CBC: Complete Blood Count, EDTA: Ethylene Die amine Tetra-acetic Acid, HGB: Hemoglobin, g/dL: Gram per Deciliter, SOPS: Standard Operation Procedures, AOR: Adjusted Odd Ratio, COR: Crude Odd Ratio, CI: Confident Interval, WHO: World Health Organization, EDHS: Ethiopian Demographic Health Survey, SPSS: Statistical Package for Social Science, ETB: Ethiopian Birr

Anemia is a condition that causes decline of erythrocytes concentration in circulation or hemoglobin in the blood and a concomitant impairment of oxygen transportation [1]. The World Health Organization (WHO) defined as hemoglobin (Hgb)<12 g/dL in adult non-pregnant women, Hgb <11g/dL in pregnant females, Hgb <13g/dL in adult men, Hgb <11g/dl in children whose age is 6-59 months, Hgb <11.5 g/dl in children whose age is 5-11years, Hgb<12 g/dl for children whose age is 12-14 years and Hgb <13 g/dL in newborns [2,3].

Globally, 1.3 billion individuals suffer from anemia, this is making it one of the most important public health issues on the international agenda [4]. Globally, on average, around 9.6 million children are severely anemic [5]. It is affecting the peoples in both developing and developed countries [6]. By 2017, 293.1 million (47.4%) under five year’s children are anemic worldwide and 67.6% of these children live in Africa [7]. In Ethiopia, 57% of children are anemic age 6-59 months was anemic according to the Ethiopian Demographic and Health Survey (EDHS) report [8].

The iron deficiency is the major cause of anemia in developing countries and results in insufficient red blood cell production. In some individuals, infections such as peptic ulcers may cause blood loss and anemia. In developing countries, iron deficiency impacts all vulnerable groups. Also, geographically specific infections like malaria and helminthic contributes to excessive red blood cell destruction, and cause of excessive red blood cell loss. Other infectious diseases also may be at play [9].

Anemia impairs mental, physical, social development and causes negative behavioral and cognitive effects resulting in poor school performance and work capacity in later years [10]. In early childhood, bad feeding habits, especially during the weaning period, exacerbate the problem. Anemia frequently develops as breast milk is replaced by foods that are poor in iron and other nutrients, including vitamin B12 and folic acid. Low oxygenation of brain tissues, a consequence of anemia, may lead to impaired cognitive function, growth and psychomotor development, especially in children. Infants, under 5-year-old children and pregnant women have greater susceptibility to anemia because of their increased iron requirements due to rapid body growth and expansion of red blood cells [10]. Moreover, anemia leads to immune system compromise result in decreasing the ability to fight infections and increasing mortality in African children where resources to determine the basic etiology remain poor [11,12].

Despite, the national and regional data on prevalence of anemia and its risk factors among under-five year children in specific setting in Ethiopia [8]. To our knowledge, no previous study has been undertaken in the study area of Bule Hora. Therefore, this study is aimed to assess the prevalence of anemia and its associated factors among children from 6-59 months of age in Bule Hora Hospital, Southern Ethiopia.

Study area, period and design

The Health facility based quantitative cross-sectional study was conducted from October 26 to November 20, 2020 at Bule Hora General Hospital, Guji Zone: Oromia Region, Southern Ethiopia. The hospital found in Bule Hora town 467 km from Addis Ababa capital city of Ethiopia. According to 2007 national census, the total population of Bule Hora town is 27820. Geographically, the town located between latitude 5°35’N and longitude 38°15’E and an altitude of 1716 meters above sea level. Regarding Bule Hora general hospital, the hospital has providing different services including pediatrics, emergency, deliver, outpatient, in patient, laboratory, and pharmacy, medical and surgical service. Nowadays, the hospital has given the service for 5 million populations in the area.

Study population

All children aged between 6 month up to 59 months who attending at Bule Hora General Hospital during data collection period and fulfilling the selection criteria were included in the study.

