Association between anemia and household water source or sanitation in preschool children: the Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project

Improved sanitation and co-occurrence of anemia and stunting in Indonesian children: A retrospective cohort study

Anemia and stunting are major public health concerns in low- and middle-income countries, including Indonesia, with significant impacts on child development, morbidity, and mortality. The aim of this study was to assess the effect of improved sanitation on the co-occurrence of anemia and stunting (CAS) in Indonesian children using pooled data from the Indonesian Family Life Survey (IFLS) across three waves, from IFLS 3 in 2000, IFLS 4 in 2007, and IFLS 5 in 2014. The sample included 839 children aged 1-5 years with complete anthropometric and hemoglobin data, measured in 2000 as the baseline cohort and followed across subsequent waves. The main independent variable was improved sanitation, and other covariates included maternal and child characteristics, parental factors, and socio-economic status. Multinomial logistic regression was used to assess the impact of sanitation over time. The prevalence of CAS was 30.75% in 2000, 6.08% in 2007, and 4.29% in 2014. Stunting-only prevalence increased from 16.21% in 2000 to 27.41% in 2007 but decreased to 19.31% in 2014. Anemia-only prevalence decreased from 31.23% in 2000 to 10.25% in 2007 and slightly rose to 16.92% in 2014. The analysis found that children with unimproved sanitation were at significantly higher risk of CAS (crude relative risk ratio (RRR): 2.49; 95% confidence interval (CI): 1.92-3.23), which decreased after adjusting for confounding factors (adjusted RRR: 1.55; 95%CI: 1.12-2.14). Similarly, the risk for anemia was higher in children with unimproved sanitation (adjusted RRR: 1. 43; 95%CI: 1.07-1.90). However, the risk for stunting was not statistically significant after adjustment. This study underscores the importance of improved sanitation in reducing anemia and stunting but also highlights the need to address other factors, such as nutrition, maternal health, and socioeconomic inequalities, through comprehensive public health policies.

Prevalence and determinants of stunting and anaemia in children aged 6-23 months: A multilevel analysis from rural Ethiopia

Low- and middle-income countries shoulder the greatest burden of stunting and anaemia in children. This calls for prompt and effective intervention measures, while the contributing factors are not fully understood. This study evaluates determinants spanning from individual-, household- and community levels including agroecology and antinutrients as unique sets of predictors. Primary data were collected from 660 rural households representing the midland (ML), highland, and upper highland (UHL) agroecological zones from northern Ethiopia. The study relates several predictors to stunting and anaemia in children aged 6-23 months. We found 49.1% and 49.7% of children were stunted and anaemic, respectively. Children living in the ML are approximately twice more likely to be stunted adjusted odds ratio (AOR: 1.869; 95% CI: 1.147-3.043) than in the UHL. The risk of stunting increases by 16.3% and 41.9% for every unit increase in phytate-to-zinc and phytate-to-iron molar ratios, respectively. A 10% increase in mean aggregated crop yield was observed to reduce the likelihood of stunting occurrence by 13.6%. Households lacking non-farm income-generating opportunities, travel longer time to access the marketplace and poor health service utilisation were associated with increased risk of stunting. Low diversity of child's diet, age of the child (18-23 months) and mothers at a younger age are significantly associated with stunting. Risk of anaemia in children is high amongst households with unimproved water, sanitation, and hygiene practices, younger age (6-11 months) and mostly occurs amongst boys. Children in the ML had a 55% reduced risk of being anaemic (AOR: 0.446; 95% CI: 0.273-0.728) as compared to the UHL. Therefore, the influence of these factors should be considered to tailor strategies for reducing undernutrition in children of 6-23 months in rural Ethiopia. Interventions should go beyond the administrative boundaries into targeting agroecological variation.

Diets, Fruit and Vegetable Intake and Nutritional Status Among Children, Adolescents and Adults in the Philippines: A Scoping Review

Suboptimal diets contribute to the risk of malnutrition and non-communicable diseases across the life course. Globally, intakes of fruit and vegetables (F&V) fall below recommendations, including in the Philippines. To promote F&V intakes, understanding the extent of inadequate intakes across population groups and key drivers of dietary patterns is needed. This narrative scoping review was conducted to map the diet, F&V intakes and nutritional status in the Philippines. PubMed was searched using keywords specific to diet, F&V intake, and nutritional status, with 50, 24 and 22 articles meeting the inclusion criteria for diet, F&V intake, and nutritional status, respectively. Available evidence indicates that across all population and sociodemographic groups, diets lacked diversity, with high intakes of energy-dense, nutrient-poor foods, such as refined rice and sugar-based foods and beverages, contributing to inadequate micronutrient intakes. Intakes of F&V were especially low across all population groups. Stunting/short height, wasting and underweight were prevalent among children and adolescents, and micronutrient deficiencies (iron, zinc, vitamin A) were common among children < 5 years of age. More than one-quarter of adults were overweight or obese and demonstrated poor cardiometabolic health. A lack of published evidence identified through this search reported on pregnant and lactating women and women of reproductive age. Published evaluations assessing the impact of interventions or programmes to improve diets or F&V intake were limited. Additional research to fill these gaps will help design interventions and target entry points to improve diet diversity and F&V intakes across all population groups.

