Prevalence of Anemia and Associated Factors among Infants and Young Children Aged 6-23 Months in Debre Berhan Town, North Shewa, Ethiopia

Background. Anemia is a problem of both the developed and developing world, which occurs in all age groups of the population. Half of the anemia cases are due to iron deficiency and affects physical growth and mental development. Nevertheless, there is a scarcity of information about anemia and associated factors among infants and young children aged 6 to 23 months in low-income countries like Ethiopia. Objective. The aim of this study was to assess the prevalence of anemia and associated factors among infants and young children aged 6-23 months. Methods. A community-based cross-sectional study design was used among 531 mothers/caregivers-children pairs in Debre Berhan Town, North Shewa, Ethiopia, from February 1 to March 2, 2018. The cluster sampling technique was used to select the study participants. Sociodemographic data were collected from mothers/caregivers using pretested structured questionnaires. Hemoglobin levels were measured using a HemoCue analyzer machine (HemoCue® Hb 301, Ängelholm, Sweden). All relevant data were described using descriptive statistics such as frequencies, proportions, mean, and standard deviation. Odds ratio and 95% CI were estimated using binary logistic regression to measure the strength of the association between anemia and explanatory variables. The level of statistical significance was declared at P<0.05. Results. The overall prevalence of anemia was 47.5% (95% CI: 43.1-51.4%) of which 18.3% were mildly anemic, 25% were moderately anemic, and 4.1% were severely anemic. In multivariable logistic regression analysis, household food insecurity (AOR = 2.7, 95% CI: 1.6-4.5), unmet minimum dietary diversity (AOR = 2.5, 95% CI: 1.4-4.3), stunting (AOR = 2.3, 95% CI: 1.2-4.3), and underweight (AOR = 2.7, 95% CI: 1.4-5.4) positively associated with anemia while having ≥4 antenatal care visits (AOR = 0.5, 95% CI: 0.3-0.9) and met minimum meal frequency (AOR = 0.25, 95% CI: 0.14-0.45) had a protective effect against anemia. Conclusion. Generally, the study showed that anemia was a severe public health problem among infants and young children in the study setting. Antenatal care visit, meal frequency, dietary diversity, underweight, stunting, and food insecurity significantly associated with anemia. Therefore, efforts should be made to strengthen infant and young child feeding practices and antenatal care utilization and ensure household food security, thereby improving the nutritional status of children. A community-based cross-sectional study was conducted from 1 February to 2 March, 2018, in Debre Berhan Town, North Shewa Zone, Amhara, Regional State, Ethiopia. Emperor Zara Yaqob founded the town and served as the capital of the North Shewa Zone. The town is located 130 km from Addis Ababa, the capital city of Ethiopia, and 690 km from Bahir Dar, the capital of the Amhara Region. The town has an altitude of 2840 meters above sea level. The area practices a mixed farming system: crop production with animal husbandry. The main crop production in the area is barley, wheat, peas, lentils, and linseed. Cattle, sheep, horses, donkeys, and mules are the main live stocks. According to the 2017 Town Health Administrative Office report, the town has a total population of 88369, of whom 14011 are under-five children and 6707 are children under two years. The town has nine kebeles (the smallest administrative unit) in Ethiopia, one referral hospital, three health centers, and 14 health posts. The source population of the study was all infants and young children aged 6–23 months and their mothers or caregivers in Debre Berhan Town. The study population was all infants and young children aged 6–23 months and their mothers/caretakers living in three randomly selected kebeles/clusters. All mother/caregiver-child pairs living for at least six months in the study were included in the study. Mothers or caregivers who were unable to respond to the interview due to their child's or their own illness and infants and children who had taken iron or vitamin A supplements or subjected to deworming or blood loss due to injury in the past three months were excluded from the study. The cluster sampling technique was used to select mother/caregiver-child pairs. Debre Berhan Town has 9 kebeles and three randomly selected kebeles are considered as clusters. The total number of children in each selected cluster was obtained from health extension workers (HEWs) family folder documentation. Based on the records of HEWs, 577 infants and young children aged 6–23 months were found in the selected clusters. The sample size was determined using a single population proportion formula with the following assumptions: prevalence of anemia among children aged 6–23 months to be 66.6% (22), 5% margin of error, 95% confidence level, design effect of 1.5, and 10% for nonresponse, which gave rise to 564 samples. In the case of more than one child being available in a given household, both children were included in the study. Due to the nature of cluster sampling, 577 infants and young children-mothers pairs living in selected clusters were included in the study. Socioeconomic and demographic data of mothers or caregivers and their children were collected through home-to-home visits using a pretested structured interviewing-administered questionnaire which was adapted from similar studies [21, 22]. The birth date of the children was recorded based on mothers' or caregivers' verbal reports. The child's dietary diversity score was assessed using the dietary diversity assessment tool adapted from the WHO standardized questionnaire for infant and young child feeding practices. It was based on the mother's or caregiver's recall of all foods given to her child in the past twenty-four hours prior to the survey. The dietary diversity score was based on seven food groups consumed by the child: grains, roots and