack of autonomy within a relationship. Our study focuses on these relational dynamics, how social norms interact with institutional practices and policy gaps to create compounded vulnerabilities.

This approach is especially relevant in the Indian context, where SRH decisions are not made in isolation but within the constraints of patriarchal family structures, caste hierarchies, economic insecurity, and healthcare gatekeeping [12,13].

Rationale for the eco-social framework

To unpack these layered vulnerabilities, we draw on the eco-social (socio-ecological) framework by Krieger [14], which conceptualizes how macro-level structures (e.g., laws, norms, policies), meso-level institutions (e.g., schools, health systems, NGOs), and micro-level relationships (e.g., family and partners) interact to influence health outcomes.

This framework is particularly suitable for the Indian context, where AGYW’s sexual health behaviors are embedded in hierarchical social systems shaped by gender, caste, and economic dependency. By situating AGYW’s experiences within this multi-level lens, the framework allows us to trace how social norms, institutional barriers, and individual agency intersect to produce differential vulnerability to STIs and HIV.

Site selection: Why Delhi NCR and Mumbai?

This study was conducted in two major urban regions: Delhi National Capital Region (NCR) and Mumbai. These locations were purposively selected due to their diverse populations, complex health infrastructures, and status as hubs of internal migration. Delhi NCR includes both urban and peri-urban communities and has seen intensive programming around adolescent health, making it a useful site for evaluating policy reach and effectiveness. Mumbai, India’s financial capital, provides a contrasting setting with its dense slum settlements, high mobility, and stark inequalities in SRH access.

Together, these cities allow us to compare and contrast the vulnerabilities faced by AGYW across socio-economic and spatial divides within urban India—contexts that are often understudied in favor of rural or high-risk settings.

Moreover, we chose the metropolitan cities of New Delhi NCR and Mumbai as the study sites since Maharashtra (ranked first) and Delhi (ranked sixth) were two states with high reports of new HIV infections in 2020 [15]. Approximately 3.90 lakh people in Maharashtra were living with HIV. At the same time, the states of West Bengal, Delhi, Punjab, Rajasthan, Madhya Pradesh, Odisha, and Haryana contributed another 18% of the total PLHIV [16]. At the subnational level, the highest adult HIV prevalence was in the northeastern region. However, Delhi has a prevalence of 0.41%, and Maharashtra has a prevalence of 0.36% among the 15–49-year population [15].

Contribution of the study

This study makes several key contributions to the existing literature on adolescent sexual and reproductive health in India. First, it offers a dynamic and intersectional understanding of vulnerability among AGYW by analyzing how multiple factors—ranging from structural norms and institutional barriers to interpersonal relationships and individual knowledge—interact to shape health outcomes. Unlike prior research that often examines these determinants in isolation, our study traces the pathways through which vulnerabilities accumulate and reinforce one another. Second, by focusing on AGYW from the general population rather than solely on high-risk groups such as sex workers or trafficking survivors, this study broadens the scope of inquiry and highlights overlooked experiences within everyday urban contexts. Third, the study critiques existing policies, such as the Rashtriya Kishor Swasthya Karyakram (RKSK), by examining how implementation gaps—due to stigma, poor institutional coordination, and inadequate outreach—limit their effectiveness. Fourth, our research includes perspectives from multiple stakeholders, including AGYW, healthcare providers, and NGO workers, allowing for a holistic view of both service delivery and demand-side constraints. Finally, through a comparative lens across two major urban centers—Delhi NCR and Mumbai—this study captures spatial and socio-economic variations in vulnerability, offering insights that can inform more context-specific and integrated adolescent health interventions. In doing so, it responds to critical gaps in both policy and research, proposing a more nuanced and comprehensive framework for addressing AGYW’s vulnerability to STIs and HIV in India.