Beyond WASH: Testing Additional Connections Between Household Water Insecurity and Child Nutrition Outcomes in Multi-Country Contexts

This study identifies multiple pathways connecting household water insecurity with child nutrition. Using nationally representative samples for 18 countries, we examine the mediating role of child's dietary diversity as a function of household water status, while also accounting for sanitation. We construct a latent household water insecurity score (HWI) and use Structural Equation approach to model underlying pathways. HWI affected child's HAZ score and hemoglobin both directly and indirectly, with a mediation from child feeding alongside effects from sanitation. Broadening the conception of household water insecurity and accommodating the indirect effects of water could improve explanations of child under-nutrition.

Childhood undernutrition mediates the relationship between open defecation with anemia among Ethiopian children: a nationally representative cross-sectional study

BACKGROUND

Poor sanitation and/or open defecation are a significant public health problem in Ethiopia, where access to improved sanitation facilities is still limited. There is a growing body of literature about the effect of open defecation on children's linear growth failure. However, very few studies about the effects of open defecation on child anemia exist. In this study, we examine whether childhood undernutrition (i.e. stunting, wasting, and underweight) mediates the relationship between open defecation and childhood anemia in children aged 6-59 months in Ethiopia.

METHODS

We used pooled Ethiopia Demographic and Health Survey data (2005-2016) comprising 21,918 (weighted data) children aged 6-59 months. Anemia was defined as an altitude-adjusted hemoglobin (Hb) level of less than 11 g/deciliter (g/dl) for children under 5 years. Childhood undernutrition was assessed using height-for-age Z-scores (HAZ), weight-for-age Z-scores (WAZ), and weight-for-height Z-scores (WHZ) for stunting, wasting, and underweight respectively. Mediation effects were calculated using the bootstrap and the indirect effect was considered significant when the 95% bootstrap confidence intervals (95% CI) did not contain zero. Moreover, separate multilevel regression analyses were used to explore the statistical association between open defecation and child anemia, after adjusting for potential confounders.

RESULTS

Our analysis revealed that nearly half (49.6%) of children aged 6 to 59 months were anemic, 46.8% were stunted, 9.9% were wasted, and 29.5% were underweight. Additionally, 45.1% of children belonged to households that practiced open defecation (OD). Open defecation was associated with anemia (AOR: 1.28; 95% CI: 1.18-1.39) and it positively predicted anemia with direct effect of β = 0.233, p < 0.001. Childhood undernutrition showed a partial mediating role in the relationship between OD and anemia. Analyzing the indirect effects, results revealed that child undernutrition significantly mediated the relationship between open defecation and anemia (stunting (βindirect = 0.014, p < 0.001), wasting (βindirect = 0.009, p = 0.002), and underweight (βindirect = 0.012, p < 0.001)). When the mediating role of child undernutrition was accounted for, open defecation had a positive impact on anemia with a total effect of βtotal = 0.285, p < 0.001.

CONCLUSION

Open defecation showed a significant direct effect on anemia. Child undernutrition remarkably mediated the relationship between OD and anemia that further magnified the effect. This finding has an important programmatic implication calling for strengthened, accelerated and large-scale implementation of strategies to end open defecation and achieve universal access to sanitation in Ethiopia.

Household environment associated with anaemia among children aged 6-59 months in Ethiopia: a multilevel analysis of Ethiopia demographic and health survey (2005-2016)

BACKGROUND

Anaemia continues to be a major public health challenge globally, including in Ethiopia. Previous studies have suggested that improved household environmental conditions may reduce anaemia prevalence; however, population-level evidence of this link is lacking in low-income countries. Therefore, this study aimed to examine the association between environmental factors and childhood anaemia in Ethiopia.

