# Prevalence Rate and Associated Risk Factors of Anaemia among under Five Years Children in Ethiopia

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## Abstract

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**Background:**Anaemia is a condition characterised by a decrease in the concentration of haemoglobin (Hb) in the blood. Anaemia suffers under five years children about 47.4% and 67.6% worldwide and developing countries including Ethiopia, respectively. The aim of this study was to assess the prevalence rate and the associated socio-economic, geographic and demographic factors of anaemia status of under five years children in Ethiopia.

**Methods:**The data for this study were obtained from the 2011 Ethiopia National Malaria Indicator Survey (EMIS 2011). A sample of 4356 under five years age children was obtained from three regional states of Ethiopia. Based on haemoglobin level, child anaemia status was ordered and takes an ordinal value as no anaemia, mild anaemia, moderate anaemia and severe anaemia, respectively. Ordinal logistic regression model, specifically the proportional odds model was used by considering with and without survey design features.

**Results:**Of the 4356 complete cases, 2190 (50.28%) were male and 1966 (49.72%) were female children under five years old. The children overall mean (SD) age was 2.68 (1.21) years. It was observed that both the mean ages and their variabilities in the regions are approximately equal to the overall mean and variability. It was also observed that in Amhara, Oromiya and SNNP regions 72.28%, 67.99% and 73.63% of the children, respectively had no anaemia; 15.93%, 13.47% and 13.56% of the children, respectively had mild anaemia; 10.99%, 15.61% and 11.33% of the children, respectively had moderate anaemia; and only 0.81%, 2.93% and 1.49% had severe anaemia, respectively. The prevalence of severe child anaemia status was higher in Oromiya region compared to Amhara and SNNP regions, respectively. Our result indicates that age, use of mosquito net, malaria RDT outcome, type of toilet facility, household wealth index, region and median altitude were significantly related to child anaemia status. However, it was observed that some covariates were model dependent, for example household wealth index and type of toilet facility were not significant when considering survey features.

**Conclusions:**Anaemia burden remains high particularly in developing countries. Controlling the burden of anaemia necessitates the formulation of integrated interventions which prioritise the highest risk groups including children under five years. The statistical model used in this paper identified individual, household and cluster level risk factors of child anaemia. The identified risk factors for example not having improved toilet facility in the dwelling where a child lived as well as poorest household wealth index suggest the policymakers should target to focus more on children from poor community. Further, the strong association between malaria infection and anaemia suggests that malaria preventative methods such as vector control methods namely, long-lasting insecticidal nets (LLINs) and indoor residual spraying of households with insecticides and including case diagnostic testing and treatment may be the most effective ways to reduce infections associated with anaemia. Such collective assessment approach may lead to more effective public health strategies and could have important policy implications for health promotion and for the reduction of health disparities.

## 1. Introduction

## 2. Materials and Methods

#### 2.1. Study Data

#### 2.2. Response and Explanatory Variables

#### 2.3. Independent Variables

#### 2.4. Statistical Model

#### 2.5. Cumulative Logit Model

**β**so that a positive value for

**β**then implies a positive relationship. Let us extend a cumulative logit model for an ordinal response in Equations (2) and (3) by considering the sample survey design features. Assume that $y$ with $K$ category is defined for the probability of having less than or equal to $k$, relative to the probability of having $y$ greater than $k,k=1,\dots ,K$. Using this definition for survey data, the cumulative logit regression model is given as:

## 3. Results

#### 3.1. Descriptive Summary

#### 3.2. Cumulative Logit Model for Anaemia Status of under Five Years Age Children

## 4. Discussion

#### Strengths and Limitations of the Study

## 5. Conclusions

## Author Contributions

## Funding

## Institutional Review Board Statement

## Informed Consent Statement

## Data Availability Statement

## Acknowledgments

## Conflicts of Interest

## References

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Region | |||||
---|---|---|---|---|---|

Variables | Amhara | Oromiya | SNNP | Total | |

Age (years) | mean (SD) | 2.617 (1.216) | 2.671 (1.222) | 2.742 (1.181) | 2.677 (1.211) |

Household size | mean (SD) | 5.526 (1.902) | 5.832 (1.987) | 5.905 (2.090) | 5.781 (1.999) |

Median alt. | mean (SD) | 2033.12 (408.83) | 1904.56 (377.62) | 1931.27 (366.9) | 1940.44 (385.74) |

Child malaria RDT | Positive, N (%) | 27 (2.72) | 24 (1.05) | 52 (4.83) | 103 (2.36) |

Negative, N (%) | 965 (97.28) | 2263 (98.95) | 1025 (95.17) | 4253 (97.64) | |

Gender | Male, N (%) | 495 (49.50) | 1155 (50.50) | 540 (50.14) | 2190 (50.28) |

Female, N (%) | 497 (50.10) | 1132 (49.50) | 337 (49.86) | 1966 (49.72) | |

Main source of drinking water | Unprotected, N (%) | 505 (50.91) | 1438 (62.88) | 586 (54.41) | 2529 (58.06) |

