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Objectives This study aims to identify the child-level, maternal-level, household-level and community-level determinants of anaemia among children aged 6-59 months, and determine the inequities of anaemia prevalence across communities in Mozambique. Design Cross-sectional study. Setting Mozambique. Participants This study used data of a weighted population of 3946 children, 6-59 months, delivered by women between 15 and 49 years of age, from the 2018 Mozambique Malaria Indicator Survey. Primary outcome measure Child’s anaemic status, measured as altitude-adjusted haemoglobin concentration (in g/L); the severity of anaemia was categorised based on predefined threshold values. Multilevel Bayesian linear regressions identified key determinants of childhood anaemia. Based on data availability and policy implications, spatial analysis was used to determine geographical variation of anaemia at the community level and areas with higher risks. Results The mean prevalence of childhood anaemia was 77.7% (SD: 5.5%). Provincially, Cabo Delgado province (86.2%) had the highest prevalence, Maputo province (70.2%) the lowest. Children with excess risk were mostly found in communities that had proximity to provincial borders: Niassa-Cabo Delgado-Nampula triprovincial border, Gaza-Inhambane border, Zambezia-Nampula border and provinces of Manica and Inhambane. Children with anaemia tended to be younger, males and at risk of having malaria because they were not sleeping under mosquito nets. In addition, children from poor families relative to children from wealthier households and those living in female-headed households were prone to anaemia. Conclusion Findings from this study provide evidence that spatial inequities in childhood anaemia exist in Mozambique, mostly concentrated in the communities living close to the provincial borders. Anaemia among children could be effectively reduced through malaria prevention, for example, bed netting. Interventions are needed that generate income for households, increase community support for households headed by women, improve malaria control, build capacity of healthcare workers to manage severely anaemic children and health education for mothers.
Mozambique is a Southeastern African country that shares boundary with the Indian Ocean to the east, Tanzania to the north, Malawi and Zambia to the northwest, Zimbabwe to the west, and Eswatini and South Africa to the southwest. The country is divided into 10 provinces and a capital city (Maputo), which are further divided into 129 districts. The districts are subdivided into 405 administrative posts and then into local communities—the lowest geographical unit. According to 2017 census, Mozambique’s population was estimated at 29 million, with preponderance of young people—nearly half (46.6%) are under age 15 years.24 Almost 6 out of 10 Mozambicans reside in rural areas.25 According to the 2019 United Nations Development Programme Human Development report, Mozambique ranks 181 out of 189 countries in human development league table, and 72.5% of its population lives in poverty.26 This is a cross-sectional study that used child recode datafile and the global positioning system (GPS) dataset of the 2018 Mozambique MIS.27 The survey was conducted between March 2018 and June 2018 by the Moçambique Instituto Nacional de Saúde, in collaboration with ICF International Calverton, Maryland, USA, to provide national and subnational estimates of anaemia and malaria indicators for policy and programmatic purposes. The details of the methodology used for the survey has been published elsewhere.28 With a stratified two-stage sampling design, face-to-face standardised questionnaire interviews were conducted among women aged 15–49 years. Using probability proportional to size, the first stage of sampling involved selection of 224 clusters or enumeration areas (otherwise known as the primary sampling units (PSU)) from the 2007 General Population and Housing Census.28 Out of the 224 clusters, 58.9% were in rural areas, while the rest were in urban areas. The second stage involved systematic sampling of 6279 households. Each household was randomly selected from the household listing, with an average of 28 households per cluster. For this study, the clusters are referred to as the ‘communities’ because they are believed to comprise homogenous or kinship populations. Of the 6279 households, the response rate was 99%, while out of the 6290 eligible women identified, 6184 could be interviewed (response rate of 98.3%). With the consent of the parents/caregivers, blood samples were collected in a microcuvette from the heel (of children aged 6–11 months) or fingers (of the children aged 12–59 months) for Hb concentration estimation. After discarding the first drop of blood to avoid possible contamination, Hb concentration was estimated with the second drop, using an automatic haematology analyser (HemoCue 201+). For this study, a subpopulation of 3652 (weighted: 3946) singletons aged 6–59 months who were alive at the commencement of the survey and had Hb concentration results reported were analysed. This is a secondary analysis of data available online27 where the datasets are deidentified of the respondents’ personal information; hence, no ethical approval was required for this specific study. However, prior to the commencement of the primary survey, ethical clearances were obtained by the Demographic and Health Survey (DHS) team from National Committee for Bioethics in Health of Mozambique (Comité Nacional de Bioética para Saúde). Also, written informed consent was obtained from all mothers during the field work. Following registration and submission of research protocol, administrative access to the dataset was granted by the DHS team, USA. The survey data files were provided at no cost for academic research.28 Patient and public involvement was not possible in this study given it was based on an analysis of secondary data.
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