Anemia and Its Associated Factors in Children Under Five in Public Health Facilities in Wolkite Town,Central Ethiopia,2024

Abstract

Background

Anemia is characterized by reduced hemoglobin, hematocrit, or red blood cell counts below normal levels for age, sex, and race. In 2019, globally, the prevalence of anemia in children aged 6 to 59 months was 39.8%, with the highest rate in the African Region at 60.2%. In Ethiopia, this rate reached 52.1%. This study aimed to assess the prevalence and associated factors of anemia in children under five in Ethiopia.

Method

A quantitative cross-sectional study was conducted at Wolkite Health Center and Hospital in March 2024. Participants were selected through systematic sampling, and data were collected via structured interviews and venous blood samples. Data analysis was performed using SPSS version 25, focusing on descriptive statistics and multivariable analysis to identify significant associations, with a significance level set at P ≤ .05.

Results

The overall prevalence of anemia among 164 participants was 39.0%, with 22.6% classified as mild, 13.8% as moderate, and 2.6% as severe. Anemia was significantly associated with inadequate dietary diversity (adjusted odds ratio [AOR] = 2.218, 95% confidence interval [CI] = 1.253–3.925) and underweight status (AOR = 2.835, 95% CI = 1.151–6.982).

Conclusion

Childhood anemia is a moderate public health issue in the study area, with significant links to recent malaria infections, inadequate dietary diversity, and underweight status. Addressing these factors is essential for improving child health outcomes.

Keywords

anemia hemoglobin hemoglobin level prevalence under-five children

Introduction

Anemia is defined as a reduction in hemoglobin, hematocrit, or red blood cells below the normal range for age, sex, and race. According to the World Health Organization, children under five are anemic if their hemoglobin level is below 110 g/L, with severity categories for mild, moderate, and severe anemia. Globally, anemia remains a major public health issue, contributing to high morbidity and mortality in children. In 2019, 39.8% of children aged 6 to 59 months around 269 million were anemic (WHO, 2021), with the highest prevalence in Africa (60.2%) and in Ethiopia at 52.1% (Hailu et al., 2024). Although there has been a gradual global decline in childhood anemia since 2000, rates have remained stagnant since 2010. A hospital-based study in the Harari region (Eastern Ethiopia) found an anemia prevalence of 33% among under-five children, with 58.7% mild, 34.9%, moderate, and 6.4% severe cases (Gemechu et al., 2024).

Iron deficiency is estimated to cause about half of all anemia cases, particularly in low-income settings with poor dietary intake (Gedfie et al., 2022; WHO, 2021). Recent evidences show that in addition to iron deficiency, infections, genetic conditions, and micronutrient deficiencies (e.g., B12, folate, and vitamin A) are major contributors to anemia across populations (Armah-Ansah et al., 2023; WHO, 2025). The etiology of anemia is multifactorial, involving biological, nutritional, socioeconomic, and environmental factors (Aliyo & Jibril, 2022; Gebreweld et al., 2019; Kebede et al., 2021; Sahiledengle et al., 2024). Risk factors in Ethiopia include stunting, wasting (a low weight-for-height), low maternal education, poor dietary diversity, and limited prenatal care (Belachew & Tewabe, 2020; Orsango et al., 2021).

Anemia can be classified by a red blood cell size and color, and common types include iron deficiency, sickle cell, vitamin deficiency, and anemia of chronic disease (Kebede et al., 2021; Niss & Quinn, 2022). In children anemia impairs cognitive, physical, and immune development (Fentaw et al., 2023; Orsango et al., 2021). WHO guidelines recommend screening for palmar pallor and hemoglobin testing (Gebereselassie et al., 2020; WHO, 2021).

Despite many national studies, no prior research has found on anemia among children under five in Wolkite town in Gurage zone, an area with high malaria burden and limited diagnostic resources (Solomon et al., 2020). This study aims to assess the prevalence and associated factors of anemia among under-five children in Wolkite's public health facilities

Review of Literature

Anemia defined by low hemoglobin or red blood cell levels, is major global health issue affecting nearly 40% of children under five, with the higher prevalence in Africa (60.2%) and Ethiopia (52.1%) (Hailu et al., 2024; WHO, 2021). A hospital-based study in eastern Ethiopia in 2022 revealed that 33% of under-five children were anemic (Gemechu et al., 2024). Anemia commonly arise from nutrient deficiencies, genetic blood disorders, parasitic infections, and other acute or chronic illnesses. Risk factors include stunting, wasting, low maternal education, poor dietary diversity, and limited prenatal care (Belachew & Tewabe, 2020).

