Hailu et al. BMC Pediatrics(2024) 24:589
https://doi.org/10.1186/s12887-024-05078-2

BMC Pediatrics

RESEARCH

Open Access

Prevalence of Anemia and its associatedfactors among 6–59 months age children
visiting public hospitals at Afar Region,
Northeast Ethiopia: a hospital-based crosssectional study
Molla Kassa Hailu1, Muluken Amare Wudu1*, Dagne Belete Gebriye2, Tarikua Afework Birhanu1 and Yemane
Eshetu Bekalu3
Abstract
Background Anemia is a significant global public health issue among children aged 6 to 59 months, particularly
in low-income countries like Ethiopia. Studies focusing on pastoral communities, especially in the Afar Region,
often underestimate the prevalence of anemia in these children. To address this information gap, this study aimed
to determine the prevalence of anemia and its associated factors among children aged 6 to 59 months in public
hospitals in the Afar Region of northeastern Ethiopia.
Method A hospital-based cross-sectional study was conducted among children aged 6 to 59 months, using
systematic random sampling, at public hospitals in the Afar Region from February 28 to April 30, 2023.The datacollection tool was adapted from the Ethiopian National Food Consumption Survey and the World HealthOrganization Infant and Young Child Feeding guidelines. Data entry was performed using EpiData version 4.2
and Anthroplus software for anthropometric measurements. Data analysis was conducted using SPSS version 26.
Binary logistic regression models were applied to identify predictors of anemia, with a p-value of ≤ 0.05 considered
statistically significant.
Result Among the 306 children aged 6 to 59 months, the overall prevalence of anemia was 46.41 (95 CI: 43.8–48.9 ).
Of the 142 anemic children aged 6 to 59 months, 62 (43.66 ) had mild anemia, 60 (42.25 ) had moderate anemia, and20 (14.08 ) had severe anemia. Key factors associated with anemia included mothers with no formal education, thelowest family monthly income, a family size greater than five, and rural residence. Additionally, a previous diagnosis ofparasitic infection, children aged 24–35 months, early weaning, a malaria diagnosis within the past three months, anddiarrhea in the last two weeks were significant predictors of anemia in children aged 6 to 59 months.

*Correspondence:
Muluken Amare Wudu
385mule@gmail.com
Full list of author information is available at the end of the article© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0
International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you
give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified thelicensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images orother third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to thematerial. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation
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Hailu et al. BMC Pediatrics(2024) 24:589

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Conclusion In the current study, anemia in children aged 6 to 59 months was classified as severe and is regarded
as a critical public health issue. This suggests that more efforts should be made to significantly decrease anemia byactively involving rural mothers with no formal education and low income who have children aged 6–59 months,
focusing on the prevention and management of malaria, diarrhea, and parasitic infections.
Keywords Anemia, 6–59 months age children, Afar region, Public hospitals, Northeastern Ethiopia

Introduction
Anemia is a condition characterized by a decrease in
the number and size of red blood cells or a reduction in
hemoglobin (Hgb) concentration, which impairs oxygen
transport throughout the body. In children aged 6 to 59
months, anemia is defined by a hemoglobin level of lessthan 110 g/L [1–3].
Anemia can result from excessive blood loss, parasitic
infections, or congenital hemolytic diseases. Different
types of anemia include iron deficiency anemia, sickle
cell anemia, vitamin deficiency anemia, aplastic anemia,
hemolytic anemia, and anemia of inflammation. Iron
deficiency is the most common cause of anemia, accounting for approximately 42 of cases in children aged 6 to 59
months worldwide [5].
Anemia is a major global public health issue, with ahigher prevalence in low-income countries due to theirincreased vulnerability to various health and socioeconomic challenges directly or indirectly associated withthe condition. While anemia can affect any age group forvarious reasons, children aged 6 to 59 months are among
the most vulnerable [6].
In 2019, the global prevalence of anemia in children
aged 6 to 59 months was 39.8 , affecting approximately
269 million children. The African region had the highest
rate of anemia among children under five, at 60.2 . Additionally, the 2021 WHO report on anemia stated thatthe prevalence of anemia among children aged 6 to 59
months in Ethiopia ranged from 40 to 60 in 2019 [7, 8].
According to the 2016 Ethiopian Demographic and
Health Survey (EDHS), 57 of Ethiopian children aged 6
to 59 months have anemia. Prevalence varies geographically, ranging from 42 in the Amhara Region to 75 in theAfar Region and 83 in the Somali Region [9]. The prevalence of childhood anemia varies across different regionsof the country. A study conducted in Kombolicha, northeast Ethiopia, found that 52.2 of children aged 6 to 59
months were anemic [10]. Similarly, studies in various
regions of Ethiopia reported the following prevalence
rates of anemia in children aged 6 to 59 months: 28.6 in
Gondar Town (northwest Ethiopia) [11], 28.5 in North
Shewa (central Ethiopia) [12], 21.6 in Tigray (northern
Ethiopia) [13], and 41.7 in Hawassa Teaching Hospital(southern Ethiopia) [14].
Numerous studies have identified several factors linked
to anemia in children aged 6 to 59 months. These include
childhood characteristics such as age, residency, feedingpractices, nutritional status, intestinal parasites, malaria
infection, iron and vitamin A supplementation, deworming, consumption of raw foods, and dietary diversity [10–13]. Additionally, family and maternal factors have been
associated with anemia in this age group. These factors
include the mother’s age, education level, marital status,
family income, waste disposal practices, maternal anemia, household food insecurity, water source, family size,
antenatal care, and maternal nutritional status [14–17].
If left untreated, anemia in children aged 6 to 59
months can have significant consequences, including
growth retardation, a weakened immune system, andincreased susceptibility to illness and mortality. It also
has severe socioeconomic impacts on families and communities [18–21]. Additionally, anemia can have lasting
effects on female offspring, resulting in low-birth-weight
newborns and postpartum hemorrhage. Children from
low-income families are at a higher risk of developing
iron deficiency anemia [22].
Despite Ethiopia’s significant efforts to combat anemia
among children aged 6 to 59 months, based on World
Health Organization (WHO) recommendations—including initiatives such as Infant and Young Child Feeding(IYCF), iron supplementation, increased meal frequency,
dietary diversity, and the management of infectious diseases like malaria, helminthic infections, and tuberculosis—anemia in the country remains classified as severe.
These efforts are in addition to existing programs like
Integrated Management of Newborn and Childhood
Illness (IMNCI), safe motherhood, malaria rollback,deworming, and tuberculosis management [7].
Despite numerous studies documenting anemia amongchildren aged 6 to 59 months in Ethiopia, research inpastoral communities, such as the Afar Region, remains
limited. These studies often overlook stool examinations,dietary diversity, and environmental factors. Moreover,unlike previous studies, this study was multi-centered.
This study aimed to address the information gap andpresent recommendations that could inspire local multisectoral managers to combat anemia and ultimately foster healthier generations.

