This study employed multilevel logistic regression model to determine predictors of anemia among 2434 children under-five years in Ghana. The study found unobserved substantial community level differences in the probability of anemia among this group of children. Thus, the probability of developing anemia differs from one community to another in the country, suggesting the need for targeted community level public health interventions aimed at reducing anemia within communities rather than universal interventions. The risk of anemia was found to be higher in children below two years, male children, children born to adolescent mothers, children born to non-Christian homes, children whose mothers were not covered with health insurance, leaving in either upper west or central region and children born to families of poorer households. Our findings’ revealed anemia was prevalent among 54% of children under five, an estimate lower than 76.6% in Sub-Sahara Africa [33] but reasonably higher in other sub-Sahara Africa countries[13, 34] and global estimates of 40.0% in 2019 [16, 35]. Although the World Health Organization considers anemia prevalence greater than 40% as a severe public health problem, findings from this study and another study showed that Ghana’s anemia prevalence in children under-five years has reduced from 78% in 2008 to 66% in 2014 and further to 54% in 2019 which implies anemia intervention control programs implemented are gradually influencing the population [36]. This shows that although Ghana’s anemia prevalence is lower than most developing countries [37] it is still a severe public health concern which needs specific geographic, behavioral, community and individual interventions to reduce it drastically.
Also, older children (> 2 years) were at a lesser risk of anemia compared to infants as shown in this study. This is in line with several studies that reported on high prevalence among infants and children under two years compared to older children[35, 38]. The higher prevalence of anemia is likely to be the effect of monotonous diets, poor feeding habits during weaning periods worsens the problem of anemia as breast milk is replaced with meals that lack irons, vitamins, and other essential nutrients. Also, during infancy, these children are more vulnerable to diseases because they have less developed immune system, and this makes them more likely to be susceptible to anemia which is largely caused by low level of iron. Although babies are born with iron stored in their bodies, because of their rapid growth, they need to absorb a lot of iron each day. Iron deficiency anemia most commonly affects babies 9 through 24 months old.
Furthermore, our results showed that the risk of anemia when a child has malaria is higher which is consistent with a study by [28, 33, 36, 39]. The main approach to preventing anemia in children under five is through malaria prevention, diagnoses, and treatment [36]. Several studies have confirmed the presence of malaria in children causes severe anemia which may lead cognitive issues and even death [34]. In some parts of Ghana, sanitation issues, vegetation, rainfall, and precipitation contribute to the formation of natural habitats for mosquitoes thereby increasing children’s risk of malaria in such regions [35].
A study conducted across multiple countries in sub-Sahara Africa confirms our findings that females were at lower risk of anemia compared to the male child although significant variations was not observed between the two genders in a study analysis of three national demographic health survey data from Ghana [7, 33, 40]. The prevalence of anemia was higher in males than females this is similar in studies conducted by [33, 34, 37, 38, 40] where male children less than 60 months older exhibited a higher fold of being diagnosed with anemia than females. Reasons being male children have a higher pre-natal and post-natal growth [41]. Conversely at puberty anemia is more prevalent in females than males due to menstruation, but that difference couldn’t be established in a study elsewhere [40].
Further, our findings of higher risk of anemia among children in poorer households is also supported by multiple literature [33, 42–44]. Children from poorer households may be fed monotonous, competition for food, insufficient meals per day, undernutritious diets which wouldn’t contain the essential nutrients to prevent anemia, hence they are being at higher risk of anemia compared to children from richer homes who because of the availability of resources may be fed with right proportions of healthy meals [7].
In addition, increase in household size was found to be associated with increased risk of anemia among children. This is supported by findings from elsewhere in Ethiopia [42] and a systematic review in Africa [13]. Reducing household crowding, improving toilet and water facilities helped in reducing the risk of anemia in children under-five years[34].
Although the univariate analysis showed that anemia was more prevalent in the rural areas compared to the urban areas, both the fixed and multilevel multivariable analysis did not show differentials in anemia prevalence between the rural and urban areas. This finding was also observed in other literature where residence was no longer significant after adjusting for other factors [7]. This suggest that, implementing interventions in just rural areas are not the best approach but instead, it imperative we go further to identify what demographic of children is associated with anemia within these rural areas. This however may not be the same for other settings [42]. In a study by Gebreweld et al, [35] children under five urban dwellers were 1.8 times more likely to be anemic than children under five rural dwellers [35].
Major findings
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Anemia was prevalent among 54.5% (95% CI: 52.0%-57.0%)
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Substantial unobserved community level differences exist in anemia prevalence.
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Anemia was highest among children below two years.
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Anemia was 50% higher among children with history of malaria in the past two weeks.
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Anemia was higher among children born to adolescent mothers.
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Anemia was higher among children to mothers in non-Christian homes.
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Anemia was over 40% more prevalent among children whose mothers were not covered by health insurance.
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Anemia was higher among children within households of 7 or more members.
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Anemia was highest in the Central and Upper East regions.
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Anemia was higher among children in poorer households compared to richer households.
Study Limitations
The study used a cross-sectional study design hence interpretation of results should be done in the context of association and not causality. Also, given that the measurement was among only children alive at the time of the survey, the results is likely to be biased especially for the exclusion of children who died due to anemia related causes. The data is also limited in terms of availability of other variables that are likely to impact the hemoglobin level such as uptake of iron supplementation, diarrhea among children and others.