Anemia impairs children's cognitive and physical development and weakens immunity (Fentaw et al., 2023). WHO recommends screening using hemoglobin tests and clinical signs. Despite national data, no prior studies have assessed anemia in Wolkite town, a high-risk area with malaria and limited resources (Solomon et al., 2020).

Methods and Materials

Study Area and Period

A quantitative cross-sectional study was conducted from March 1 to 30, 2024, in Wolkite town, situated in the Gurage Zone of Central Ethiopia, approximately 159 km southwest of the capital, Addis Ababa. Wolkite serves as the capital of Gurage Zone, with an average annual temperature of 18.6°C and an average rainfall of 1,244 mm. The town is located at an elevation between 1,910 and 1,935 m above sea level. The Central Statistical Agency of Ethiopia reported data from the 2007 Census, and based on projections from City Population (2023), the population of Wolkite city is expected to reach 103,000 (City Population, 2023). The town is served by three government health facilities: one specialized hospital and two health centers. Wolkite Health Center, located in Bekur Sub-city, provides healthcare services to the local population and surrounding areas such as Kebena and Abeshge. Wolkite University Specialized and Referral Hospital, situated in Gubre Sub-city, is 172 km away and functions as a teaching hospital for medical and nursing students of Wolkite University. Established in 2019, the hospital offers a range of services, including medical, surgical, maternal and child health, and pediatric care.

Population

All children aged between 6 months and 59 months who attended care and treatment at Wolkite Health center and Wolkite University Specialized and Referral Hospital during the data collection period were included, and those under-five children who were treated with iron supplements and/or blood transfusion in the past 3 months were excluded.

Inclusion and Exclusion Criteria

All children aged 6 to 59 months who attended care and treatment at Wolkite Health Center and Wolkite University Specialized and Referral Hospital during the data collection period were included. Children who had received iron supplementation or a blood transfusion within the previous 3 months were excluded.

Sampling

The sample size was determined by using single population proportion formula with 95% confidence interval (CI), and 5% margin of error with prevalence of 52.2% from a study in Kombollcha (Fentaw et al., 2023).

n = Z α / 2^{2} \frac{p (1 - p)}{d^{2}}

n = (1.96) (1.96) (0.522) (0.478) / (0.05) 2 \approx 383

Thus, adding 10% nonresponse rate, the final sample size was 421.

The participants in the study were chosen through a systematic random sampling technique. The first child was selected randomly using a lottery method, and subsequently, every 12th child was selected according to the sequence of their visits.

Data Collection Tool and Procedure

Data collection was conducted using a structured, interviewer-administered questionnaire adapted from existing literature (Aliyo & Jibril, 2022), the WHO guidelines for measuring dietary diversity and meal frequency, and the Food and Nutrition Technical Assistance (FANTA) guidelines for assessing household food insecurity (FANTA, 2007). The questionnaire was initially prepared in English, then translated into Amharic, and subsequently back-translated into English by language experts to ensure consistency. The instrument was pretested on 5% of the sample size at another health center in the city. The pretest demonstrated content validity with a score of 0.79. Data collection was performed by two trained nurses using face-to-face, interviewer-administered structured questionnaires. Prior to the interviews, participants were provided with a clear explanation of the study's purpose. To prevent double sampling of participants who were referred to the hospital, a marker was applied to their middle finger.

Blood Sample Collection

Blood samples were collected in strict adherence to the standard operating procedures (SOPs), with a 3 mL venous blood sample to determine the hemoglobin levels of the children, and no other laboratory tests other than hemoglobin were involved. Two experienced laboratory technicians were responsible for collecting the samples in tubes containing ethylenediaminetetraacetic acid (EDTA). The materials used for the blood collection included syringes with needles and EDTA-containing blood collection tubes. The procedure was conducted using strict aseptic techniques.

Anthropometric Measurement

Anthropometric assessments, including height-for-age, weight-for-height, and weight-for-age, were conducted following the WHO guidelines (World Health Organization, 2006). Each of the three measurements was expressed as standard deviation (SD) units in terms of Z-scores compared to the median of the WHO 2006 standard population.

Operational Definitions

Anemic: Under-five children with blood hemoglobin levels of <11 g/dL were declared anemic, and those under-five children with blood hemoglobin levels of ≥ 11 g/dL were not anemic (WHO, 2025).