Protected, N (%) | 246 (24.80) | 346 (15.13) | 214 (19.87) | 806 (18.50) | |

Piped water, N (%) | 241 (24.29) | 503 (21.99) | 277 (25.72) | 1021 (23.44) | |

Type of toilet facility | Others, N (%) | 379 (38.21) | 1036 (45.30) | 130 (12.07) | 1545 (35.47) |

Pit latrine, N (%) | 360 (36.29) | 1055 (46.13) | 572 (53.11) | 1987 (45.62) | |

Flush and hanging toilets, N (%) | 253 (25.50) | 196 (8.57) | 375 (34.82) | 824 (18.92) | |

Household used mosquito nets | No, N (%) | 241 (24.29) | 1462 (63.93) | 627 (58.22) | 2330 (53.49) |

Yes, N (%) | 751 (75.71) | 825 (36.07) | 450 (41.78) | 2026 (46.51) | |

Household wealth status | Poorest, N (%) | 166 (16.73) | 675 (29.51) | 133 (12.35) | 974 (22.36) |

Second, N (%) | 227 (22.88) | 491 (22.47) | 254 (23.58) | 972 (22.31) | |

Middle, N (%) | 173 (17.44) | 357 (15.61) | 274 (25.44) | 804 (18.46) | |

Fourth, N (%) | 231 (23.29) | 376 (16.44) | 196 (18.20) | 803 (18.43) | |

Richest, N (%) | 195 (19.66) | 388 (16.97) | 220 (20.43) | 803 (18.43) | |

Child anaemia status | No anaemia, N (%) | 717 (72.28) | 1555 (67.99) | 793 (73.63) | 3065 (70.36) |

Mild, N (%) | 158 (15.93) | 308 (13.47) | 146 (13.56) | 612 (14.05) | |

Moderate, N (%) | 109 (10.99) | 357 (15.61) | 122 (11.33) | 588 (13.50) | |

Severe, N (%) | 8 (0.81) | 67 (2.93) | 16 (1.49) | 91 (2.09) |

**Table 2.**The Brant test of parallel regression assumption results for fitted initial main effects cumulative logit model for anaemia data.

Predictor | Category | Df | ${\mathit{\chi}}^{2}$ | p-Value |
---|---|---|---|---|

Age (years) | 2 | 1.69 | 0.4300 | |

Malaria RDT outcome | Positive | 2 | 10.24 | 0.0060 |

Mosquito net use | Yes | 2 | 1.60 | 0.4490 |

Household size | 2 | 5.77 | 0.0560 | |

Type of toilet facility | Pit latrine | 2 | 1.33 | 0.5160 |

Flush & hanging toilets | 2 | 4.31 | 0.1160 | |

Household wealth status | Second | 2 | 1.23 | 0.5400 |

Middle | 2 | 1.89 | 0.3890 | |

Fourth | 2 | 1.50 | 0.4720 | |

Richest | 2 | 2.58 | 0.2750 | |

Region | Amhara | 2 | 21.84 | <0.0001 |

SNNP | 2 | 3.68 | 0.1580 | |

Median altitude | 2 | 3.90 | 0.1430 | |

All predictors model | 26 | 64.24 | <0.0001 |

**Table 3.**Results of final multivariate cumulative logit model for the relationship of anaemia prevalence to predictor variables without considering survey features.

Predictor | Category | $\widehat{\mathit{\beta}}$ | $\mathbf{se}\mathbf{\left(}\widehat{\mathit{\beta}}\mathbf{\right)}$ | t-Value | OR | 95% CI for OR | p-Value |
---|---|---|---|---|---|---|---|

Intercept | 1–2 | −2.4136 | 1.3922 | −173.367 | <0.0001 | ||

2–3 | −1.5254 | 0.0365 | −41.759 | <0.0001 | |||

3–4 | 0.7218 | 1.0605 | 6.8060 | <0.0001 | |||

Age (years) | −0.3255 | 0.0271 | −12.0330 | 0.7222 | (0.6848,0.7615) | <0.0001 | |

Mosquito net use | Yes | −0.2253 | 0.0706 | −3.1920 | 0.7983 | (0.6952,0.9168) | 0.0014 |

Malaria RDT outcome | Positive | 1.4967 | 0.0069 | 217.4010 | 4.4668 | (4.4069,4.5274) | <0.0001 |

Household size | −0.0292 | 0.0157 | −1.8660 | 0.9712 | (0.9418,1.0015) | 0.0620 | |