METHODS

In this study, we conducted an analysis of the data from the Ethiopian Demographic and Health Survey (EDHS), a nationally representative population-based survey conducted in Ethiopia between 2005 and 2016. The study included a total of 21,918 children aged 6-59 months. Children were considered anemic if their hemoglobin (Hb) concentration was less than 11.0 g/dl. To examine the association between environmental factors and anemia, we used multilevel mixed-effect models. These models allowed us to control for various confounding factors including: child, maternal, household and community-level variables. The study findings have been reported as adjusted odds ratios (AORs) along with 95% confidence intervals (CIs) at a significance level of p < 0.05.

RESULTS

The study found the overall prevalence of childhood anaemia to be 49.3% (95%CI: 48.7-49.9) between 2005 and 2016 in Ethiopia. The prevalence was 47.6% (95%CI: 46.1-49.1) in 2005, 42.8% (95%CI: 41.8-43.8) in 2011, and increased to 57.4% (95%CI: 56.3-58.4) in 2016. The pooled data showed that children from households practising open defecation were more likely to be anaemic (AOR: 1.19, 95% CI: 1.05-1.36). In our survey specify analysis, the odds of anaemia were higher among children from households practising open defecation (AOR: 1.33, 95% CI: 1.12-1.58) in the EDHS-2011 and EDHS-2016 (AOR: 1.49, 95% CI: 1.13-1.90). In contrast, neither household water sources nor the time to obtain water was associated with anaemia after controlling for potential confounders. The other variables significantly associated with childhood anaemia include: the child's age (6-35 months), not fully vaccinated (AOR: 1.14, 95%CI: 1.05-1.24), children not dewormed in the last 6 months (AOR: 1.11, 95%CI: 1.01-1.24), children born to mothers not working (AOR: 1.10, 95%CI: 1.02-1.19), children from poor households (AOR: 1.18: 95%CI: 1.06-1.31), and rural residence (AOR: 1.23, 95%CI: 1.06-1.42).

CONCLUSION

In Ethiopia, about fifty percent of children suffer from childhood anemia, making it a serious public health issue. Open defecation is a major contributing factor to this scourge. To address this issue effectively, it is recommended to strengthen initiatives aimed at eliminating open defecation that involve various approaches, including sanitation infrastructure development, behavior change campaigns, and policy interventions. In addition, to reduce the burden of anemia in children, a multi-faceted approach is necessary, involving both prevention and treatment strategies.

Anemia in children aged 6-59 months was significantly associated with maternal anemia status in rural Zimbabwe

Globally, anemia is a public health problem affecting mostly women of reproductive age (WRA, n = 452) and children aged 6-59 months (n = 452) from low- and lower-middle-income countries. This cross-sectional study assessed the prevalence and determinants of anemia in WRA and children aged 6-59 months in rural Zimbabwe. The venous blood sample was measured for hemoglobin utilizing a HemoCue machine. Anthropometric indices were assessed and classified based on World Health Organization standards. Socioeconomic characteristics were assessed. The median (±inter quartile range (IQR)) age of WRA was 29 ± 12 years and that for children was 29 ± 14 months. The prevalence of anemia was 29.6% and 17.9% in children and WRA, respectively, while the median (±IQR) hemoglobin levels were 13.4 ± 1.8 and 11.7 ± 1.5 g/dl among women and children, respectively. Multiple logistic regression analysis was used to assess determinants of anemia. Anemia in children was significantly associated with maternal anemia (odds ratio (OR) = 2.02; 95% CI 1.21-3.37; p = .007) and being a boy (OR = 0.63; 95% CI 0.41-0.95; p = .029), while anemia in WRA was significantly associated with the use of unimproved dug wells as a source of drinking water (OR = 0.36; 95% CI 0.20-0.66; p = .001) and lack of agricultural land ownership (OR = 0.51; 95% CI 0.31-0.85; p = .009). Anemia is a public health problem in the study setting. The positive association between maternal and child anemia reflects the possibility of cross-generational anemia. Therefore, interventions that focus on improving preconceptual and maternal nutritional status may help to reduce anemia in low-income settings.

Prevalence and determinants of anemia among children aged from 6 to 59 months in Liberia: a multilevel analysis of the 2019/20 Liberia demographic and health survey data

Background

Anemia is a serious worldwide public health issue that happens at any stage of life but primarily affects young kids and pregnant mothers. Although anemia has a significant impact on child health, its magnitude and associated factors in children aged 6-59 months have not been yet studied in Liberia. Therefore, the aim of this study was to identify the prevalence and determinants of anemia in children aged 6-59 months in Liberia.