Household Food Insecurity Assessment

Food and Nutrition Technical Assistance prepare questionnaire contain nine questions for the assessment of household food insecurity (Foodand NutritionTechnicalAssistance [FANTA], 2007). Children whose height-for-age Z-score ≤ 2 SD from the median of the reference population were considered Stunted, children whose weight-for-height Z-score < 2 SD from the median of the reference population were considered Wasted, and children whose weight-for-age Z-score < 2 SD from the median of the reference population were underweight.

Data Analysis and Presentation

Data entry was performed using Epi-Data version 4.6 and subsequently exported to Statistical Package for the Social Sciences (SPSS) version 25 for analysis. Descriptive statistics were used to summarize the sociodemographic characteristics of the participants. A binary logistic regression model was employed to identify factors associated with anemia. Variables that showed a P-value of ≤ .25 in the bivariate analysis were considered candidates for inclusion in the multivariable analysis. Multivariable logistic regression was conducted to control for potential confounding factors and determine the true effects of the selected predictor variables. The strength of association between various factors and anemia was assessed using adjusted odds ratios (AOR) with 95% CI, with a P-value of ≤ .05 regarded as statistically significant.

Results

Sociodemographic Characteristics of Participants

In this study 421 under-five children were enrolled. The participants’ ages ranged from 6 to 59 months, with a mean (SD) age of 30.21(±15.294) months. Among 421 children under the age of five, 213(50.6%) were female, and the majority 196 (46.6%) of children's mothers/caregivers were house wives. Three hundred and twenty-one (76.2%) had male household head, 366 (86.9%) were married and 361 (85.7%) of caregivers were female. More than half, 238(56.5%) were from urban areas. Approximately, 112 (26.6%) of children's caregivers had higher than high school education. Out of 421 children under the age of 5, approximately 190 (45.1%) were Muslims. One hundred and seventy-five (41.6%) were living in a household with four family members, and the majority of households, 360 (85.5%) had incomes greater than 1500 Ethiopian birr (Table 1).

Table 1.

\demographic Characteristics of Under-Five Children in Wolkite Health Center and Wolkite University Referral and Specialized Hospital in Wolkite Town (n = 421).

Variables	Category	Frequency	Percent
Age	6–11 months	65	15.4
	12–23 months	84	20.0
	24–35 months	119	28.3
	36–47 months	81	19.2
	48–59 months	72	17.1
Sex of child	Male	208	49.4
Sex of child	Female	213	50.6
Religion of caregiver	Orthodox	178	42.3
	Muslim	190	45.1
	Protestant	48	11.4
	Catholic	5	1.2
Sex of caregiver	Male	60	14.3
Sex of caregiver	Female	361	85.7
Marital status of caregiver	Married	366	86.9
	Divorced	33	7.8
	Widowed	7	1.7
	Single	13	3.1
	Other	2	0.5

Child Feeding History

Among 421 under-five children, 311 (73.9%) had adequate dietary diversity practice, 266 (63.2%) introduction of complementary food less than or at 6 months, 243 (57.7%) mothers/caregivers have nutritional information, 315 (74.6%) had used animal products, 150 (35.6%) face mild food insecurity within 4 weeks, 392 (93.1%) had adequate meal frequency per day of their age, while majority 184 (43.7%) breastfeeding practice continued at 6 to 12 months (Table 2).

Table 2.

Child Feeding-Related Factors Among Under-Five Children in Wolkite Health Center and Wolkite University Referral and Specialized Hospital in Wolkite Town (n = 421).

Variables	Category	Frequency	Percent
Introduction of complimentary food	<6 or = 6 months	266	63.2
Introduction of complimentary food	>6 months	155	36.8
Duration of breastfeeding	<6 months	41	9.7
	6–12 months	184	43.7
	1–2 years	97	23.0
	Above 2 years	99	23.5
Nutritional information	Yes	243	57.7
Nutritional information	No	178	42.3
Animal product use	Yes	315	74.8
Animal product use	No	106	25.2
Dietary diversity	Inadequate DD	110	26.1
Dietary diversity	Adequate DD	311	73.9
Household food insecurity	Food secure	122	29.0
	Mild food insecurity	150	35.6
	Moderate food insecurity	139	33.0
	Severe food insecurity	10	2.4
Meal frequency	Inadequate MF	29	6.9
Meal frequency	Adequate MF	392	93.1

Note. DD=dietary diversity; MF=meal frequency.