Methods
Study area and period

The study was conducted in public hospitals in the Afarregion from February 28 to April 30, 2023. Ethiopia is
divided into 12 regional states, one of which is the Afar

Hailu et al. BMC Pediatrics(2024) 24:589

National Regional State. This state covers an area of
278,000 square kilometers and is situated between 9
N and 12 N latitude and 40 E and 42 E longitude in the
Great East African Rift Valley. The capital city of the AfarNational Regional State is Samara, located 570 km northof Addis Ababa in the country’s northeast. The Afarregion is served by seven public hospitals, which cater toan estimated population of 5 million people.
Study design and populations

A hospital-based cross-sectional study design was
employed. All 6-59-month-old children who visited
Afar Region public hospitals were sources of population.
However, randomly selected 6-59-month-old children
who visited selected Afar Region public hospitals wereconsidered as study units.
Eligibility criteria

This study included all children aged 6 to 59 months
who visited the selected public hospitals. Children with aknown bleeding disease, severe illness, mentally ill mothers or caregivers, and children who had received bloodtransfusions in the previous three months were excluded
from the study.
Sample size determination and sampling procedures

The required sample size for the study was determinedusing a single population proportion formula. The calculation employed a formula for a single population withthe following parameters: a confidence level of 95 , a margin of error of 0.05, and an anemia prevalence of 75 in
the Afar region [9]. .
By including a 10 non-response rate, the total sample
size increased to 317.
Out of the seven public hospitals in the study area, four
were selected using a simple random sampling method
via lottery methods: Asaita District Hospital, Dubti General Hospital, Kelewan General Hospital, and Mohammed Aklie Memorial Hospital. The average number ofchildren aged 6 to 59 months visiting each hospital permonth was calculated based on the number of such visits
in the quarter preceding the data collection. This resulted
in an overall monthly average of 1,400 visits, with 390 at
Asaita District Hospital, 410 at Dubti General Hospital,
300 at Kelewan General Hospital, and 300 at Mohammed Aklie Memorial Hospital. Based on these averages,
a proportionate allocation to size was determined foreach hospital. Consequently, 88 children were allocatedto Asaita District Hospital, 93 to Dubti General Hospital, 68 to Kelewan General Hospital, and 68 to Mohammed Aklie Memorial Hospital. The Emergency Triage
Assessment and Treatment (ETAT) registration book wasused as the sampling frame. Initially, the first child wasselected using a lottery method, and then every fourth

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child aged 6 to 59 months was included in the study using
systematic random sampling.
Study variables
Dependent variable

Anemia among children aged 6 to 59 months.
Independent variables

Sociodemographic factors related to the child and theirparents.
Maternal and child health-related factors wereassessed, including maternal antenatal care (ANC), placeof delivery, postpartum care (PNC), child immunization
history, and the child’s nutritional status based on WHO
anthropometric measures.
Child feeding practices, encompassing dietary diversity
scores.
Environmental factors, including the source of waterand the status and type of latrines.
The medical history and laboratory examinations
included screening for parasitic infections and malaria,
assessed through hematologic and stool tests.
Operational definitions

