Spatial variation and determinants of childhood anemia among children aged 6 to 59 months in Ethiopia: further analysis of Ethiopian demographic and health survey 2016

Anemia is a disease that is characterized by a decreased number of red blood cells or hemoglobin levels that result in the insufficient oxygen-carrying capacity of blood to meet the cellular metabolic demand of the body [1]. Iron deficiency is the major cause of anemia and there are also other causes of anemia like, nutritional deficiency, acute and chronic inflammations that affect the synthesis of hemoglobin and production [1, 2].

Globally, anemia affects more than 27% of the world’s population which is nearly 1.93 billion. However, there is a high burden of anemia cases in low and middle-income countries which is more than 89% [3]. Among the global burden of anemia two-third of under-five/ preschool children in Africa and southeast Asia were anemic [4]. On the other hand, according to World Health Organization (WHO) 2017 report, the global prevalence of anemia in under-five children was 41.7% whereas in the Africa region was 59% [5]. In sub-Saharan Africa including Ethiopia, the national prevalence of anemia among under five or preschool children was above 40% [6‐8]. For example, in Ethiopia, the prevalence of anemia was persistently increased among 6–59 months of children from 44% in 2011 to 56% in 2016 within 5 years [6, 7].

World Health Organization defined as anemia is a major public health problem when prevalence is above 40% and Therefore, anemia is a worldwide public health problem that affects both developing and developed countries [4]. It increased mortality and morbidity of human health as well as poor social and economic development [4]. It occurs in all population groups of a human beings. However, children and pregnant women were the more risk age groups for anemia. The result of anemia in children is very severe and complicated like increasing child mortality, impaired cognitive and physical development [2, 4]. Previous various factors were associated with childhood anemia. For example, household wealth index [9‐13], Family size [14‐16], giving more diversified diet [12, 17, 18], stunting [7‐10, 12, 14, 19], malaria infection [10, 11, 20], anemic mothers [13, 16, 19] history of diarrhea [12, 21], and history of fever [11, 13, 18] were determinant factors of childhood anemia.

Even though the Ethiopian government and different partners applied tremendous efforts to control the disease, anemia in under 5 years of children continues as a major public health problem [18]. As you know still anemia is a high burden of disease among under-five children and it varies from country to country, region to region. Identifying geographical variations of anemia among children is very important to prioritize and design targeted prevention and intervention programs to reduce the burden of anemia among children at the national level. Therefore, understanding the spatial variation and determinants of anemia among this group of children is important to design effective interventions and to manage program resources fairly.

Identifying and handling factors of childhood anemia is very important to reduce the prevalence of childhood anemia and allocate resources fairy and give more emphasis for regions that had a high distribution of childhood anemia for a better outcome. Thus, this study is designed to assess spatial distribution and determinants of anemia among children aged 6 to 59 months in Ethiopia. The conceptual frame work is described in detail (Fig. 1).

Different methods of spatial analysis most consistently demonstrate anemia high risk and low-risk regions. The hotspot areas (high risk of childhood anemia) were aggregated in the North and southeastern part of Somali, North West and Sothern part of Afar, Northern part of Gambella, Dire Dawa, and Hareri. Whereas the most significant clusters were North West of part Oromia, Harari, and Dire Dawa, North West Somali, and entire and North West Afar regions. Regional differences in feeding habits, the distribution of infectious diseases, and the availability and access to use maternal and child health care services could be the most important reasons for the result of regional variability of childhood anemia in our country [33]. Geographic variation is the risk of anemia and dynamics of the soil content of minerals since the identified high-risk regions were categorized to Eastern and South-Eastern parts of the country. Meaning high-risk regions share similar environmental conditions as evidenced by boundary formation to each other. In addition, epidemiological factors such as fever and stunting which are identified as determinants of anemia in different studies including our studies were more common in some regions. Similarly, the finding from Nigeria showed a distinct North-South divide in the Hemoglobin concentration of the children and that states in the Northern part possess a higher risk of anemia [11]. Furthermore, our finding is also supported by the study conducted in sub-Saharan Africa which concludes that the distribution of anemia is driven by large-scale environmental factors [8]. These all imply that the dynamics of the mineral content of the soil is the most probable explanation for observed geographical variation in the risk of anemia.

According to mixed-effect logistic regression, age of the child, the religion of mother, wealth index, mother’s current working status, maternal anemic status, number of under-five children in the household, fever in the last 2 weeks, and stunting were statistically significant factors childhood anemia in Ethiopia.