Birth History and Maternal Comorbid Condition

Of the 421 under-five children, 315 (74.8%) were delivered by spontaneous vaginal delivery (SVD), 233 (55.3%) had no history of maternal anemia, majority of the children, 364 (86.5%) had no history of birth asphyxia, and 410 (97.4%) took immunization of their age. Among 421 under-five children, 43 (10.2%) were underweight, 6(1.4%) stunted, and 5(1.2%) wasted.

Out of 421 under-five children enrolled in the study, 402 (95.5%) had no history of blood loss, 414 (98.3%) had no history of surgery, and 417 (99.0%) had no history of blood loss due to injuries. One hundred and eighty-seven (44.4%) had recent history of fever followed by recent history of diarrhea 164 (39.0%), and 88 (20.9%) had intestinal protozoa followed by malaria infection 74 (17.6%), 401 (95.2%) had no chronic disease and 15 (3.6%) soil-transmitted helminthic infection (Table 3).

Table 3.

Birth History and Maternal Comorbid Illness Among Under-Five Children in Wolkite Health Center and Wolkite University Referral and Specialized Hospital in Wolkite Town (n = 421).

Variables	Category	Frequency	Percent
Mood of delivery	SVD	315	74.8
	Instrumental delivery	28	6.7
	CS delivery	78	18.5
History of maternal anemia	Yes	125	29.7
	No	233	55.3
	Unknown	63	15.0
History of birth asphyxia	Yes	57	13.5
History of birth asphyxia	No	364	86.5
Immunization of the age	Yes	410	97.4
Immunization of the age	No	11	2.6
Weight for age	Underweight	43	10.2
Weight for age	Normal weight	378	89.8
Height for age	Stunted	6	1.4
Height for age	No stunted	415	98.6
Weight for height	Wasted	5	1.2
Weight for height	No wasted	416	98.8

Note. CS=caesarean section; SVD=spontaneous vaginal delivery.

Prevalence of Anemia

Based on the hemoglobin cutoff value, less than 11 g/dL was categorized as anemic, and Hgb values of 10 to 10.9, 7 to 9.9, and less than 7 g/dL were determined to be mild, moderate, and severe, respectively (WHO, 2021). The overall prevalence of anemia was 164 (39.0%; Figure 1). Among children with anemia under 5 years of age, 95 (22.6%) were mild, 58 (13.8%) moderate, and 11 (2.6%) severe. Children with anemia scores hemoglobin values of mild anemia = 10 to 10.9 g/dL, moderate anemia = 7 to 9.9 g/dL, and severe anemia = less than 7 g/dL (WHO, 2021; Figure 2).

Figure 1.

The Anemia Among Under-Five Children Attended Wolkite Health Center and Wolkite University Referral and Specialized Hospital in Wolkite Town 2024.

Figure 2.

Anemia Level Among Under-Five Children Attended Wolkite Health Center and Wolkite University Referral and specialized Hospital in Wolkite Town 2024.

Factor Associated With Anemia in Under-Five Children

In bivariate analysis, child sex, educational level of care giver, place of residence, monthly income of caregiver, dietary diversity practice, nutritional information, meal frequency, history of maternal anemia, recent history of fever, recent malaria infection, recent history of diarrhea, household food insecurity, and underweight had a P-value of <.25 and were considered candidates for multivariable analysis.

In multivariable analysis, the chance of having anemia was approximately seven times higher among children under the age of 5 who's sex was male (AOR = 7.252, 95% CI = 4.176–12.592) than being female. Additionally, children who had lived in rural areas had four times more likely to have anemia (AOR = 4.295, 95% CI = 2.499–7.382) than lived in urban areas. Under-five children with history of recent fever had two times higher chance to have anemia (AOR = 2.183, 95% CI = 1.203–3.960) than their counterparts. Similarly, the children who had recent malaria infection were four times more likely to have anemia (AOR = 4.387, 95% CI = 2.097–9.179) than those who did not have recent malaria infection. Additionally, children who had inadequate dietary diversity had two times more likely to have anemia (AOR = 2.218, 95% CI = 1.253–3.925) than children with adequate dietary diversity practice. Similarly, under-five children with underweight had nearly three times higher chance to have anemia (AOR = 2.835, 95% CI = 1.151–6.982; Table 4).

Table 4.

Factors Associated With Anemia in Among Under-Five Children in Wolkite Health Center and Wolkite University Referral and Specialized Hospital in Wolkite Town, Ethiopia.