Malnutrition Children aged 6 to 59 months with aweight-for-length/height between 2 SD and 3 SD fromthe median were classified as moderately wasted, while
those with a weight-for-length/height 3 SD were classified
as severely wasted [9]. Similarly, children with a length/
height-for-age between 2 SD and 3 SD from the medianwere considered moderately stunted, and those with alength/height-for-age 3 SD were considered severely
stunted [9].
Anemia Children aged 6 to 59 months with a hemoglobin (Hgb) level of 11.0 g/dl or higher were classified
as non-anemic. Those with an Hgb level below 11.0 g/dl
were considered anemic. Specifically, Hgb values of 10.0
to 10.9 g/dl indicated mild anemia, values of 7.0 to 9.9 g/
dl indicated moderate anemia, and values below 7.0 g/dl
indicated severe anemia [9]. This reference value applies
to both male and female children, as there is no genderdifference in hemoglobin levels until age 12 [24, 25].
Dietary diversity score This score was calculated bycounting the number of food categories consumed in theprevious 24 h. For children aged 6 to 23 months, a consumption of 5 to 8 food groups was considered indicativeof adequate dietary diversity, while for children aged 24
to 59 months, a consumption of 4 to 7 food groups wasdeemed adequate [26].

Hailu et al. BMC Pediatrics(2024) 24:589

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Data collection tools and procedures

Blood specimen collection and hematologic examination

In the current study, pretested questionnaires, developed
based on previous literature [10, 15, 17, 27, 28], wereused to collect relevant data. Data collection involved
face-to-face interviews, chart reviews, hematologic andstool examinations, and anthropometric measurements.
Section one of the questionnaire covered sociodemographic factors related to the child and their parents or
caregivers. Section two focused on maternal and childhealth, including factors such as maternal antenatal care
(ANC), place of delivery, postpartum care (PNC), child
immunization history, and the child’s nutritional statusthrough WHO anthropometric measures. Section threeassessed child feeding practices, including dietary diversity scores. The questionnaire was developed using theFood and Agriculture Organization (FAO) / Food andNutrition Technical Assistance (FANTA) recommendations for measuring family and individual dietary diversity [29] and the WHO Infant and Young Child Feeding(IYCF) guidelines [26], both of which are based on the
24-hour recall technique. Additionally, participants
were asked whether their child had consumed food fromeach of eight food groups in the 24 h prior to the survey
for children aged 6 to 23 months, and from seven foodgroups for children aged 24 to 59 months. Section 4
addressed environmental factors such as water source
and latrine status and type. Section 5 evaluated anemia
status, parasitic infections, and malaria infection throughhematologic and stool examinations. To ensure consistency, the questionnaire was originally written in English,translated into Afaragna, and then back-translated into
English by experts fluent in both languages. Data collection was carried out by four qualified pediatric nurses
and four medical laboratory technicians.

Capillary blood samples were obtained from children
under rigorous aseptic measures by skilled laboratory
professionals after asking their parents or caregivers
about their willingness. The Cell-DYN 1800 machinery
was used to measure hemoglobin concentration.

Anthropometrics examinations

Data processing and analysis

Anthropometric measurements were conducted in thehospital examination room. Weight was measured using a
digital Seca scale (SECA, Germany) to the nearest 0.1 kg.
To ensure privacy, participants wore light clothing and no
shoes during the measurement. Each adolescent’s weight
was recorded twice, and if the variance between the two
measurements exceeded 0.5 kg, both readings were discarded, and the procedure was repeated. Otherwise, theaverage of the two measurements was used for analysis.
Height was measured to the nearest 0.1 cm using a stadiometer (SECA, Germany). Participants stood on themeasuring board without shoes, in the normal anatomical position, with their heels, buttocks, shoulders, and theback of their heads touching the board. The headband of
the stadiometer was positioned flat against the crown of
the head, forming a 90-degree angle with the board.

For analysis, the data was entered into EpiData version
4.2 and exported to Statistical Package for the Social
Sciences (SPSS) version 26.0 (IBM-SPSS., Chicago, IL,
USA). To determine nutritional status, anthropometricdata was entered and analyzed using WHO Anthroplus
software Version 3.2. Before conducting the final analysis, an exploratory analysis was performed to check for
missing values, outliers, and assumptions. For categorical variables, frequency and percentage were used. To
investigate factors associated with anemia, a binary logistic regression model was used. Variables with p valuesof < 0.25 in the bivariable analysis were included in themultivariate analysis. In the multivariable analysis, theadjusted odds ratio (AOR) with a 95 confidence interval
was used to assess the strength of the association, and a p
value of < 0.05 was used to declare it statistically significant. Furthermore, multicollinearity was reviewed, andto assess the relative effects of explanatory variables on

