Magnitude of anemia and associated factors among children aged 6–59 months at Debre Markos referral hospital, Northwest Ethiopia: a hospital-based cross-sectional study

Anemia can be defined as a reduction in the hemoglobin, hematocrit, or red cells number or their capacity to carry oxygen becomes insufficient to meet the physiological needs [1]. Anemia, the most common micro-nutrient deficiency disorder, can affect a person at all stages of life at any time, particularly among children aged 6–59 months and pregnant women, because of their higher iron requirements [2]. According to the World Health Organization (WHO) criteria, anemia is considered in terms of age and sex based on the average hemoglobin levels: Children from 6 months to 6 years old = 11 g / dl, Children aged 7 to 14 years = 12 g / dl, Adult men > 15 years of age = 13 g / dl, pregnant women = 11 g / dl, and non-pregnant women = 12 g / dl [3, 4]. In the population, anemia with a magnitude of 40%, 20–39.9%, 5–19.9% and < 5% is graded as severe, moderate, mild and no public health problem, respectively [5]. It is the world’s second leading cause of death and morbidity for the entire global burden of disease, affecting 1.62 billion people, accounting for 24.8% of the population, of whom 47.4% are children under 5 years of age [6, 7]. Anemia in children aged 6–59 months is a major health issue in nearly all developing world countries with an estimated magnitude of about 43%; with regional disparities of 62.3% in Africa, 53.8% in South East Asia and 21.9% in the Western Pacific region [4]. The magnitude of anemia in children ranges from 5% in North America to 22% in Europe and 30–63% in Asia, 12–58% in Africa [8, 9]. The magnitude of anemia among hospitalized children in various parts of Africa has been studied; 56.3% in Uganda; 83.2% in Southern Tanzania and 44–56% in Ethiopia [10‐12]. In Ethiopia, anemia affects as many as six out of ten children under 5 years of age, but the proportion varies across the country due to food, income and culture disparities, for example, in the Somali region 83%, in Afar 75%, in Dire Dawa 72%, in the Amhara region 42% [13].

Anemia etiology is frequently multifactorial and interrelated in a complex manner, and anemia is correlated with socioeconomic, biological, environmental and nutritional factors such as stunting, low dietary diversity, food scarcity, timely initiation of supplementary feeding, deworming, wasting, educational status, parasite infestations, maternal weight and antenatal care visits [11, 14‐18]. There are also numerous root causes of anemia, including blood loss, decreased RBC production, infectious diseases, maternal anemia during pregnancy, although 50% of its causes are iron deficiencies [19‐22]. If left untreated, childhood anemia has severe consequences, including growth retardation, impaired motor and cognitive development, poor school performance, exposure to comorbid diseases, adult anemia predictors and increased morbidity and mortality [23, 24]. It also has adverse effects on economic development, physical, mental and social health [25].

Even its magnitude has shown decreases across regions; it continues to be a significant public health issue worldwide [26]. Although few local studies have shown magnitude of anemia, data on children are not available particularly in our study area. To minimize the anemia impacts, this section of the population needs to be stressed in order to provide an integrated package of interventions. Thus, evidence-based development of possible strategies and response to the problem will contribute significantly. In addition, it is a paramount importance to generate epidemiological data, identify risk factors and determine the magnitude of the anemia that regional and national public policies are being reformed; it is also important for program planners and policy makers to develop adaptable intervention and control strategies for the local context. Furthermore, these factors are more prevalent and with greater focus on the prevention aspects of anemia, concrete evidence is created in which evidence can encourage policymakers and program managers to implement effective intervention to monitor and mitigate the negative consequences of childhood anemia. However, as far as the authors are aware, there was no previous studies in the study area. This study was therefore aimed to explore the magnitude of anemia and identify associated factors among children aged 6–59 months at Debre Markos referral hospital, Northwest Ethiopia.

The purpose of this study was to determine the magnitude and associated factors of anemia in children aged 6–59 months who visited Debre Markos Referral Hospital in Northwest Ethiopia. Despite the progress of nutritional interventions, anemia remains one of the major health problems in developing countries resulting in serious health outcomes, particularly among children aged 6–59 months and pregnant women [2]. It is a moderate to severe public health issue that has been significantly associated with negative effects on the overall health of children, social and economic development [35, 36]. According to the report by the WHO and the United Nations on progress towards the Millennium Development Goals (MDGs), although significant progress has been made towards achieving MDG4 to reduce the number of under-five mortality rates worldwide, the rate of decline remains insufficient to meet the stated goal in developing countries,including Ethiopia [37, 38]. This raises concerns about the future and effectiveness of interventions that reduce anemia, because the magnitude of anemia is a powerful indicator for assessing the impact and effectiveness of interventions [2].