Sample size and sampling technique

Sample size was determined using a single population proportion formula considering the prevalence of anemia from a previous study 66.8% [13].

Where, d=Margin of error between the sample and the population (d=5%), n=Sample size, Z α/2=95% confident interval (1.96), P=66.8% Prevalence.

Then adding 15% non-response rate considering the response rate of previous study, thus the final sample size was 392. Convenient sampling technique was used for all Under-five children that fulfill the inclusion criteria during the study period.

Data collection instruments and procedure

The data were collected using the structured questionnaire which adapted from previous literature [14]. The questionnaire was prepared in English with written form and orally translated in to Oromia and Amharic language, then back to English to ensure its consistency. Five percent of total sample respondents were interviewed during the pre-test in another health institution. After this, the questionnaire was edited accordingly, and then adapting the final version of the questionnaire to interview children’s parents/caregivers.

The data collectors were explained the objective of the study to children’s parents/caregivers. Highlighting on the benefit of being tested for Hgb and what would be done if the child is anemic. The data collectors were given details to the patient/caregiver that no name of participant written on the questionnaire and confidentiality were protected and got verbal consent. Data was collected through pretested and structured questionnaire by face-to face interviewing the children’s patient/caregiver. The questionnaire was used to collect sociodemographic data and associated factors (Supplementary file).

Blood sample collection

By following standard operating procedure (SOPs) strictly, 3 ml venous blood sample was collected. Experienced laboratory technicians were collected the samples in the tubes containing ethylene diamine tetra-acetatic acid (EDTA). The Complete Blood Count (CBC) reports from the hematology analyzer (Cell-DYN 1800) in the hospitals include hemoglobin (Hgb) analysis was done as per the manufacturer’s instruction.

Study variables

Dependent variable: Prevalence of anemia

Independent variable

Sociodemographic: Age of child, religion, sex of child, sex of caregiver, marital status of caregivers, educational status of caregiver, income, family size, household head, residence and parent’s occupation.

Feeding related factors: nutrition knowledge, food insecurity, dietary diversity practices, animal product (no eating meat), meal frequency, breastfeeding practice, and introduction complementary

Health care and diseases characteristics: Acute blood loss, blood transfusion reaction, surgical procedure, recent history of accident, history of intestinal protozoan infections, history of malaria infection, epistaxis, history soil-transmitted helminthic infection and history chronic diseases.

Operational definitions

Anemia -Hemoglobin (Hgb) <11 g/dL in children whose age is 6-59 months [15].

Mild anemia: Hgb value is 10-10.9g/dL [15].

Moderate anemia: Hgb value 7-9.9g/dL for children 6-59 months [15].

Severe anemia: Hgb value <7g/dL for children aged 6-59 months [15].

Low income: family monthly income less than 750birr (ETB) [16].

Moderate income: family monthly income from 750-1500 ETB [16]

High income: family monthly income greater than 1500 ETB [16]

Data quality control

To assure data quality, 5% of estimated sample were pre-tested at Bule Hora health center before the data collection to see whether the questionnaires are simple and understandable. After every data collection the completeness and consistency of the questionnaire were checked. Data collectors training and daily supervision were made before and during the data collection period.

During blood sample analysis, the standard operating procedures (SOPs) and manufacturers’ instruction were strictly followed for all laboratory activities. Sample was checked whether hemolysis, clotting and enough volume before run the test. When machine passed the control, the samples were analyzed. Finally, the laboratory test result was recorded and specimens were managed properly.