Stool specimen collection and examination

Before collecting stool samples, parents and children
were informed about the study’s goals and given specific instructions on how to properly collect and store
the samples in labelled containers. Each child’s 2 mg
feces sample was collected in a clean plastic jar labeledwith an identity number. Within 30 min of collecting thesample, a wet-mount smear was made using saline and/or iodine solution for direct microscopic detection ofintestinal parasites. The direct smear was inspected bytrained medical laboratory personnel using 10x and 40x
objectives to detect helminth eggs, larvae, and protozoan
parasites.
Data quality control

Data quality was ensured through rigorous design, translation, pre-testing of the questionnaire, and data collector
training. Every day after data collection, the lead investigator and supervisors examined the completed questionnaire for completeness, and adjustments were made forthe following day. For all laboratory activities, standard
operating procedures and the manufacturer’s instructions were rigorously followed. The expiry date of all laboratory reagents was examined. Samples were examined
to ensure that they met accepted criteria such as volume,
uniformity, and collection time. The cleanliness of microscopic slides and cover glasses was tested.

Hailu et al. BMC Pediatrics(2024) 24:589

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Table 1 Socio demographic characteristics of 6–59 months
age children and their parents attending at Afar region public
hospitals, North Eastern Ethiopia, 2023
Characteristics
Sex of child

Category
Male
FemaleAge of child (in 6–11
month)
12–23
24–35
36–47
48–59
Marital status
SingleMarriedDivorced
WidowedEducational
Illiterate
status(mother)Write and readFirst cycle (1–4)
Second cycle (5–8)
secondary (9–12)
tertiary (12+)
Educational
Illiterate
status(father)Able to Write and readFirst cycle (1–4)
Second cycle (5–8)
Secondary (9–12)
Tertiary (college andabove)
Occupational
House wife
status(mother)
Employee
Merchant
FarmerDaily worker
Other
Occupational
Employeestatus(father)Merchant
FarmerDaily worker
Other
Family monthly < 3000(Birr)
income (Ethio3000–7500(Birr)
pian Birr)> 7500(Birr)
Residence
Rural
Urban
Birth interval
No previous birth< 24 month≥ 24 months
Family members 2–4≥5Frequency
145
161
51
70
77
59
49
36
221
39
10
120
73
32
21
40
20
64
68
12
48
80
34

Percent
47.39
52.61
16.67
22.88
25.16
19.28
15.86
11.76
72.2
12.75
3.27
39.22
23.86
10.46
6.86
13.07
6.54
20.92
22.22
3.92
15.69
26.14
11.11

174
49
35
38
7
3
109
63
97
25
12
107
111
88
107
199
75
156
75
136
170

56.86
16.01
11.44
12.42
2.89
0.98
35.62
20.59
31.70
8.17
3.92
34.97
36.27
28.76
34.97
65.03
24.51
50.98
24.51
44.44
55.56

Occupational status (mother); others (sex worker, private business), Occupational status(father); others (driver, broker, and private business)the outcome, the final logistic model’s goodness of fit was
non-significant for the Hosmer and Lemshow tests but
significant for the Omnibus test.
Ethical approval and consent to participate The study
protocol was evaluated and approved by Wollo University College of Medicine and Health science research andcommunity service committee with reference No_(WU/
CMHS/20/123/2023) and ethical clearance was obtained.
Additionally, before commencing the study, permission
letters were obtained from each hospital manager and thequality assurance department. Written informed consent
was obtained from each children mother. Moreover, thisstudy was conducted in compliance with the Declarationof Helsinki. The purpose and significance of the study
were clearly explained to the children’s mothers during thehematologic, stool, and anthropometric assessments. The
autonomy and dignity of the participants were respected,
and they were allowed to pause the assessments if theyexperienced any discomfort. Anonymous data wereobtained and the confidentiality of participants information was secured. Moreover, subject confidentiality andany special data security requirements were maintained
and assured through the use of codes instead of participants’ names.
ResultSocio-demographic characteristics of participants

Out of 317 participants, 306 children aged 6 to 59 months
were included, resulting in a response rate of 96.5 . The
mean age of the children was 39.6 months (SD ± 26.34
months). Of the total 306 children aged 6 to 59 months,
185 (66.5 ) were older than 24 months, 161 (52.61 ) werefemale, and 199 (65.03 ) came from urban areas. A totalof 120 (39.2 ) of the children’s mothers had no formal
education, and 170 (55.56 ) of the study participants lived
in households with five family members. Additionally,
111 (36.3 ) had incomes ranging from 3,000 to 7,500 Ethiopian birr (Table 1).
Child and maternal health related characteristics

About 240 children (78.43 ) were fully immunized, while
56 (18.3 ) had experienced diarrhea in the two weeks
prior. Before the 48-hour survey, 129 children (42.16 )had a fever. Additionally, 88 children (28.76 ) were moderately wasted, and 48 (15.7 ) were moderately stunted.
Of the total participants, 219 (71.56 ) were born in a hospital, but only 66 (21.56 ) received postnatal care, with 36(54.55 ) receiving just one visit (Table 2).
Child feeding practices