Variables	Category	Anemic	Nonanemic	COR (95% CI)	AOR (95% CI)
Sex	Male	127 (61.0%)	81 (39.0%)	7.458 (4.751–11.707)	7.252 (4.176–12.592)***
Sex	Female	37 (17.3%)	176 (82.7%)	1	1
Place of residence	Urban	52 (21.8%)	186 (78.1%)	1	1
Place of residence	Rural	112 (61.2%)	71 (38.3%)	5.642 (3.679–8.654)	4.295 (2.499–7.382)***
Recent history of fever	Yes	107 (57.2%)	80 (42.8%)	4.153 (2.740–6.296)	2.183 (1.203–3.960)**
Recent history of fever	No	57 (24.3%)	177 (75.7%)	1	1
Recent history of malaria infection	Yes	51 (68.9%)	23 (31.1%)	4.592 (2.673–7.888)	4.387 (2.097–9.179)***
Recent history of malaria infection	No	133 (32.5%)	234 (67.5%)	1	1
Dietary diversity	Inadequate DD	64 (58.2%)	46 (41.8%)	2.936 (1.877–4.592)	2.218 (1.253–3.925)**
Dietary diversity	Adequate DD	100 (32.2%)	211 (67.8%)	1	1
Weight for age	Underweight	33 (76.7%)	10 (23.3%)	6.222 (2.973–13.022)	2.835 (1.151–6.982)*
Weight for age	Normal weight	131 (34.7%)	247 (65.3%)	1	1

Note: Statistical significance at P < .001=***, P < .01=** and at P < .05=*.

AOR=adjusted odd ratio; CI=confidence interval; COR=crude odd ratio.

Discussion

The prevalence of anemia among children under five attending Wolkite health center and Wolkite University referral and specialized hospital was found to be 39.0%, which, according to WHO criteria, qualifies as a moderate public health concern (WHO, 2011). This finding is consistent with the global estimate reported by WHO in 2021 (39.8%), and similar to studies conducted in Northern Tamzania (37.9%; Mboya et al., 2020) and Guguftu, Northeast Ethiopia (41.1%; Gebreweld et al., 2019).

However, the prevalence observed in this study is lower than estimates from the WHO African region (60.2%) and Ethiopia nationally (52.1%; WHO, 2021), as well as data from the 2016 Ethiopian Demographic and Health Survey (EDHS) (57%). It is also lower than findings from South and Southeast Asia (57.2%; Sunuwar et al., 2023), Indonesia (76.1%; Randell et al., 2022), sub-Saharan Africa (64.1%; Tesema et al., 2021), and several Ethiopian countries. Variations in the prevalence may reflect differences in age groups studied, sample size, methodology, and regional context. For example, the Debre Brhan study included younger children (6–23 months), who are more vulnerable to anemia. Conversely, this study's prevalence was higher than in China (24.4%; Elmardi et al., 2020), Debre Markos (11.9%; Alamneh et al., 2021), Southern Ethiopia (32%; Orsango et al., 2021), and Bule Hora (13.2%; Aliyo & Jibril, 2022). These disparities may result from differences in hemoglobin cut-of-points, cultural practices, dietary patterns, and healthcare access.

Multivariable analysis revealed that male sex was significantly associated with anemia, consistent with findings from sub-Saharan Africa (65.3%; Tesema et al., 2021) and Nepal (45,65; Khanal et al., 2023). Due to faster growth, there is increase in their vulnerability. Despite son preference in some cultures, evidences suggest that girls are more likely to be neglected nutritionally (Dagne & Nigatu, 2019).

Rural residence was another significant factor, consistent with findings from china (32.8%) (Elmardi et al., 2020) and Ethiopian settings like Guguftu (49.5%) and Shaban Gibe (42.3%) (Gebreweld et al., 2019; Kebede et al., 2021). Limited healthcare access, poor sanitation, and low awareness about anemia ay contribute (Sahiledengle et al., 2024).

Children with a history of fever in the previous 2 weeks had higher anemia rates, aligning with studies from South and Southeast Asia (Sunuwar et al., 2023), sub-Saharan Africa (Tesema et al., 2021), and EDHS analysis (Asresie et al., 2020). Fever may signal infections like malaria or pneumonia. Which impair red blood cell production or increase destruction (Asresie et al., 2020). Recent malaria infection was also a significant factor, consistent with findings from Bule Hora (Aliyo & Jibril, 2022). Malaria contributes to anemia, with significant blood cell loss occurring after treatment and hemoglobin levels often dropping to their lowest between 3- and 7-day post-therapy (Chambrion et al., 2022).

