Anemia adversely affects children’s mental, physical and social development, particularly in Africa. In the early stages of life, it leads to severe negative consequences on the cognitive, growth and development of children.
This study aimed to assess anemia and associated risk factors among children under-five years old in the West Guji Zone, southern Ethiopia, from October to November 2020.
A hospital-based quantitative cross-sectional study was conducted at Bule Hora General Hospital, Southern Ethiopia. A convenience sampling technique was used to include 375 under-five children enrolled in the study. The pretested structure questionnaire was used to collect socioeconomic and demographic characteristics of study individuals after taking appropriate written informed consent. Then, a venous blood sample was collected from each child and analyzed for hemoglobin determination using a Midray BC 3000 Plus machine. Binary logistic regression models were used to identify associated factors of anemia. A p-value ≤ 0.05 was considered statistically significant.
The overall prevalence of anemia among under-five children was 13.2% (50) [95% CI = 5.2–21.2%]. Among anemic children under-five years of age, 12% (6) had mild anemia, 32% (16) had moderate anemia and 56% (28) had severe anemia. In this study, anemia was significantly associated with a history of intestinal protozoan infection [AOR = 2.55, 95% CI = 1.28–10.42], malaria infection [AOR = 5.01, 95% CI = 0.18–11.44] and soil-transmitted helminths infection [AOR = 6.39, 95% CI = 1.75–29.08].
Citation: Aliyo A, Jibril A (2022) Assessment of anemia and associated risk factors among children under-five years old in the West Guji Zone, southern Ethiopia: Hospital-based cross-sectional study. PLoS ONE 17(7): e0270853. https://doi.org/10.1371/journal.pone.0270853
Editor: Hoh Boon-Peng, UCSI University, MALAYSIA
Received: March 19, 2022; Accepted: June 20, 2022; Published: July 5, 2022
Copyright: © 2022 Aliyo, Jibril. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the manuscript and it’s Supporting information files.
Funding: The authors not received specific funding for this work.
Competing interests: No authors have competing interest.
Abbreviations: AOR, adjusted odds ratio; CBC, complete blood count; CI, confidence interval; COR, crude odds ratio; EDHS, Ethiopian Demographic Health Survey; EDTA, ethylene diamine tetraacetic acid; ETB, Ethiopian Birr; g/dL, gram per deciliter; HGB, hemoglobin; SOPS, standard operation procedures; SPSS, Statistical Package for Social Science; WHO, World Health Organization
Anemia is a condition that causes a decline in erythrocyte concentration in circulation or hemoglobin in the blood and a concomitant impairment of oxygen transportation . The World Health Organization (WHO) defined anemia as hemoglobin (Hgb)<12 g/dL in adult nonpregnant women, Hgb <11 g/dL in pregnant females, Hgb <13 g/dL in adult men, Hgb <11 g/dl in children aged 6–59 months, Hgb <11.5 g/dl in children aged 5–11 years, Hgb<12 g/dl for children aged 12–14 years and Hgb <13 g/dL in newborns [2, 3].
Globally, 1.3 billion individuals suffer from anemia, making it one of the most important public health issues on the international agenda . Globally, on average, approximately 9.6 million children are severely anemic . It affects people in both developing and developed countries . By 2017, 293.1 million (47.4%) children under-five years of age were anemic worldwide, and 67.6% of these children lived in Africa . In Ethiopia, 57% of children aged 6–59 months are anemic according to the Ethiopian Demographic and Health Survey (EDHS) report .
Iron deficiency is the major cause of anemia in developing countries and results in insufficient red blood cell production. In some individuals, infections such as peptic ulcers may cause blood loss and anemia. In developing countries, iron deficiency impacts all vulnerable groups. Additionally, geographically specific infections such as malaria and helminthic contribute to excessive red blood cell destruction and cause excessive red blood cell loss. Other infectious diseases may also be at play .