The vast majority of children, 276 (90.19 ), received colostrum feeding; 164 (53.6 ) were exclusively breastfed for
4–6 months; 152 (49.67 ) started complementary feedingHailu et al. BMC Pediatrics(2024) 24:589

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Table 2 6–59 months old children and maternal health andhealth service-related profile who visiting at Afar region public
hospitals, North Eastern Ethiopia,2023

Table 3 Children aged 6–59 months feeding characteristics who
visiting at Afar region public hospitals, North Eastern Ethiopia,
2023

Characteristics
Fully Immunizedchildcharacteristics
Colostrum
feeding

Response
Yes
No
Yes
No

Having diarrhea
preceding two
weeks
Weight–for-height Normalof child
Moderate wasting
Sever wasting
Height/Length-for- Normal
age of child
Moderate stunting
Sever stuntingChild had fever last Yes
2 daysNo
ANC follow up
YesNo
Frequency of ANC 1
visit
2–3
Place of delivery≥4

At home
Health institutions
Postnatal care visit Yes
No
Frequency of PNC 1
visit
2–3
>3

Frequency
240
66
56
250

Percentage
78.43
21.57
18.3
81.7

210
88
8
243

68.63
28.76
2.61
79.41

48
15
129
177
209
97
40
138
31

15.69
4.9
42.16
57.84
68.3
31.7
19.14
66.0
14.83

87
219
66
240
36
27
3

28.43
71.56
21.56
78.43
54.55
40.91
4.54

less than 6 months; 125 (40.85 ) received semi-fluid complementary feeding; 211 (69.1 ) had an inadequate dietary
diversity score; and 171 (55.89 ) had an inadequate meal
frequency of 2–3 times per day (Table 3).
Environmental characteristics

The vast majority of households, 241 (78.76 ), had nowater supply, and 172 (56.21 ) used an open field to dispose of solid waste. Furthermore, 195 (63.73 ) of thehouseholds had insects, the majority of which were mosquitoes (81, or 41.54 ). Additionally, more than half of thehouseholds (55.5 ) had a latrine (Table 4).
Child clinical profile

Approximately 103 children aged 6 to 59 months (33.7) had a parasitic infection in the current study. Amongthese, 51 (49.51 ) were infected with Entamoeba histolytica. Additionally, 72 children (23.53 ) had a history ofmalaria infection in the previous three months (Table 5).
Prevalence of 6-59-month-old child anemia

In the current study, the overall prevalence of anemia
was 142 cases, representing 46.41 (95 CI: 43.8 − 48.9 ).
Among these 142 anemic children, 62 (43.66 ) had mild

Pre-lacteal
feeding
Initiating breast
feeding

Exclusive breast
feeding

Duration of breast
feeding
Complementary
feeding initiations
Dietary diversity
Practice
Types of weaning
food introduced
Meal frequency
per day

Response
Yes
No
Yes
No
Within one hourWithin day
No breast feedingat all< 4 months
4–6 months
6–11 months≥ 1 year< 24 months> 24 months< 6 months
At 6 months≥ 6 months
Adequate
Not adequate
Fluid
Semi-fluid
Family food
2–3 times
3–5 times
4–6 times

Frequency
276
30
82
224
178
98
30

Percent
90.19
9.81
26.8
73.2
58.2
32
9.8

76
164
64
2
159
147
118
152
36

24.84
53.6
20.91
0.65
51.96
48.04
38.56
49.67
11.76

95
211
160
125
21
171
102
33

30.9
69.1
52.29
40.85
6.86
55.89
33.3
10.78

Table 4 Environmental characteristics of 6–59 months oldchildren who visiting at Afar region public hospitals North
Eastern Ethiopia 2023
Characteristics
Had Safe water supply
Dispose refuse

Insect in the house
Types of insects

Latrine for defecation
Status of latrine
Types of latrines

Category
yes
NoOpen field
Communal pit
OthersYes
No
Mosquitoes
Fly
Both
OthersYes
No
PrivateCommunal
Pit latrine
VIPL

Frequency
65
241
172
110
24
195
111
81
56
47
11
170
136
130
40
159
11

percent
21.24
78.76
56.21
35.95
7.84
63.73
36.27
41.54
28.72
24.1
5.6
55.6
44.4
76.47
23.53
93.5
6.5

Hailu et al. BMC Pediatrics(2024) 24:589

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Table 5 Clinical profile of 6–59 months old children who visiting
at Afar region public hospitals North Eastern Ethiopia 2023
Clinical profile
Had Intestinal helminths
history
Current Parasitic/Protozoa
infection
Types of parasite/protozoa

Had Malaria diagnosis in thelast three months
Hemoglobin level

Anemia status of children
Severity of Anemia

Response
yes
No
yes
No
Giardia lambila
Entamoeba
histolaytica
Enterobius
vermicularis
YesNo≥ 11 mg/dl
10–10.9 g/dl
7.1–9.9 g/dl
≤ 7 g/dl
Non-anemic
AnemicMild Anemic
Moderate
AnemicSevere Anemic