Inadequate dietary diversity was significantly associated with anemia, as supported by studies in India (69.2%; Kathuria et al., 2023), Ghana (52.9%; Parbey et al., 2019), and other parts of Ethiopia. Poor diet leads to deficiencies in iron, folate, vitamin B12, and other nutrients vital for red blood cell production (Belachew & Tewabe, 2020).

Lastly, underweight status was linked to a higher anemia risk. Similar associations were found in Egypt (6.6%; Fouad et al., 2023), Ethiopia (50.2% in Guguftu, 62.4% in Debre Brhan; Gebreweld et al., 2019; Molla et al., 2020), and sub-Sharan Africa (Tesema et al., 2021). Malnutrition impairs nutrient absorption and weakens immunity, exacerbating malnutrition impairs nutrient absorption and weakens immunity, exacerbating anemia risk (Chambrion et al., 2022).

Strengths and Limitations

This study applied validated tools and WHO guidelines to assess anemia and its related factors, confirmed anemia through lab-based hemoglobin testing, and used multivariate regression to identify significant predictors, all while adhering to ethical standards. The findings offer valuable insights for targeted public health interventions. However, the study did not differentiate between the various classifications of anemia. Additionally, due to budget constraints, stool examinations for the assessment of protozoan and helminth infections could not be conducted. Another key limitation is that other blood parameters, such as serum ferritin and peripheral smear, were not assessed, limiting the ability to determine the specific cause and types of anemia

Implications for Nursing Practice

The study highlights key implications for nursing practice, emphasizing the need for early anemia screening, especially in high-risk group such as male children, those in rural areas, and those with recent infections or poor nutrition. Nurses should prioritize caregiver education on dietary diversity and iron-rich foods, conduct regular nutritional assessment, and support infection prevention efforts, particularly for malaria. Community outreach, timely referrals, and collaboration with other healthcare providers are also essential to effectively manage and reduce anemia in under-five children.

Conclusion

Childhood anemia represents a significant public health issue in the study area. Factors such as being male, living in rural areas, having a history of recent fever, recent malaria infection, inadequate dietary diversity, and underweight were found to be strongly associated with childhood anemia. To address this issue, it is recommended to implement effective preventive strategies, including the use of bed nets, timely diagnosis and treatment of malaria and other infections, and improving dietary diversity to reduce the risk of childhood anemia.

Footnotes

Abbreviations

Acknowledgements

The authors would like to express their deepest appreciation to participating hospital, data collectors, supervisors and the study participants for their kind invaluable contributions, without them this study wouldn’t be realized.

ORCID iD

Tigistu Gebreyohannis Gebretensaye

Ethical Consideration

Ethical approval for the study, including procedures involving blood sample collection was obtained from the College of Health Science, Addis Ababa University, Ethical Review Committee (Ref: CHS/NSG/008.017/24). Formal support letter was written to Wolkite Health center and Wolkite University Specialized Referral Hospital. Participants were informed about the study objectives prior to the data collection. Informed consent was obtained from participants parents/significant others. The study adhered to the principles outlined in the Declaration of Helsinki. Participation to the study was absolutely voluntary. Confidentiality of the data was ensured by anonymizing identifiers. And use of unique ID numbers. Anemic children were linked to the respective health center or hospital OPDs for care and treatment.

Consent for Publication

All authors in the list have read the manuscript and agreed for the publication of the article in the journal.

Authors’ Contributions

BM, AH, and NT were involved in the conceptualization. BM participated in the investigation; BM, AH, NT, and TG were involved in data curation, formal analysis, methodology, resources, project administration, original draft writing; and AH, TG, and NT were involved in supervision, validation, and visualization; TG and AH prepared the manuscript. All authors reviewed, read, and approved the final version of the manuscript.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The datasets used and analyzed are available from the corresponding author on reasonable request.

References

Alamneh

Y. M.

Akalu

T. Y.

Shiferaw

A. A.

Atnaf

(2021). 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. Italian Journal of Pediatrics, 47(1), 172. https://doi.org/10.1186/s13052-021-01123-3

Aliyo

Jibril

(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

Armah-Ansah

E. K.

Adu

Agyapong

Addo

A. A.

Adusei

(2023). Determinants of anemia among women of reproductive age: A cross-sectional study in Mali. Archives of Public Health, 81(1), 1–10. https://doi.org/10.1186/s13690-023-01023-4

Asresie

M. B.

Fekadu

G. A.

Dagnew

G. W.

(2020). Determinants of anemia among children aged 6–59 months in Ethiopia: Further analysis of the 2016 Ethiopian Demographic Health Survey. Advances in Public Health, 2020 (1), Article 3634591.