Data processing and analysis

Data was entered, sorted and categorized. Data cleaning was performed to check for completeness, accuracy, and missed values and any errors identified were corrected. Then, data was analyzed using SPSS version 22. Descriptive statistics (mean, frequency) was carried out to describe the sociodemographic status of the participants presented by table, pie chart and graph. Binary logistic regression model was fitted to identify factor associated with anemia. Variables with a P-value ≤ 0.25 in the bivariate analysis were considered as a candidate for the multivariate analysis. The multivariate logistic regression was done to control for possible confounding and identify the true effect of the selected predictor variables. The model fitness checked with Hosmer-Lemeshow test. The extant association between the different variables related with anemia were measured using (AOR) at 95% CI. P-value ≤ 0.05 was considered to be statistically significant.

Socio demographic and economic status

The total of 392 under-five children, 375 were participated in this study with 95.7% response rate. The participant’s age ranges from 6 to 59 months with mean (SD) age of 3.3(± 2.195) months. Among 375 under-five children, 54.4% (204) were female and majority 39.7% (149) of children’s mothers/caregivers were farmers. More than half, 54.4% (204) were from rural area. About 29.4 %(110) of children caregivers were unable to read and write. Out of 375 under-five children about 55.9% (210) were protestants. Almost half of them 44.3% (166) were living in a household having 3 family size and the majority of household 36.8% (138) were income less than 750 Ethiopian birr (Table 1).

Feeding related factors

Regarding feeding practices, among 375 under-five children 69.1% (259) dietary diversity practice, 79.4% (298) introduction of complementary food after 6 months, 61.8% (232) mothers/ caregivers don’t have nutritional knowledge, 23.5% (88) faces food insecurity within four weeks, 69.2% (259) had meal three times feed per day while majority 80.8% (303) breastfeeding practice at 6-12 months (Table 2).

Health care and disease’s characteristics

Out of 375 under-five children enrolled in the study, 17.6 % (66) of them had intestinal protozoa followed by soil-transmitted helminthic infection 16.2% (61) and malaria infection 14.7% (55) (Table 3).

Prevalence of anemia

Based on hemoglobin cutoff value, less than 11g/dL categorize as anemic, of these Hgb value 10-10.9g/dl, 7-9.9g/dl, less than 7g/ dL determined as mild, moderate and severe, respectively [17]. The overall prevalence of anemia was 13.2% (50) (Figure 1). Among anemic under five children, 12 % (6) were mild, 32% (16) moderate and 56% (28) severe anemic categories (Figure 2).

Factor associated with prevalence of anemia

In bivariate analysis variables like child age-group, child sex, family size, income of caregiver, dietary diversity practice, breastfeeding practice, have nutritional knowledge, meal frequency, history of intestinal protozoa infection, history of helminthic infection, history of malaria infection was with at p-value of <0.25 and considered as a candidate for multivariate analysis.

In multivariate analysis, the chance of having anemia were about 2 times higher among under five children who had intestinal protozoan infection history [AOR= 2.13, 95% CI =1.35-9.270] compared with their counterpart. Also, children had soiltransmitted helminths infection history were 6 times chance to have anemia [AOR=6.09, 95% CI=2.047-27.54] when compared with their counterpart. Similarly, the children who had history of malaria infection were nearly 5 times more likely [AOR=5.42, 95% CI=0.307-11.034] to have anemic than those do not have malaria infection history (Table 4).

In this study, the overall prevalence of anemia among under-five children attending Bule Hora General Hospital was 13.2 % (50) at (95% CI=5.2-21.2%). According to WHO definition, anemia can be defined as mild, moderate and severe public health problem when the prevalence is 5-19.9%, 20-39.9% and greater than 40%, respectively. Therefore, the prevalence of anemia in this study is considered as mild public health concern [18].