Type of toilet facility | Pit latrine Flush& hanging toilet | −0.1613 −0.1946 | 0.0692 0.0923 | −2.3300 −2.1090 | 0.8231 0.8510 | (0.6869,0.9864) (0.7430,0.9748) | 0.0198 0.0349 |

Household wealth status | Second Middle | −0.0776 −0.0891 | 0.0684 0.0733 | −1.1350 −1.2150 | 0.9253 0.9148 | (0.8091,1.0581) (0.7923,1.0562) | 0.2565 0.2243 |

Fourth Richest | −0.4051 −0.2937 | 0.0761 0.0701 | −5.3260 −4.1920 | 0.6669 0.7455 | (0.5745,0.7741) (0.6498,0.8553) | <0.0001 <0.0001 | |

Region | Amhara SNNPR | −0.1192 −0.2335 | 0.0929 0.0880 | −1.2820 −2.6520 | 0.8876 0.7918 | (0.7397,1.0651) (0.6663,0.9409) | 0.1997 0.0079 |

Median altitude | −0.0009 | 0.0001 | −15.8580 | 0.9990 | (0.9989,0.9992) | <0.0001 |

**Table 4.**Results for the final cumulative logit model for the relationship of anaemia prevalence to predictor variables considering survey features.

Predictor | Category | $\widehat{\mathit{\beta}}$ | $\mathbf{se}\left(\widehat{\mathit{\beta}}\right)$ | t-Value | $\mathit{O}{\mathit{R}}_{\mathit{y}\mathbf{\le}\mathit{k}\mathbf{:}\mathit{j}}$ | $95\%\mathbf{CI}\mathit{O}{\mathit{R}}_{\mathit{y}\le \mathit{k}:\mathit{j}}$ | p-Value |
---|---|---|---|---|---|---|---|

Intercept | 1–2 | −2.8125 | 0.3391 | −8.2950 | <0.0001 | ||

2–3 | −1.9268 | 0.3559 | −5.4140 | <0.0001 | |||

3–4 | 0.3469 | 0.4024 | 0.8620 | 0.3887 | |||

Age (years) | −0.3829 | 0.0420 | −9.1160 | 0.6820 | (0.6280,0.7410) | <0.0001 | |

Gender Age $\times $ Gender Mosquito net use | Female Yes | −0.3308 0.0963 −0.2684 | 0.1469 0.0512 0.1047 | −2.2510 1.8820 −2.5640 | 0.7180 1.1010 0.7650 | (0.5380,0.9590) (0.9960,1.2180) (0.6220,0.9390) | 0.0244 0.0598 0.0103 |

Malaria RDT outcome | Positive | 1.5075 | 0.2468 | 6.1090 | 4.5150 | (2.7790,7.3380) | <0.0001 |

Household size | −0.0293 | 0.0211 | −1.3890 | 0.9710 | (0.9320,1.0120) | 0.1647 | |

Type of toilet facility | Pit latrine Flush& hanging toilet | −0.2165 −0.2972 | 0.1134 0.1408 | −1.9080 −2.1110 | 0.8050 0.7430 | (0.6440,1.0070) (0.5630,0.9800) | 0.0564 0.0347 |

Household wealth status | Second Middle | −0.0359 −0.0224 | 0.1295 0.1254 | −0.2770 −0.1790 | 0.9650 0.9780 | (0.7480,1.2450) (0.7640,1.2510) | 0.7818 0.8582 |

Fourth Richest | −0.3189 −0.1994 | 0.1499 0.1400 | −2.1280 −1.4240 | 0.7270 0.8190 | (0.5410,0.9760) (0.6220,1.0790) | 0.0334 0.1544 | |

Region | Amhara SNNPR | −0.1558 −0.2873 | 0.1258 0.1217 | −1.2380 −2.3600 | 0.8560 0.7500 | (0.6680,1.0960) (0.5900,0.9530) | 0.2157 0.0183 |

Median altitude | −0.0010 | 0.0002 | −5.7200 | 0.9980 | (0.9986,0.9993) | <0.0001 |

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**MDPI and ACS Style**

Zewude, B.T.; Debusho, L.K.
Prevalence Rate and Associated Risk Factors of Anaemia among under Five Years Children in Ethiopia. *Nutrients* **2022**, *14*, 2693.
https://doi.org/10.3390/nu14132693

**AMA Style**

Zewude BT, Debusho LK.
Prevalence Rate and Associated Risk Factors of Anaemia among under Five Years Children in Ethiopia. *Nutrients*. 2022; 14(13):2693.
https://doi.org/10.3390/nu14132693

**Chicago/Turabian Style**

Zewude, Bereket Tessema, and Legesse Kassa Debusho.
2022. "Prevalence Rate and Associated Risk Factors of Anaemia among under Five Years Children in Ethiopia" *Nutrients* 14, no. 13: 2693.
https://doi.org/10.3390/nu14132693