Belachew

Tewabe

(2020). Under-five anemia and its associated factors with dietary diversity, food security, stunted, and deworming in Ethiopia: Systematic review and meta-analysis. Systematic Reviews, 9(1), 31. https://doi.org/10.1186/s13643-020-01289-7

Chambrion

Depond

Angella

Mouri

Kendjo

Fricot-Monsinjon

Roussel

Biligui

Tantaoui

Taieb

Argy

Houzé

Piarroux

Siriez

J.-Y.

Jaureguiberry

Larréché

Théllier

Cenac

Buffet

Ndour

P. A.

(2022). Altered subpopulations of red blood cells and post-treatment anemia in malaria. Frontiers in Physiology, 13, 875189. https://doi.org/10.3389/fphys.2022.875189

City Population. (2023). Welkite population statistics . Retrieved July 2023, from https://www.citypopulation.de/en/ethiopia/

Dagne

Nigatu

(2019). Prevalence and associated factors of anemia among adolescent girls in Ethiopia: A systematic review and meta-analysis. Systematic Reviews, 8, 386. https://doi.org/10.1186/s13643-019-1250-9

Elmardi

K. A.

Adam

Malik

E. M.

Ibrahim

A. A.

Elhassan

A. H.

Kafy

H. T.

, …, Kremers

(2020). Anaemia prevalence and determinants in under 5 years children: Findings of a cross-sectional population-based study in Sudan. BMC Pediatrics, 20(1), 538. https://doi.org/10.1186/s12887-020-02434-w

10.

Fentaw

Belachew

Andargie

(2023). Anemia and associated factors among 6 to 59 months age children attending health facilities in Kombolcha town, Northeast Ethiopia: A facility-based cross-sectional study. BMC Pediatrics, 23(1), 209. https://doi.org/10.1186/s12887-023-04002-z

11.

Food and Nutrition Technical Assistance (FANTA). (2007). Household Food Insecurity Access Scale (HFIAS) for measurement of food access: Indicator guide. FHI 360/FANTA.

12.

Fouad

H. M.

Yousef

Afifi

Ghandour

A. A.

Elshahawy

Elkhawass

, …, Shalaby

(2023). Prevalence of malnutrition and anemia in preschool children: A single center study. Italian Journal of Pediatrics, 49(1), 75. https://doi.org/10.1186/s13052-023-01476-x

13.

Gebereselassie

BirhanSelassie

Menjetta

Alemu

Tsegaye

(2020). Magnitude, severity, and associated factors of anemia among under-five children attending Hawassa University Teaching and Referral Hospital, Hawassa, Southern Ethiopia, 2016. Anemia, 2020 (1), 7580104. https://doi.org/10.1155/2020/7580104

14.

Gebreweld

Ali

Fisha

(2019). Prevalence of anemia and its associated factors among children under five years of age attending Guguftu Health Center, South Wollo, Northeast Ethiopia. PLoS ONE, 14(7), e0218961. https://doi.org/10.1371/journal.pone.0218961

15.

Gedfie

Getawa

Melku

(2022). Prevalence and associated factors of iron deficiency and iron deficiency anemia among under 5 children: A systematic review and meta-analysis. Global Pediatric Health, 9, 2333794X221110860. https://doi.org/10.1177/2333794X221110860

16.

Gemechu

Asmerom

Sileshi

Belete

Ayele

Nigussie

, …, Arkew

(2024). Anemia and associated factors among under-five children attending public hospitals in Harari Regional State, eastern Ethiopia: A cross-sectional study. Medicine, 103(21), e38217. https://doi.org/10.1097/MD.0000000000038217

17.

Hailu

M. K.

Wudu

M. A.

Gebriye

D. B.

Birhanu

T. A.

Bekalu

Y. E.

(2024). Prevalence of anemia and its associated factors among 6–59 months age children visiting public hospitals at Afar Region, Northeast Ethiopia: A hospital-based cross-sectional study. BMC Pediatrics, 24(1), 589. https://doi.org/10.1186/s12887-024-05078-2

18.

Kathuria

Bandyopadhyay

Srivastava

Garg

P. R.

Devi

K. S.

Kurian

, …, Mehra

(2023). Association of minimum dietary diversity with anaemia among 6–59 months’ children from rural India: An evidence from a cross-sectional study. Journal of Family Medicine and Primary Care, 12(2), 313–319. https://doi.org/10.4103/jfmpc.jfmpc_926_22

19.