Methods

The data was extracted from Liberia Demographic and Health Survey, conducted from October 2019 to February 2020. The sample was obtained using a stratified two-stage cluster sampling technique. An overall weighted sample of 2,524 kids aged 6-59 months was involved in the final analysis. We used Stata version 14 software for data extraction and analysis. A multilevel logistic regression model was employed to identify factors associated with anemia. Variables with a P-value of <0.2 in the bivariable logistic regression analysis were selected as candidates for multivariable analysis. In multivariable analysis, the adjusted odds ratios (AOR) with the 95% confidence interval (CI) were declared as the determinants of anemia.

Results

The prevalence of anemia in children aged 6-59 months in Liberia was 70.8% [95% CI: 68.9%, 72.5%]. Of these, 3.4% were severe anemia, 38.3% were moderate anemia and 29.1% were mild anemia. Children aged 6-23 and 24-42 months, being stunted, children from households with unimproved toilet facilities, children from households with unimproved water sources, and lack of media (television) exposure were significantly associated with higher odds of anemia. However, using mosquito bed nets, living in the Northwestern and Northcentral region were significantly associated with lower odds of anemia among children 6-59 months.

Conclusion

In this study, anemia in kids aged 6-59 months in Liberia was a main public health issue. Age of the child, stunting, toilet facility, water source, exposure to television, mosquito bed net use, and region were significant determinants of anemia. Therefore, it is better to provide intervention for the early detection and management of stunted children. Similarly, interventions should be strengthened to address unimproved water sources, unimproved toilet facilities, and lack of media exposure.

Improving the approach to assess impact of anaemia control programs during pregnancy in India: a critical analysis

Around 42.7% of women experience anaemia during pregnancy in low- and middle-income countries. Countries in southeast Asia (with prevalence ranging between 40 and 60%) have reported a modest decline over the past 25 years. Nearly half the pregnant women continue to be anaemic in India between 2005-06 and 2015-16, although severe anaemia has reduced from 2.2% to 1.3%.India has been committed to achieving a target of 32% prevalence of anaemia in pregnant women from 50% by 2022. There are concerns around stagnancy in the prevalence of anaemia in pregnancy despite a strong political commitment. The paper puts forth the arguments that should be considered while introspecting why India might run the risk of not achieving the expected reduction. The reported findings highlight several methodological issues such as hemoglobin cut-offs used to determine anaemia during pregnancy, method of estimation of Hb, and less emphasis on causes other than iron deficiency anemia.

Childhood and Adolescent Anemia Burden in India: The Way Forward

The burden of anemia in Indian children, based on capillary blood sampling, is believed to be profound and worsening (67.1%) according to the successive National Family Health Surveys (NFHS). This might be an overestimate. The recent Comprehensive National Nutrition Survey of Indian children, that used venous blood sampling, found only less than half (30.7%) the NFHS prevalence, of which only one third was due to iron deficiency (ID). Unfortunately, the apparently worsening NFHS anemia burden estimate has been interpreted as an inadequacy of the present iron supplementation policy. This has led to additional iron supply through mandatory rice fortification. However, the lack of efficacy of iron supplementation appears inevitable, if the true prevalence of iron deficiency anemia is only about 10%. Thus, etiology is a critical consideration when devising appropriate and effective prevention policies. Future policies must focus on precision, thoughtfulness, restraint, and community engagement.

Prevalence of Obesity and Anemia Among Early Adolescents in Junior Secondary Schools: A Cross-Sectional Study in Ouagadougou, Burkina Faso

BACKGROUND

The school presents an ideal environment to positively impact the long-term health and nutrition outcomes of early adolescents, who are at risk of obesity and anemia.

METHODS

In this cross-sectional survey, we described differences in weight and anemia by sociodemographic, diet and physical activity indicators among 1059 students aged 11 to 15 years from 22 junior secondary schools in Ouagadougou, Burkina Faso. Weight was based on body mass index (BMI) z-scores according to the WHO reference and anemia status was defined by standardized hemoglobin (Hb) measure cut-offs. We calculated dietary diversity scores (DDS) from a 24-hour dietary recall and a global diet quality score (GDQS) from a 7-day dietary recall.

RESULTS

The prevalence of obesity (5%) and anemia (50%) was relatively high among the students, which differed significantly between gender, household wealth and school grade, but not age groups. Eighteen percent of the female adolescents were overweight or obese and 22% were moderately anemic compared to 13% and 16% of the male adolescents. Dietary diversity was significantly different between weight categories, but not anemia status. For physical activity, those taking transportation to school were significantly more likely to be overweight or obese. In adjusted multivariable Poisson regression analyses, only the DDS was significantly associated with thinness and both thinness and anemia, while taking transportation to school was significantly associated with overweight among adolescents.