This is lower than the previous study conducted in Western China (51.2%) [19], Eastern Sudan (86%) [20], Cape Verde West Africa (51.8%), [21], Nigeria (70.5%) [22], Tanzania (77.2%) [23], Gonder town Ethiopia (66.8%) [24], Gonder, Ethiopia (58.6%), [25], Wagmra zone, Ethiopia (66.6%) [26], South Wollo, Northeast Ethiopia (41.1%) [16]. The difference prevalence might be due to variations in number of participant, sample analysis equipment, hemoglobin cut off points, difference cultural, geographical and behavioral characteristics of the community. In contrast, this finding was higher than report from Brazil (10.2%) [27], In Sub-Sahara Africa (9.7%) [28]. The possible reason might be due to age difference of study participants, in our study the study participants were aged from 6-59 months, but in Sub-Sahara Africa study participants were aged below 36 months.

Multivariate analysis showed that having previous intestinal protozoa infection was significantly associated with prevalence of anemia among under-five children. This finding is in line with study conducted in Pawe Town, Benishangul Gumuz, region [29] and Gonder, Ethiopia [25]. Similarly, children who had previous malaria infection was significantly associated with anemia among under-five children. This finding agrees with study conducted in Ghana [30]. In addition, an anemia was 6 times more likely among children previous soil-transmitted helminthic infections compared with their counterpart. This finding in consistent with study conducted in Gonder, Ethiopia [31]. Possible justification could be due to the intestinal wall bleeding, erythrocyte lysis, reduction of iron and damage organs involve in hematopoiesis.

Out of 375 under-five children involved in study near half 48.5% (182) were infected with at least one of the following species of parasite, Plasmodium spp, Entamoeba histolytical, Giardia lambia, Ascaris lumbricoides, Strongyloides stercoralis, Trichuris trichuria, Enterobius vermicularis and Hookworm. Of those children infected with malaria 22 (40%), soil-transmitted helminths, 22 (36.1%) and intestinal protozoa 11 (16.7%) were found anemic. The parasite species may deplete red blood cells through loss of blood in time of diarrhea and gastrointestinal bleeding.

Strength of the study

This research could elaborate the important part of health accessibility issue especially in child health and identified associated factors of anemia.

Limitation of the study

Being a hospital-based study, convenient sampling technique applied, and small sample size used, the result cannot be extrapolated to the larger community. Also, this study does not differentiate the specific cause of anemia, such as iron, B12 and folates.

The present study demonstrated that a 13.2% the overall prevalence of anemia among under-five children attended Bule Hora General Hospital. This finding was low compared with previous studies conducted in different parts of Ethiopia. The factors significantly associated with anemia were recently history of intestinal protozoa infections, soil-transmitted helminths, and malaria infection. Therefore, early diagnosis, treatment and preventions of parasites infection should be important in reduction of anemia among under-five children.

First of all, we would like to thank Bule Hora University, college of medicine and health sciences, department of Nursing for giving us a chance to undertake this research. Next, we would like to extend our thanks to Bule Hora University nursing department staffs who guided and provided us different information for enriching our research development and Bule Hora General Hospital staff for their unlimited cooperation in giving us information to develop the research. Finally, we would like to extend gratitude’s to our beloved family and friends for valuable patience during research development.

Data essential for the conclusion are included in this manuscript. Additional data can be obtained from the corresponding author on a reasonable request.

The study was conducted after ethical approval from Bule Hora University Research and Ethical Review Committee. The official letter was written to Bule Hora General Hospital. The informed, voluntary, written signed consent were obtained from the study participant, parent/caregiver and institution. The children’s parents/caregivers were informed about the purpose of the study and written informed consent was obtained before the questionnaire was administered then blood sample were collected from the study participant. Participation in the study was voluntary. The participants were informed their right to quite/refuse their participation at any stage of the study if they do not want to participate. To ensure confidentiality of participant’s information, codes were used any identifier of participants not written on the questionnaire on the test tube. Any abnormal test results of participants were communicated to the concerned body.

AA: Conceptualizations, planned, supervises, designed the experiment, performed the experiment and all tests. AJ and YD: data analysis, drafted and revised the manuscript. All authors reviewed and approved manuscript

We declare that do not have conflict of interest on all activities pertain this research work.

No specific fund for this study

 Not applicable.