Frequency
10
296
103
203
47
51

Percent
3.3
96.7
33.7
66.3
45.63
49.51

5

1.63

72
234
164
62
60
20
164
142
62
60

23.53
76.5
53.59
20.26
19.61
6.53
53.59
46.41
43.66
41.38

20

14.08

Fig. 1 Distribution of anemia by severity among 6–59 months old children who visiting at Afar region public hospitals, North Eastern Ethiopia,2023 (n = 142)

anemia, 60 (41.38 ) had moderate anemia, and 20 (14.08) had severe anemia (Fig. 1). The highest prevalence wasobserved in the age group of 24 to 35 months (68.8 ), with
rates gradually decreasing as the children’s age increased(Fig. 2).
Factors associated with Anemia

In a multivariate analysis, children aged 24 to 35 months
were three times more likely to be anemic than children
aged 48 to 59 months (AOR = 3.12, 95 CI: 1.47–7.11).
Children with mothers who had no formal education

were seven times more likely to be anemic (AOR = 7.06,
95 CI: 2.81–19.30) compared to children with mothers who had tertiary education. Furthermore, children
from rural areas were six times more likely to be anemic than children from urban areas (AOR = 6.11, 95 CI:
1.49–8.99). Children from families with five or moremembers were nearly four times more likely to be anemic (AOR = 3.76, 95 CI: 1.82–5.98) compared to thosefrom families with 2 to 4 members. Children who begancomplementary feeding early were 3.5 times more likely
to be anemic (AOR = 3.51, 95 CI: 2.36–6.51) than those
who started later. Children who had previously experienced a parasitic infection were nearly four times more
likely to be anemic (AOR = 3.76, 95 CI: 2.82–5.98) compared to those who had not. Additionally, children who
had malaria in the previous three months were 3.4 times
more likely to be anemic (AOR = 3.37, 95 CI: 2.16–11.31)
than those who had not had malaria. Similarly, children
who had diarrhea were three times more likely to be anemic (AOR = 2.9, 95 CI: 1.57–3.81) than those who did nothave diarrhea (Table 6).

Discussion
In the current study, the overall prevalence of anemia
among children aged 6 to 59 months attending public
hospitals in the Afar region was 46.41 . This indicatesthat anemia is a severe public health concern for thisage group, according to the WHO classification of anemia severity (> 40 ) [30]. This prevalence is comparable tostudies conducted in Kombolicha town [10], Debre Brehan (47.5 ) [16], Shanan Gibe Hospital (48.9 ) [31], andJimma Medical Center in South West Ethiopia (44.8 )[32]. However, it is lower than the national average [9],the 2016 EDHS report for the Afar region [9], as well as
findings from Ghana (78.4 ) [33] and Uganda (58.8 ) [34].
This discrepancy might be due to differences in study
settings; the studies mentioned above were conductedin community-based settings, which might result in ahigher prevalence of anemia. Other possible explanations
include differences in sample size, geographic variations,seasonal factors, and the equipment used for sample
analysis. Additionally, the prevalence found in the current study is higher than that reported in northwest Ethiopia (Gondar Town) [11], central Ethiopia (North Shewa)[12], northern Ethiopia (Tigray) [13], and southern Ethiopia (Hawassa Teaching Hospital) [14]. This disparity may
be attributed to the fact that the study area is frequently
affected by drought and conflict, has an inadequate safe
water supply, is a pastoral community, and experiences
lower productivity. These factors likely contribute to foodinsecurity in the region.
In the current study, children aged 6 to 59 months
who were from mothers with no education and had thelowest monthly family income were more likely to be

Hailu et al. BMC Pediatrics(2024) 24:589

Page 8 of 11

Fig. 2 Distribution of anemia by age among 6–59 months old children who visiting at Afar region public hospitals, North Eastern Ethiopia,2023

Table 6 Factors Associated with Anemia of 6–59 months old children who visiting at Afar region public hospitals, North Eastern
Ethiopia,2023
Variable

category

Maternal educational levelilliterate
Able to read & writeFirst cycle (1–4)
Second cycle (5–8)
Secondary school (9–12)
Tertiary education< 3000 Birr
3000–7500 Birr
> 7500 Birr
Rural
Urban
6–11
12–23
24–35
36–47
48–59
No previous birth< 24 months≥ 24 months
2–4
≥5
Yes
No
At 6 months< 6months≥ 6 months
Yes
No
Yes
No