Anemia impairs mental, physical, and social development and causes negative behavioral and cognitive effects, resulting in poor school performance and work capacity in later years . In early childhood, poor feeding habits, especially during the weaning period, exacerbate the problem. Anemia frequently develops as breast milk is replaced by foods that are poor in iron and other nutrients, including vitamin B12 and folic acid. Low oxygenation of brain tissues, a consequence of anemia, may lead to impaired cognitive function, growth and psychomotor development, especially in children. Infants, children under 5 years old and pregnant women have greater susceptibility to anemia because of their increased iron requirements due to rapid body growth and expansion of red blood cells . Moreover, anemia leads to immune system compromise, resulting in a decreased ability to fight infections and increased mortality in African children, where resources to determine the basic etiology remain poor [10, 11].
There are national and regional data on the prevalence of anemia and its risk factors among children under-five years of age in different parts of Ethiopia such as Gonder town (66.8%) , Wagmra zone, Ethiopia (66.6%)  and Shanan Gibe hospital 48.9% . To our knowledge, no previous study has been undertaken in the study area of Bule Hora. Therefore, this study aimed to assess the assess of anemia and its associated factors among children from 6–59 months of age in Bule Hora Hospital, southern Ethiopia.
Study area, period and design
The hospital-based quantitative cross-sectional study was conducted from October 26 to November 20, 2020, at Bule Hora General Hospital, Guji Zone: Oromia Region, southern Ethiopia. The hospital found in Bule Hora town 467 km from Addis Ababa capital city of Ethiopia. According to the Bule hora town municipality administrative, the current total population of Bule Hora town is 67,297. Geographically, the town is located between latitude 5°35’N and longitude 38°15’E and an altitude of 1716 meters above sea level. Regarding Bule Hora General Hospital, the hospital provides different services, including pediatrics, emergency, delivery, outpatient, patient, laboratory, pharmacy, medical and surgical services. Currently, the hospital has given the service for 5 million people in the area.
Study population and selection
All children aged between 6 months and 59 months who attended Bule Hora General Hospital during the data collection period and voluntarily participated were included in the study. Children who were outside the range, had active bleeding and underwent surgery before one month were excluded from the study.
Sample size and sampling technique
The sample size was determined using a single population proportion formula considering the prevalence of anemia from a previous study 66.8% . where d = Margin of error between the sample and the population (d = 5%), n = Sample size, Z α/2 = 95% confident interval (1.96), P = 66.8% Prevalence. Then, a 15% nonresponse rate was added considering the response rate of a previous study; thus, the final sample size was 392. A convenience sampling technique was used for all under-five children who fulfilled the inclusion criteria during the study period.
Data collection instruments and procedure
The data were collected using a structured questionnaire adapted from previous literature . The questionnaire was prepared in English in written form, orally translated into the Oromia and Amharic languages, and then returned to English to ensure its consistency. Five percent of the total sample respondents were interviewed during the pretest in another health institution. After this, the questionnaire was edited accordingly, and then the final version of the questionnaire was adapted to interview children’s parents/caregivers. The data collectors explained the objective of the study to the children’s parents/caregivers. Highlighting on the benefit of being tested for Hgb and what would be done if the child is anemic. The data collectors were given details to the patient/caregiver that no name of participant written on the questionnaire and confidentiality were protected, and verbal consent was obtained. Data were collected through pretested and structured questionnaires by face-to-face interviews with the children’s patients/caregivers. The questionnaire was used to collect sociodemographic data and associated factors [S1 File].
Blood sample collection
By strictly following the standard operating procedure (SOPs), a 3 ml venous blood sample was collected. Experienced laboratory technicians collected the samples in tubes containing ethylenediaminetetraacetic acid (EDTA). The complete blood count (CBC) reports from the hematology analyzer (Midray BC 3000Plus manufactured by Jeevika, Chinese Company) in the hospitals, including hemoglobin (Hgb) analysis, were performed as per the manufacturer’s instructions.
Anemia—Hemoglobin (Hgb) <11 g/dL in children whose age is 6–59 months .
Mild anemia: The Hgb value is 10–10.9 g/dL .
Moderate anemia: Hgb value 7–9.9 g/dL for children 6–59 months .
Severe anemia: Hgb value <7 g/dL for children aged 6–59 months .
Low income: family monthly income less than 750 birr (ETB) .
Moderate income: family monthly income from 750–1500 ETB 
High income: family monthly income greater than 1500 ETB 
Data quality control
To assure data quality, 5% of the estimated sample was pretested at the Bule Hora health center before the data collection to determine whether the questionnaires were simple and understandable. After every data collection, the completeness and consistency of the questionnaire were checked. Data collector training and daily supervision were performed before and during the data collection period.