Age is one of the most important predictors of childhood anemia. The odds of developing childhood anemia in children whose age was between 12 and 23, 24–35, 36–47 and 48–59 months is lower by 32, 62, 75, and 84% respectively as compared with those whose age was between 6 and 11 months. This finding is consistent with several studies around the world [9, 10, 12‐17, 19‐23]. This is due to a wide gap between high iron demand for fast growth [4] and low iron supply because of inappropriate initiation of complementary feeding [12, 34] and the highest depletion of the prenatal iron store starting at 6 months of age [35]. Furthermore, children’s age more than 12 months commonly consume a variety of foods that contain iron contents like meat, fish, poultry, and cereals [36]. In addition, different infectious diseases like intestinal helminths are very common in younger children because they might ingest contaminated things into their mouths compared to older ones, particularly children living in an unsanitary environment [37, 38]. All these reasons in turn younger age which is less than 12 months more prone to anemia.

Wealth index was a determinant factor of childhood anemia in Ethiopia The odds of developing anemia in a child with family wealth index of poor, middle, richer, and richest was lower by 25.8, 40.4, 35.2, and 43.3% compared with those with family wealth index of poorest, respectively. The finding is supported by studies conducted in Brazil [9, 13], Nigeria [11], and Ethiopia [10, 12]. Evidence suggested that children from lower socioeconomic status are susceptible to various nutritional disorders like anemia, as well as prone to easily preventable diseases [39‐41]. That is why children from the poorest families are less likely to provide a balanced diet because no capability to afford and utilized diversified foods and they are prone to poor health conditions that cause anemia like parasitic infections [4, 42].

The odds of developing anemia in a child whose mother was currently working is lower by 13.3% as compared with those whose mother was currently not working. This finding was consistent with the previous study conducting Ethiopia [16]. The possible reason could be increased empowerment of working mothers to care for their children and other health-related actions [43, 44]. Therefore, working mothers are exposed to different health education regarding child caring and they know the impact of disease very well.

Maternal anemia is also another important factor of childhood anemia. The odds of having anemia in children whose mother was anemic is 1.53 times as compared to their counterparts. The result is in line with findings in Cuba [19], Burma [13], and Ethiopia [16]. This is the fact that maternal anemia can be a risk factor for the development of childhood anemia [45]. It is explained by the influence of poor maternal iron reserve during pregnancy and breastfeeding on the iron store of their child [46, 47]. Besides, maternal anemia increases the risk of maternal death, preterm birth, and low birth weight [48, 49]. This leads to children being more prone to develop anemia.

The odds of developing anemia in children whose household had three or more under-five children is 1.19 times that of children whose household had one or two under-five children. This result was concordant with previous studies conducted in Brazil [14], Lao People’s Democratic Republic [15], and Ethiopia [16]. The possible reason could be when the number of under-five children increases has an impact on health problems due to competition for foods, getting appropriate health care services this also leads to infections and cross contaminations [50]. This might worsen the quality of care for children, and increase the risk of anemia.

Fever is also one of the determinants of childhood anemia. The odds of developing anemia in children who had a fever within the last 2 weeks preceding the interview is 1.36 times that of children who had no fever within the last 2 weeks. This finding is consistent with studies conducted in Burma [13], Nigeria [11], and Southern Ethiopia [18]. This could be a fever in children that can be caused by different infectious diseases like malaria, septicemia, tuberculosis, and kalazar that cause anemia by infecting and destructing red blood cells or by different mechanisms [51].

Children with moderate or severe stunting were 1.30 and 1.82 times more likely to have anemia than children who were not stunted. This result is in agreement with previous studies conducted in Burma [13], Kenya [20], and Ethiopia [10, 12, 16‐18, 24]. Pathophysiological explanation implies reverse causation between stunting and anemia. In malnourished children, gastrointestinal epithelium disturbance leads to the development of anemia by impairing the absorption of nutrients [51]. on the other hand, anemia during the period of rapid growth leads to irreversible growth retardation [4, 46], coexist with other micronutrient deficiencies, and stunting may increase the development of anemia by a synergism association. The problem of anemia continues to be a public health challenge in these countries, particularly in Africa, with serious consequences for the most vulnerable populations such as children and pregnant women. Therefore, to reduce childhood anemia in different settings policies and programs for anemia control should account for the spatial heterogeneity of anemia.

This study found that childhood anemia was not random in Ethiopia. High-risk areas for childhood anemia were found in West of part Oromia, Harari, Dire Dawa, North West Somali, and entire and North West Afar regions of the country. Anemia is a major public health problem in Ethiopia in under-five children. In general, age of child, wealth index, mother’s current working status, maternal anemic status, number of under-five children in the household, fever in the last 2 weeks, and stunting were variables that had achieved statically significant association for childhood anemia. Therefore, high-risk areas for childhood anemia needs to be given priority and targeted with interventions to reduce the burden of childhood anemia in under-five children.