Family monthly income

ResidenceAge of child in months

Birth interval

Family size
Diarrhea in the last 2 weeks
Initiation of weaning feeding

Current parasite infection
Malaria diagnosis in the last 3 months

Anemia status
Anemic
Non-anemic
69(58.3 )51(41.7 )41(56.2 )32(43.8 )13(40.7 )19(59.3 )4(19.1 )17(80.9 )11(27.5 )29(72.5 )4(20 )
16(80 )
59(55.1 )48(44.9 )48(43.2 )63(56.8 )35(39.8 )53(60.2 )81(75.7 )26(24.3 )61(31.6 )132(68.4 )22(43.1 )29(56.9 )37(52.9 )33(47.1 )53(68.8 )24(31.2 )12(20.3 )47(79.7 )18(36.7 )31(63.3 )27(36 )
48(64 )
85(54.5 )71(45.5 )30(40 )
45(60 )
63(46.3 )73(53.7 )79(46.5 )91(53.5 )25(44.6 )31(55.4 )117(46.8 )133(53.2 )51(43.2 )67(56.8 )59(38.8 )93(61.2 )12(33.3 )24(66.7 )54(52.4 )49(47.6 )88(43.3 )115(56.7 )42(58.3 )30(41.7 )100(42.7 )134(57.35 )

COR

AOR

P-value

4.09(1.98,8.51)
1.55(0.87,4.62)
0.71(0.35,1.97)
4.36(1.92,9.23)
0.23(1.43,3.36)
1.00
6.06(1.73,21.28)
2.24(1.49,3.36)
1.00
3.57(1.09,7.55)
1.00
3.27(2.50,8.45)
7.12(1.93,11.32)
2.32(1.93,5.78)
1.35(1.21,7.25)
1.00
1.22(0.51,2.73)
4.51(1.21,8.02)
1.00
1.00
4.51(1.21,8.01)
1.52(1.99,2.81)
1.00
1.00
2.82(1.21,6.10)
3.61(1.41,9.22)
4.51(2.13,7.56)
1.00
2.56(2.42,9.23)
1.00

7.06(2.81,19.3)
2.57(1.39,7.23)
0.43(0.13,1.51)
3.45(1.32,11.17)
1.21(0.32,2.29)
1.00
5.19(1.24,21.75)
2.11(1.21,3.69)
1.00
6.11(1.49,8.99)
1.00
4.62(0.85,7.44)
5.31(0.91,10.13)
3.12(1.47,7.11)
1.45(0.93,8.24)
1.00
1.16(3.92,3.21)
2.17(1.83,8.05)
1.00
1.00
3.76(1.82,5.98)
2.98(1.57,3.81)
1.00
1.00
3.51(2.36,6.51)
2.34(0.53,10.81)
3.76(2.82,5.98)
1.00
3.37(2.16,11.31)
1.00

0.02
0.023
0.05
0.3
0.71
0.001
0.023
0.01
0.1
0.08
0.00
0.23
0.84
0.003

0.004
0.003

0.03
0.61
0.029
0.005

Hailu et al. BMC Pediatrics(2024) 24:589

anemic. These findings are consistent with studies conducted in Kombolicha Town [10], Gondar Town [11],Gugufitu [15], Hawassa Referral Hospital [14], Tigray[27], and Shanan Gibe Hospital [31]. This may be because
children of mothers with no education might lack awareness about meal frequency and dietary diversity, which
can contribute to anemia. Additionally, families withthe lowest income may experience reduced productivity
and worsened food insecurity due to overcrowding, ultimately leading to higher rates of anemia. This suggeststhat enhancing parental education and promoting diversified agricultural practices could help address food security issues, including anemia.
In this study, children aged 6 to 59 months living inrural areas were more likely to be anemic than thosein urban settings. This finding aligns with results froma study conducted at Shanan Gibe Hospital in southwestern Ethiopia [31]. One possible explanation is thatlowland rural areas are more prone to anemia due to frequent droughts, inadequate water supplies, poor waste
disposal practices, higher rates of malaria, and limited
dietary diversity, as these areas are often pastoral communities. Conversely, a study from Gugufitu district innortheastern Ethiopia [15] found that urban children
were more likely to be anemic than those in rural areas.
This discrepancy might be attributed to differences inagricultural practices, geographic conditions, and watersupply. Gugufitu district benefits from more productive
and diversified agriculture, higher altitude (over 3000 m),
lower malaria prevalence, and better access to safe watercompared to the study area.
Children aged 24 to 35 months were found to be moreanemic than younger infants up to 24 months old. Thisfinding contrasts with studies conducted in Kilte Awulaelo Woreda [27], Hawassa Referral Hospital [14], Gugufitu [15], Menz Gera [12], and Kombolicha [10], whichfound that younger children (6–24 months) were moreanemic than older children. One possible explanationis that younger infants may benefit from breastfeeding,while older children, who are transitioning to a morediverse diet, might have less nutritional variety in theirdiet. This lack of diversity during this period can makethem more vulnerable to anemia.
Children who were weaned early were more susceptible
to anemia than those who began weaning at the appropriate age. This finding aligns with studies conductedin Gugufitu and Kombolicha Towns [10, 15]. The likely
explanation is that exclusive breastfeeding for up to six
months, as recommended by the WHO, is the optimal
feeding strategy. This approach helps prevent respiratory,
diarrheal, and chronic diseases and reduces the risk ofanemia [35]. These findings imply that starting supplemental feeding too early significantly increases the risk ofdiarrheal illness and anemia.