During blood sample analysis, the standard operating procedures (SOPs) and manufacturers’ instructions were strictly followed for all laboratory activities. The sample was checked for hemolysis, clotting and enough volume before running the test. When the machine passed the control, the samples were analyzed. Finally, the laboratory test result was recorded, and the specimens were managed properly.
Data processing and analysis
Data were entered, sorted and categorized. Data cleaning was performed to check for completeness, accuracy, and missed values, and any errors identified were corrected. Then, the data were analyzed using SPSS version 22. Descriptive statistics (mean, frequency) were carried out to describe the sociodemographic status of the participants presented by table, pie chart and graph. A binary logistic regression model was fitted to identify factors associated with anemia. Variables with a p-value ≤ 0.25 in the bivariate analysis were considered candidates for the multivariate analysis. Multivariate logistic regression was performed to control for possible confounding and identify the true effect of the selected predictor variables. The model fitness was checked with the Hosmer–Lemeshow test. The extant association between the different variables related to anemia was measured using AOR at 95% CI. A p-value ≤ 0.05 was considered statistically significant.
Ethics approval and consent to participate
The study was conducted after ethical approval from the Bule Hora University Research and Ethical Review Committee. The official letter was written to Bule Hora General Hospital. Informed, voluntary, written signed consent was obtained from the study participant, parent/caregiver and institution. The children’s parents/caregivers were informed about the purpose of the study, and written informed consent was obtained before the questionnaire was administered. Then, blood samples were collected from the study participants. Participation in the study was voluntary. The participants were informed of their right to quite/refuse their participation at any stage of the study if they did not want to participate. To ensure confidentiality of participant information, codes were used, and any identifier of participants was not written on the questionnaire on the test tube. Any abnormal test results of participants were communicated to the concerned body.
Sociodemographic and economic status
Of the 392 children under the age of five, 375 participated in this study, with a 95.7% response rate. The participants’ ages ranged from 6 to 59 months, with a mean (SD) age of 3.3 (± 2.20) months. Among 375 children under the age of five, 54.4% (204) were female, and the majority 39.7% (149) of children’s mothers/caregivers were farmers. More than half, 54.4% (204), were from rural areas. Approximately 29.4% (110) of child caregivers were unable to read and write. Out of 375 children under the age of five, approximately 55.9% (210) were protestants. Majority of children 67.7% (254) were living in a household less than 3 family members, and the majority of households 36.8% (138) had incomes less than 750 Ethiopian birr (Table 1).
Regarding feeding practices, among 375 under-five children, 69.1% (259) reported dietary diversity practices, 79.4% (298) reported the introduction of complementary food after 6 months, 61.8% (232) reported that mothers/caregivers did not have nutritional knowledge, 23.5% (88) reported food insecurity within four weeks, 79.5% (298) reported eating three times and above per day, and the majority of 80.8% (303) reported breastfeeding practices at 6–12 months (Table 2).
Health care and disease characteristics
Out of 375 under-five children enrolled in the study, 17.6% (66) had a history of intestinal protozoa followed by soil-transmitted helminthic infection 16.2% (61) and malaria infection 14.7% (55) (Table 3).
Prevalence of anemia
Based on the hemoglobin cutoff value, less than 11 g/dL was categorized as anemic, and Hgb values of 10–10.9 g/dl, 7–9.9 g/dl, and less than 7 g/dL were determined to be mild, moderate and severe, respectively. The overall prevalence of anemia was 13.2% (50). Among anemic children under-five years of age, 12% (6) were mild, 32% (16) were moderate and 56% (28) were severe (Fig 1).
Factor associated with prevalence of anemia
In bivariate analysis, variables such as child age group, child sex, family size, income of caregiver, dietary diversity practice, breastfeeding practice, nutritional knowledge, meal frequency, recent intestinal protozoan infection, recent helminthic infection, and recent malaria infection had a p-value of <0.25 and were considered candidates for multivariate analysis. In multivariate analysis, the chance of having anemia was approximately 3 times higher among children under the age of five who had a history of intestinal protozoan infection [AOR = 2.55, 95% CI = 1.28–10.42] than among their counterparts. Additionally, children who had a history of soil-transmitted helminths infections were 6 times more likely to have anemia [AOR = 6.39, 95% CI = 1.75–29.08] than their counterparts. Similarly, the children who had a history of malaria infection were nearly 5 times more likely [AOR = 5.01, 95% CI = 0.18–11.44] to have anemic than those who did not have recent malaria infection (Table 4).