In this study, the overall magnitude of anemia among children aged 6–59 months was found to be 11.9% (95% CI: 8.5–16.2%). It is a public health problem that should be addressed using appropriate preventive strategies as anemia contributes to childhood morbidity and mortality [39]. According to the WHO, if the magnitude is greater than 5%, anemia is considered a public health problem, however, the magnitude of the problem is defined as mild, moderate and severe when the magnitude is 5–19.9%, 20–39, 9% and ≥ 40% respectively [40]. Consequently, there is a mild public health problem in the study area that should be addressed using appropriate preventive methods as anemia leads to child morbidity and mortality [39]. This finding is comparatively close to other local studies carried out at Mekelle (11%) [30, 41], but higher than the study done at Addis Ababa (5.83%) [42]. Also this study was comparatively close to other local studies carried out in Lithuania (10.1%) [43], Serbia (10.8%) [44], Mexico (12%) [45], and Brazil (9.3%) [41]. This could be explained by the high magnitude of chronic early childhood undernutrition in study area based on the 2016 DHS reports [46]. Furthermore, the possible explanations for variations in the magnitude of anemia between the present study and the above studies may be related to the seasonal and geographical variation of risk factors and disparities in the socioeconomic status of the populations.

The current study findings were lower than the studies done at Kersa (27.1%) [47], Filtu (23.66%) [48], Libo-Kemkem and Fogera districts (30.9%) [49], Kenya (28.8–35.3%) [50], West Africa (23.8%) [51], China 34% [52]. The potential reason for this study’s low magnitude of anemia may be attributed to variations in the research timeframe and the impact of the biannual deworming system which is a major public health initiative recently initiated by government to minimize intestinal infection by offering antihelmintics.

In this research, household income has also been associated with anemia among children. Children living in households with lower monthly incomes were more likely to suffer from anemia than those with higher incomes. This is supported by similar findings in a study carried out in Brazil and northern Ethiopia [53, 54]. This is because children from poor families are less likely to get iron-rich foods such as animal products and less likely to be able to afford health care during illness due to poverty. It is, therefore, necessary to engage women in income-generating activities so that their children have better health care and supplementary food.

In addition, children eating low dietary diversity were found to be more likely to be anemic than their counterparts according to this report. Children who were given less than four food categories per day were 1.71 times more likely than their peers to develop anemia, and children who were food insecure were 2.87 times more likely than their counterparts to develop anemia [55, 56]. This might be attributed to the absence of nutritious meals with high protein quality, enough micronutrient content and bioavailability, macro-minerals, iron, and essential fatty acids in children from food insecure homes, all of which raise the risk of childhood anemia [57]. This might be attributed to the seasonal shortage of citric fruits, which aid iron absorption, as well as social and economic constraints to obtaining animal-based meals like meat. As a result, it is essential to educate the community about the need of giving iron-rich foods to all children.

Similarly, beginning of the complimentary feeding before 6 months, the chances of anemia were three times higher than those of children who started supplemental feeding after 6 months. This study is consistent with a study conducted in northern Ethiopia, Lebanon, Brazil and China [14, 58‐60], early solid or liquid meal introduction is linked to childhood anemia. Infections and mal-absorption are more likely in newborns who are exposed before the age of 6 months. This might be due to a lack of awareness about the necessity of exclusive breast feeding for infants; as a result, they introduce cow milk at least 6 months earlier. Consequently, the early initiation of supplementary feeding like cow’s milk before the age of 6 months does not substitute iron-rich diets, which may lead to iron deficiency anemia [61].

Once more, the magnitude of anemia was substantially high in children with intestinal parasite infection, which is confirmed by research from Tanzania and Nigeria [62, 63]. This may be because the majority of intestinal parasites, particularly hookworm and hemoparasites like malaria, contribute to blood loss and/or red cell destruction and thus contribute to anemia. Deworming is thus an essential intervention in children because intestinal parasites, particularly hookworm infection, lead to blood loss in the intestines, which in turn contributes to anemia. This study has some limitations: The first limitation of this study is that subclinical infections other than intestinal parasites and malaria have not been evaluated, thus limiting the study’s generalizability for possible risk factors. This research is quantitative; if qualitative approach was also used it would be stronger to examine the extra determinants of anemia. This research was often revealing of maternal bias as they recalled their previous past. Also, anthropometry-related measurement errors may have been introduced. Using small samples, it’s difficult to generalize to society at large. Therefore, larger studies need to demonstrate true associations in the population. Despite these limitations, it is the first hospital-based cross-sectional study that has attempted to show the magnitude and associated factors of childhood anemia severity in the study area, which contributes greatly to improving the health of children aged 6–59 months.

Overall, anemia is considered a public health problem among children aged 6–59 months attending at Debre Markos referral hospital, based on the cut-off point of the World Health Organization. Poor dietary diversity, complementary feeding initiation time, household food insecurity, intestinal parasite infection and family income were significantly associated with childhood anemia. Thus, this needs for proven interventions in public health such as food diversification, anti-helmintic drug provision and household food security. In addition, educating women about nutrition and diet diversification, as well as involving them in alternative sources of income-generating activity, can be vital in the study area. On top of that, more extensive longitudinal studies using a larger sample size, including analysis of all indices of red blood cells, red cell morphology, serum micronutrient levels and subclinical infections, should be conducted to establish a causal-effect relationship between anemia and its contributing factors.