tubers, legumes and nuts, dairy products, flesh foods, eggs, vitamin A-rich fruits and vegetables, and other fruits and vegetables [18]. Household food security status was measured using the Household Food Insecurity Access Scale (HFIAS), a structured, standardized, and validated tool developed by the Food and Nutrition Technical Assistance (FANTA), which has nine occurrences and frequency of occurrence questions based on the previous four weeks or one-month recall method [27]. Anthropometric data, such as the child's height and weight, were also collected. The child's length was measured to the nearest 0.1 centimeters using the United Nation Children's Fund (UNICEF) horizontal wooden length board with a movable headpiece on a flat surface. Children were kept in a recumbent position and the five contact points, including the head, shoulders, buttocks, calves, and heels, were maintained against the length of the board in a straight direction. The child's weight was measured to the nearest 0.1 kg. The weight of a child was estimated by subtracting the mother's/caregiver's weight record from the weight record of both mother and child obtained together. Each anthropometric measurement was measured after removing shoes, heavy clothes, and capes. Each participant was measured twice and the average value was taken when there were variations between two consecutive measurements. The weight scale was adjusted to zero level and calibrated using a standard 2 kg weight object before weighing each study participant. Hemoglobin level was measured with a HemoCue analyzer machine (HemoCue® Hb 301, Ängelholm, Sweden). The HemoCue HB 301 analyzer has internal quality control, the self-test. Every time the analyzer is turned on, the analyzer automatically verifies the measurement performance. This test is performed at regular intervals if the analyzer remains switched on. Upon passing the self-test, the display will show the HemoCue system and three dashes showing that the analyzer is ready to perform the measurement [28]. When an error code was displayed due to self-test failure, a quality control measure was performed according to the recommended guideline. A separate lancet was used for each child's finger pricking. After wiping off the first two drops of the blood sample, a third drop was collected and completely filled to a cuvette in one continuous motion. Hemoglobin data were adjusted during analysis at an altitude of 2840 meters above sea level and hemoglobin adjustment was done according to the WHO 2011 recommendation [29]. The hemoglobin cutoff point is based on the WHO's classification of under-five anemia, defined as hemoglobin level <11 g/dL [5]. A child with a hemoglobin value <11 g/dL was confirmed as anemic. Data collection tools were prepared in English and translated into Amharic and then translated back into English to check for its consistency. Pretest was done on 5% of the study sample in the nonselected kebele. Two days of training was given to data collectors and supervisors on the objectives and context of the study, content of the questionnaire, how to fill the questionnaire in the field, interview technique, household selection procedure, respondent approaching technique, hemoglobin, and anthropometric measurement. The relative technical error of measurement (%TEM) was calculated to minimize intra- and interobserver variability [32]. Data collection was supervised by two BSc nurses, and the principal investigator supervised the overall data collection process. Data were double-entered by two independent data clerks for cross-validation. First, data were checked for completeness, accuracy, and consistency before entering the computer. Data were then coded and entered into Epi-Data version 3.1 and exported to IBM-SPSS version 22 statistical software for analysis. The household wealth index was computed using principal component analysis (PCA) with all its assumptions, after which it was categorized into five quintiles: lowest, second, middle, fourth, and highest. Nutritional indices of infants and young children, such as height-for-age Z-score (HAZ), weight-for-age Z-score (WAZ), and weight-for-height Z-score (WHZ), were calculated according to the WHO 2006 multicenter growth reference [23]. WHO Anthros 2005 Software version 3.2.2 was used to calculate Z-scores, and infant and young children were categorized as being stunted (HAZ <−2 SD Z-scores), underweight (WAZ <−2SD Z-scores), and wasted (WHZ <−2SD Z-scores). Bivariate logistic regression was done to see the association between each independent variable and the outcome variable, anemia. Covariates with P value <0.25 during bivariate logistic regression analyses such as maternal education, wealth index, child's sex and age, food security status, antenatal care follow-up, birth interval, introduction of complementary foods, dietary diversity, meal frequency, undernutrition (stunting, underweight), and presence of fever and diarrhea were retained for multivariable logistic regression analysis to control for all possible confounders and to identify predictors of anemia. Multicollinearity between independent variables was checked using the value of standard error (SE), whereby all variables with SE less than 2 were considered. Model fitness was checked with the Hosmer–Lemeshow test and its P value was greater than 0.05. In a multivariable analysis, adjusted odds ratio (AOR) and 95% confidence interval were estimated to measure the strength of association between the dependent variable and covariates. The level of statistical significance was declared at P value <0.05. Before the commencement of data collection, Haramaya University Institutional Health Research Ethics Review Committee (IHRERC) reviewed and approved the study with reference number C/Ac/R/D/01/878/18. Each study participant was informed, and voluntary, written, and signed consent was secured. Children who were found to be anemic during data collection were linked to the nearest health facility for treatment.