Research design

This study employed a qualitative research design grounded in constructivist grounded theory [17] to explore the pathways of vulnerability to STIs and HIV among adolescent girls and young women (AGYW) in Delhi NCR and Mumbai. A qualitative approach was appropriate given the exploratory and context-sensitive nature of our research question. AGYW’s sexual and reproductive health (SRH) vulnerabilities are shaped by deeply embedded cultural, structural, and interpersonal dynamics that quantitative approaches often overlook [18].

We used the eco-social framework [14] as our analytic scaffold (Figure 1). This framework conceptualizes how social, institutional, and structural determinants interact over time to influence health outcomes, enabling us to organize data into macro, meso, and micro layers of vulnerability. The figure illustrates the interaction of three interrelated levels influencing adolescent girls’ and young women’s (AGYW) vulnerability: macro-level structural factors (e.g., gender norms, policy gaps, poverty); meso-level institutional and community factors (e.g., school-based silences, healthcare bias, NGO interventions); and micro-level individual and interpersonal factors (e.g., self-efficacy, partner negotiation, stigma). Arrows depict the dynamic and bidirectional relationships among levels, emphasizing that vulnerability emerges through cumulative and intersecting processes rather than isolated determinants. The framework guided both the coding process and the interpretation of themes presented in the Results section.

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Fig 1. Adapted Eco-Social Framework for Understanding AGYW Vulnerability to STIs/HIV.

https://doi.org/10.1371/journal.pone.0336593.g001

Sampling and participants

We used purposive sampling [19] to ensure variation in age, marital status, education, social class, and sexual experience. Forty-Two AGYW aged 16–24 participated in in-depth interviews (IDIs), complemented by four focus group discussions (FGDs). Participants were recruited from low-income and more privileged backgrounds to represent diverse urban experiences.

To supplement purposive sampling and enhance diversity, we used snowball sampling [20], especially to recruit AGYW from higher education institutions who were harder to reach through community-based organizations. Although non-probability sampling techniques may inherently introduce selection bias, we undertook several measures to minimize its impact. We strategically diversified our recruitment sites to include a broad range of settings—such as community centers, health clinics, educational institutions, and informal gathering spaces—to capture varied socio-demographic and geographic contexts. Additionally, we prioritized the inclusion of participants from diverse backgrounds in terms of age, socioeconomic status, education levels, and sexual and reproductive health experiences. This intentional heterogeneity enhanced the representativeness of our sample and strengthened the credibility and transferability of our qualitative findings. The manuscript is aligned with the COREQ checklist [21].

Key informants (KIs)

We conducted 18 Key Informant Interviews (KIIs) with individuals who had programmatic, clinical, or community experience in adolescent health. These included: Clinical doctors and nurses from both public and private hospitals; NGO program managers, peer educators, and field workers; Government health officials involved in RKSK implementation.

KIIs were used to understand service-level constraints, policy implementation challenges, and systemic stigma. Unlike IDIs and FGDs with AGYW that explored lived experiences, KIIs provided institutional and structural perspectives, complementing and contextualizing AGYW narratives [22].

Data collection

We collected data during March and September 2023. Two trained female researchers experienced in SRH qualitative research conducted interviews and FGDs. All sessions took place in private, safe locations: NGO offices, health centers, or mutually agreed-upon spaces. Interviews lasted 40–90 minutes on average.

For AGYW under 18, parental consent and adolescent assent and for adult participants, informed consents were obtained in line with ethical protocols [23]. Sessions were audio-recorded with participants’ permission and transcribed verbatim. All transcripts were translated into English where necessary.

To build trust, interviewers began with general rapport-building questions and gradually transitioned to sensitive topics. Participants could opt to go off-record at any point or pause interviews when needed. We also provided referral resources for psychological support if needed. These strategies helped minimize psychological distress and ensured emotional safety [24].

Reflexivity and researcher positionality

The research team engaged in continuous reflexivity. Interviewers were women with strong experience in qualitative research involving AGYW and backgrounds in public health and sociology.

women interviewers deliberately positioned themselves as empathetic listeners rather than authoritative figures. To reduce interviewer influence on participant responses, they consistently used open-ended questions, maintained neutral body language, and provided repeated reassurances about confidentiality throughout the conversations.