Page 9 of 11

In the current study, children who had previously diagnosed parasite infection and malaria and had diarrhea inthe last two weeks were more likely to have anemia. This
is in line with studies in Shanan Gibe Hospital, southwest Ethiopia, and Kombolicha, northeastern Ethiopia,
respectively [10, 31]. One possible explanation is thatparasitic and malaria infections lead to the destruction of
red blood cells (RBCs), resulting in a significant decreasein RBC count, commonly known as anemia. Additionally, the parasites that cause diarrhea also contribute toanemia. This suggests that further efforts are needed to
improve the safe water supply, increase the uptake ofdeworming treatments, and enhance malaria control
measures.
Strength and limitation of the study

The study was conducted in a multi-center setting andused a measurement tool that considered various factors associated with anemia in children aged 6–59
months, including anthropometric data, stool examinations, environmental factors, and relevant child feedingpractices. Anemia was determined solely using hemoglobin concentration criteria; however, the addition ofother measurements such as serum ferritin may allow for
improved case distinction. Because this is an institutionbased study, the findings cannot be generalized to thegreater community. Objective approaches did not prove
the presence of comorbidities such as malaria and diarrhea. We simply asked parents if their child had been
exposed to these situations in the previous three months
or two weeks. The recall and comprehension of respondents would influence the reliability of this reply. Furthermore, because this study was conducted just during
a single season, the prevalence may not be representative
throughout the year.

Conclusion
According to the WHO classification, the prevalenceof anemia among children aged six to 59 months in the
study area was severe, posing serious public health challenges. Factors significantly associated with anemia
included the child’s age, maternal education, family size
and income, rural residence, early initiation of weaning,and diagnoses of diarrhea, malaria, and parasitic infections. Extensive community- and facility-based efforts
to promote exclusive breastfeeding should be strengthened. Empowering mothers through adult educationand mixed farming can also help address food security
issues. Additionally, improvements in safe water supply,
deworming programs, and malaria control activities are
essential. Researchers are encouraged to use follow-up
studies to explore more biomarkers to better understandthe origins of anemia and its fluctuations over time.

Hailu et al. BMC Pediatrics(2024) 24:589

Abbreviations
ANC	Antenatal Care
AOR	Adjusted Odds Ratio
CI	Confidence Interval
COR 	Crude Odds Ratio
EDHS	Ethiopian Demographic and Health Survey
g/dl 	Gram per deciliter
Hgb 	Hemoglobin
IYCF	Infant and Young Child Feeding
IMNCI	Integrated Management of Neonatal and Child Illness
PNC 	Post Natal Care
RBC	Red Blood Cell
SD	Standard Deviations
TB	TuberculosisWHO	World Health Organization
Acknowledgements
The authors would like to thank the Afar region public hospitals managers,
the care providers, and the participants families for their kind cooperation. The
authors are also thankful to the data collectors and the study participants.
Author contributions
Molla Kasssa made substantial contributions to conception and design,acquisition of data, or analysis and interpretation of data; Muluken Amare
involving in drafting the article or revising it critically for important intellectual
content; agreed to submit to the current journal; gave final approval of theversion to be published; and agree to be accountable for all aspects of thework; Tarikua Afework , Yemane Eshetu, and Dagne Belete took part in revising
it critically for important intellectual content. Furthermore, involved more inacquisition of data, or analysis and interpretation of data.
Funding
No external funds were obtained; only institutional support from Afar region
public hospitals and Wollo university.
Data availability
All data generated or analyzed during this study are included in the
manuscript and are also available from the corresponding authors up on
request.

Declarations
Ethical approval and consent to participate
This study was approved by the Wollo University College of Medicine and
Health science research and community service committee and ethicalclearance was obtained. Additionally, before commencing the study,
permission letters were obtained from each hospital manager and thequality assurance department. Written informed consent was obtained fromeach children mother. Moreover, this study was conducted in compliancewith the Declaration of Helsinki. The purpose and significance of the study
were clearly explained to the children’s mothers during the hematologic,stool, and anthropometric assessments. The autonomy and dignity of theparticipants were respected, and they were allowed to pause the assessments
if they experienced any discomfort. Anonymous data were obtained and theconfidentiality of participants information was secured. Moreover, subject
confidentiality and any special data security requirements were maintained
and assured through the use of codes instead of participants’ names.
Consent for publication
Not applicable.
Competing of interests
The authors declare no competing interests.
Author details
1
Department of pediatrics and child health Nursing, College of Medicine
and Health Sciences, Wollo University, P. O. Box: 1145, Dessie, Dessie
1145, Ethiopia
2
Department of maternity and reproductive health Nursing, College ofMedicine and Health Sciences, Wollo University, Dessie 1145, Ethiopia

Page 10 of 11

3

Department of Public Health Nutrition, College of Medicine and Health
Sciences, Wollo University, Dessie 1145, Ethiopia
Received: 23 November 2023 / Accepted: 11 September 2024

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