Kebede

Getaneh

Endalamaw

Belay

Fenta

(2021). Prevalence of anemia and its associated factors among under-five age children in Shanan Gibe Hospital, Southwest Ethiopia. BMC Pediatrics, 21(1), 1–9. https://doi.org/10.1186/s12887-021-02671-1

20.

Khanal

Pokhrel

Singh

S. K.

Yadav

S. K.

Kafle

(2023). Prevalence of iron deficiency anemia among under five years children in a tertiary health care center of Nepal. Journal of College of Medical Sciences–Nepal, 19(3), 288–293. https://doi.org/10.3126/jcmsn.v19i3.55954

21.

Mboya

I. B.

Mamseri

Leyaro

B. J.

George

Msuya

S. E.

Mgongo

(2020). Prevalence and factors associated with anemia among children under five years of age in Rombo district, Kilimanjaro region, Northern Tanzania. F1000Research, 9, 1102. https://doi.org/10.12688/f1000research.24707.3

22.

Molla

Egata

Mesfin

Arega

Getacher

(2020). Prevalence of anemia and associated factors among infants and young children aged 6–23 months in Debre Berhan Town, North Shewa, Ethiopia. Journal of Nutrition and Metabolism, 2020, 2956129. https://doi.org/10.1155/2020/2956129

23.

Niss

Quinn

C. T.

(2022). Classification and diagnosis of anemia in children and neonates. In Fish

J. D.

Lipton

J. M.

Lanzkowsky

(Eds.), Lanzkowsky’s manual of pediatric hematology and oncology (7th ed., pp. 37–59). Academic Press.

24.

Orsango

A. Z.

Habtu

Lejisa

Loha

Lindtjørn

Engebretsen

I. M. S.

(2021). Iron deficiency anemia among children aged 2–5 years in southern Ethiopia: A community-based cross-sectional study. PeerJ, 9, e11649. https://doi.org/10.7717/peerj.11649

25.

Parbey

P. A.

Tarkang

Manu

Amu

Ayanore

M. A.

Aku

F. Y.

, …, Kweku

(2019). Risk factors of anemia among children under five years in the Hohoe Municipality, Ghana: A case-control study. Anemia, 2019, 2139717. https://doi.org/10.1155/2019/2139717

26.

Randell

Rachmi

C. N.

Jusril

Fox

Wibowo

, …, Raynes-Greenow

(2022). Prevalence of, and factors associated with anaemia in children aged 1–3 years in Aceh, Indonesia: A cross-sectional study. Nutrition and Health, 2601060221116195 https://doi.org/10.1177/02601060221116195

27.

Sahiledengle

Mwanri

Agho

K. E.

(2024). Household environment associated with anaemia among children aged 6–59 months in Ethiopia: A multilevel analysis of Ethiopia Demographic and Health Survey (2005–2016). BMC Public Health, 24(1), 315. https://doi.org/10.1186/s12889-024-17780-y

28.

Solomon

Kahase

Alemayehu

(2020). Trend of malaria prevalence in Wolkite Health Center: An implication towards the elimination of malaria in Ethiopia by 2030. Malaria Journal, 19(1), 112. https://doi.org/10.1186/s12936-020-03527-5

29.

Sunuwar

D. R.

Singh

D. R.

Pradhan

P. M. S.

Shrestha

Rai

Shah

S. K.

Adhikari

(2023). Factors associated with anemia among children in South and Southeast Asia: A multilevel analysis. BMC Public Health, 23(1), 343. https://doi.org/10.1186/s12889-023-15265-y

30.

Tesema

G. A.

Worku

M. G.

Tessema

Z. T.

Teshale

A. B.

Alem

A. Z.

Yeshaw

, …, Liyew

A. M.

(2021). Prevalence and determinants of severity levels of anemia among children aged 6–59 months in sub-Saharan Africa: A multilevel ordinal logistic regression analysis. PLoS ONE, 16(4), e0249978. https://doi.org/10.1371/journal.pone.0249978

31.

World Health Organization. (2006). WHO child growth standards: Length/height-for-age, weight-for-age, weight-for-length, weight-for-height, and body mass index-for-age: Methods and development. World Health Organization.

32.

World Health Organization. (2021). Global anaemia estimates . Retrieved from https://www.who.int/data/gho/data/themes/topics/anaemia_in_women_and_children

33.

World Health Organization. (2024). Guideline on haemoglobin cutoffs to define anaemia in individuals and populations .

34.

World Health Organization. (2025). Anaemia: Key facts. https://www.who.int/news-room/fact-sheets/detail/anaemia