Additionally, daily debriefing sessions were conducted among the research team to reflect on fieldwork experiences, discuss challenges encountered, process emotional responses, and identify any emerging biases that might affect data collection or interpretation. We also maintained writing memos and positionality journals. This helped recalibrate the interview approach and maintain sensitivity to participants’ social contexts [25].

Trustworthiness and data saturation

To enhance credibility, we employed triangulation across: Methods (IDIs, FGDs, KIIs), data sources (AGYW and professionals) and locations (Delhi NCR and Mumbai). Member checks were conducted with a subset of AGYW to validate interpretations. We monitored data saturation during concurrent analysis and determined it had been reached when no new codes or themes emerged from subsequent interviews [26].

Ethical considerations

Ethical approval was obtained from the Sigma Scientific Board (10071/IRB/22–23). Informed consent and assent were taken, and participants were informed of their right to withdraw at any time. All the consents were collected in written format, where anonymity and confidentiality clauses were explicitly declared. All personal identifiers were removed, and pseudonyms were used to maintain confidentiality.

Researchers were trained to monitor emotional discomfort and were prepared to refer participants to trusted counselors or NGO staff if required. However, no severe distress was observed during fieldwork.

Data analysis

We used reflexive thematic analysis [27,28], supported by NVivo 12. This qualitative approach was chosen because it allows exploration of how and why vulnerabilities are experienced and constructed—insights that would not be attainable through quantitative designs alone. While quantitative data can identify the prevalence of early marriage or limited service access, qualitative inquiry reveals the lived meanings, emotional consequences, and contextual power dynamics that shape these experiences. For instance, participants’ narratives exposed subtle forms of relational coercion and institutional stigma that numerical indicators could not capture.

Seven representative transcripts were initially open-coded. Coding was conducted independently by three researchers and then refined through iterative team discussions to build a comprehensive coding tree. We adopted a hybrid approach combining deductive and inductive strategies: deductive codes were derived from the eco-social framework (e.g., “macro-level norms,” “meso-institutional barriers,” “micro-relationship power”), while inductive codes emerged from participants’ phrasing and recurring concepts (e.g., “school silence,” “fear of judgment,” “negotiating protection”).

To ensure transparency and analytic rigor, each code was linked to verbatim quotations in NVivo. Codes were then grouped into preliminary categories (e.g., “sources of SRH knowledge,” “gendered decision-making,” “provider bias”). Through constant comparison and memo-writing, these categories were progressively refined into overarching themes. For example, the initial codes “teacher avoidance,” “embarrassment discussing menstruation,” and “skipped chapters” were merged into the theme “Institutional silences in SRH education.” Similarly, “partner resistance,” “emotional pressure,” and “condom negotiation” informed the theme “Gendered autonomy and relational coercion.”

Themes were elaborated through: (i) theme merging—when overlapping codes were identified; (ii) theme refinement—by revisiting and collapsing subcategories; and (iii) tri-level mapping—aligning themes with macro, meso, and micro layers of the eco-social model. The final thematic map, validated against our code matrix (see Supplementary Codesheet in S1 Data), comprised three central themes: (1) SRH knowledge and misinformation; (2) sexual autonomy and partner negotiation; and (3) health-seeking behaviors and stigma. These reflected the dynamic interactions among structural, institutional, and individual-level forces shaping AGYW vulnerability. Each theme was mapped against the corresponding level of the eco-social model (see Fig 1), allowing us to trace how structural, institutional, and interpersonal forces converged to shape AGYW’s lived experiences.

COREQ compliance

This study adheres to the Consolidated Criteria for Reporting Qualitative Research (COREQ) 32-item checklist [21]. We transparently report researcher characteristics, sampling strategies, interview settings, data analysis processes, and ethical safeguards. A completed COREQ checklist is available in the supplementary materials.