In this study, the overall prevalence of anemia among under-five children attending Bule Hora General Hospital was 13.2% (50) (95% CI = 5.2–21.2%). According to the WHO definition, anemia can be defined as a mild, moderate and severe public health problem when the prevalence is 5–19.9%, 20–39.9% and greater than 40%, respectively. Therefore, the prevalence of anemia in this study is considered a mild public health concern .
This is lower than the previous study conducted in Western China (51.2%) , Eastern Sudan (86%) , Cape Verde West Africa (51.8%), , Nigeria (70.5%) , Tanzania (77.2%) , Gonder town Ethiopia (66.8%) , Gonder, Ethiopia (58.6%), , Wagmra zone, Ethiopia (66.6%) , South Wollo, Northeast Ethiopia (41.1%)  and Shanan Gibe hospital 48.9% . The difference in prevalence might be due to variations in the number of participants, sample analysis equipment, hemoglobin cutoff points, and cultural, geographical and behavioral characteristics of the community. In contrast, this finding was higher than reports from Brazil (10.2%)  and Ebonyi, Nigeria (9.7%) . The possible reason might be due to the age difference of the study participants, and the children who were recently treated or who took iron supplements were not excluded from the study.
Multivariate analysis showed that having a previous intestinal protozoan infection was significantly associated with the prevalence of anemia among under-five children. This finding is in line with a study conducted in Pawe town, Benishangul Gumuz, region , Gonder, Ethiopia  and Shanan Gibe hospital . Similarly, children who had previous malaria infection were significantly associated with anemia among under-five children. This finding agrees with a study conducted in Ghana . In addition, anemia was 6 times more likely among children with previous soil-transmitted helminthic infections than among their counterparts. This finding is consistent with a study conducted in Gonder, Ethiopia . Possible justification could be due to intestinal wall bleeding, erythrocyte lysis, reduction of iron absorption and damaged organs involved in hematopoiesis.
Out of 375 children under-five years of age involved in the study, nearly half (48.5%, 182) were infected with at least one of the following species of parasites: Plasmodium spp., Entamoeba histolytical, Giardia lambia, Ascaris lumbricoides, Strongyloides stercoralis, Trichuris trichuria, Enterobius vermicularis and Hookworm. Of those children infected with recent malaria, 22 (40%), soil-transmitted helminths, 22 (36.1%) and intestinal protozoa 11 (16.7%) were found to be anemic. The parasite species may deplete red blood cells through loss of blood at the time of diarrhea and gastrointestinal bleeding.
Strength and limitations of the study
The strength of this study, it could elaborate the important part of health accessibility issues, especially in child health, and identified associated factors of anemia. Regarding the limitations of the study, as a convenience sampling technique was applied, the result cannot be extrapolated to a larger community. Respond bias may have been introduced during the interviews. Additionally, this study does not differentiate the types of anemia such as hemolytic, sickle cell and thalassemia.
The present study demonstrated a 13.2% overall prevalence of anemia among children under the age of 5 who attended Bule Hora General Hospital. This finding was low compared with previous studies conducted in different parts of Ethiopia. The factors significantly associated with anemia were recent intestinal protozoan infections, soil-transmitted helminths, and malaria infection. Despite the limitations, where it highlights the necessity for early comprehensive care in diagnosis and treatment with attention of prevention program (deworming) for reduction of anemia among under-five children.
First, we would like to thank Bule Hora University, College of Medicine and Health Sciences, Department of Nursing for giving us the chance to undertake this research. Next, we would like to extend our thanks to Bule Hora University nursing department staffs who guided and provided us with different information for enriching our research development and Bule Hora General Hospital staff for their unlimited cooperation in giving us information to develop the research. Finally, we would like to extend gratitude to our beloved family and friends for valuable patience during research development.
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