CONCLUSION

We encourage the promotion of school-based interventions and provision of a curriculum on health and healthy eating in order to reduce obesity, anemia, and its comorbidities.

Associations of bacterial enteropathogens with systemic inflammation, iron deficiency, and anemia in preschool-age children in southern Ghana

Anemia remains a pervasive public health problem among preschool-age children in Ghana. Recent analyses have found that anemia in Ghanaian children, particularly in Southern regions, is largely attributable to infectious causes, rather than nutritional factors. Infections with enteropathogens can reduce iron absorption and increase systemic inflammation, but few studies have examined direct links between enteropathogens and anemia. This study investigated associations between detection of individual bacterial enteropathogens and systemic inflammation, iron deficiency, and anemia among 6- to 59-month-old children in Greater Accra, Ghana. Serum samples were analyzed from a cross-sectional sample of 262 children for concentrations of hemoglobin (Hb), biomarkers of systemic inflammation [C-reactive protein (CRP) and α-1-acid glycoprotein (AGP)], and biomarkers of iron status [serum ferritin (SF) and serum transferrin receptor (sTfR)]. Stool samples were analyzed for ten bacterial enteropathogens using qPCR. We estimated associations between presence of each enteropathogen and elevated systemic inflammation (CRP > 5 mg/L and AGP > 1 g/L), iron deficiency (SF < 12 μg/L and sTfR > 8.3 mg/L) and anemia (Hb < 110 g/L). Enteropathogens were detected in 87% of children’s stool despite a low prevalence of diarrhea (6.5%). Almost half (46%) of children had anemia while one-quarter (24%) had iron deficiency (low SF). Despite finding no associations with illness symptoms, Campylobacter jejuni/coli detection was strongly associated with elevated CRP [Odds Ratio (95% CI): 3.49 (1.45, 8.41)] and elevated AGP [4.27 (1.85, 9.84)]. Of the pathogens examined, only enteroinvasive Escherichia coli/Shigella spp. (EIEC/Shigella) was associated with iron deficiency, and enteroaggregative Escherichia coli (EAEC) [1.69 (1.01, 2.84)] and EIEC/Shigella [2.34 (1.15, 4.76)] were associated with anemia. These results suggest that certain enteroinvasive pathogenic bacteria may contribute to child anemia. Reducing exposure to enteropathogens through improved water, sanitation, and hygiene practices may help reduce the burden of anemia in young Ghanaian children.

Household Water Access, Dietary Diversity and Nutritional Status among Preschoolers in Poor, Rural Areas of Central and Western China

Poor child feeding and childhood malnutrition are major public health problems in rural central and western China, with little evidence about their environmental determinants. This study aimed to investigate whether household water access is associated with dietary diversity and nutritional outcomes. We analyzed the cross-sectional data of 3727 children aged 6 to 59 months in rural central and western China, applying multivariate linear and logistic models to estimate the effect of water access on children’s anthropometric indices, hemoglobin, and dietary diversity. We found that unimproved water access was linked to a lower likelihood of achieving dietary diversity (OR = 0.65, 95% CI 0.44 to 0.98, p = 0.039); lower height-for-age z-score (β = −0.34, 95% CI −0.49 to −0.19, p < 0.001) and hemoglobin concentration (β = −2.78, 95% CI −5.16 to −0.41, p = 0.022); higher odds of stunting (OR = 1.50, 95% CI 1.01 to 2.25, p = 0.047) and anemia (OR = 1.34, 95% CI 1.02 to 1.77, p = 0.037). The associations between water access and nutritional outcomes were not explained by dietary diversity and were stronger in children who did not receive iron supplementation. These findings provide evidence for designing water-based nutritional interventions in China.

Childhood and Adolescent Anemia Burden in India: The Way Forward

The burden of anemia in Indian children, based on capillary blood sampling, is believed to be profound and worsening (67.1%) according to the successive National Family Health Surveys (NFHS). This might be an overestimate. The recent Comprehensive National Nutrition Survey of Indian children, that used venous blood sampling, found only less than half (30.7%) the NFHS prevalence, of which only one third was due to iron deficiency (ID). Unfortunately, the apparently worsening NFHS anemia burden estimate has been interpreted as an inadequacy of the present iron supplementation policy. This has led to additional iron supply through mandatory rice fortification. However, the lack of efficacy of iron supplementation appears inevitable, if the true prevalence of iron deficiency anemia is only about 10%. Thus, etiology is a critical consideration when devising appropriate and effective prevention policies. Future policies must focus on precision, thoughtfulness, restraint, and community engagement.