Overview of sample characteristics and analytical strategy

Our study included 42 in-depth interviews (IDIs), 4 focus group discussions (FGDs), and 18 key informant interviews (KIIs) across two urban locations: Delhi and Mumbai. Table 1 outlines the socio-demographic composition of our AGYW sample. While the majority had completed secondary school, notable variation existed by city and marital status: Mumbai had a higher proportion of married AGYW (20%) compared to Delhi (12.5%), and a greater proportion of participants engaged in paid work (14.3% vs. 3.13%). Though statistically insignificant, these indicative differences informed our intersectional reading of qualitative narratives, allowing us to understand how economic status, marital status, and geography shaped AGYW’s awareness, autonomy, and health-seeking behavior.

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Table 1. Socio-economic status of the participants.

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Using the adapted eco-social model (Fig 1), we categorized findings across macro- (structural/policy), meso- (institutional/community), and micro- (individual/interpersonal) levels. The results are presented under three broad thematic categories: (1) Awareness and Knowledge of SRH, (2) Sexual Autonomy and Negotiation, and (3) Health-Seeking Behaviors. Each theme integrates qualitative insights with quantitative patterns from Table 1 to reveal key relationships and contrasts across sub-groups ensuring consistency between the conceptual framework and thematic analysis.

Theme 1: Awareness and knowledge of SRH, STIs, and HIV

Theme 2: Sexual autonomy and negotiation of safe practices

Theme 3: Health-seeking behaviors and barriers to care

Policy and programmatic implications

To summarize, our findings point to the following actionable policy implications:

Designing multi-level interventions with structural sensitivity

Programs must address macro norms (e.g., gender inequality, child marriage), meso institutions (e.g., school-based SRH curricula, health service stigma), and micro behaviors (e.g., condom negotiation, STI testing). This requires intersectoral collaboration among education, health, and women’s development departments. Structural levers, such as conditional cash transfers for girls’ education, urban livelihood schemes for young women, and parental counseling modules, must be mainstreamed into SRH strategies.

Expanding and localizing comprehensive sexuality education (CSE)

CSE must extend beyond schools to colleges, vocational training centers, and community platforms. Given the reluctance of some male teachers to teach SRH, dedicated SRH facilitators—preferably female and trained in adolescent psychology—should be deployed. Curricula should include discussions on gender norms, consent, pleasure, and healthy relationships, and be adapted for cultural and linguistic contexts.

Investing in gender-sensitive healthcare training

SRH modules for providers should go beyond biomedical knowledge and include empathy, confidentiality, and bias mitigation. Youth-friendly health certification should be mandatory for clinics in urban slums and high-prevalence zones. Feedback loops, e.g., anonymous patient satisfaction tools, could help track and improve adolescent-friendly services.

Strengthening NGO-government integration through institutional frameworks

We recommend formal partnerships between RKSK and NGOs, with defined roles in awareness generation, service delivery, and follow-up care. Peer educator programs should be funded as part of RKSK with proper training, incentives, and retention strategies. Public-private collaboration platforms may be established to coordinate efforts, share data, and ensure quality assurance.

Creating safe and inclusive platforms for AGYW

Peer-led digital platforms, moderated chat services, and anonymous helplines can enable confidential SRH queries. Community safe spaces like youth hubs or adolescent-friendly clubs should also include disabled, married, LGBTQ + , and out-of-school AGYW. Intersectionality may be mainstreamed in program design: mobile SRH clinics for low-mobility groups, sign-language-enabled IEC tools for the hearing-impaired, and culturally adapted messaging for marginalized communities.

Engaging male stakeholders across touchpoints

Male educators, peer mentors, partners, and community leaders should be sensitized to adolescent girls’ SRH needs. Interventions should challenge norms around masculinity, consent, and protection use. School-based sessions and social media campaigns targeted at boys can help foster supportive behaviors and reduce stigma.