Determinants of Anaemia among Children aged 6–59 Months in Zambia: A Multilevel Analysis of the 2024 ZDHS

Abstract

Anaemia among children aged 6–59 months remains an important public health problem globally, particularly in low- and middle-income countries. The condition is associated with impaired cognitive and motor development, increased susceptibility to infection and other adverse child health outcomes. In Zambia, nationally representative evidence shows a substantial burden of childhood anaemia. However, determinants operate at individual, household and community levels, and conventional single-level analyses may not adequately account for the hierarchical structure of Demographic and Health Survey data. This study therefore examined the prevalence and factors associated with anaemia among children aged 6–59 months in Zambia using the 2024 Zambia Demographic and Health Survey (ZDHS). This was a quantitative, analytical cross-sectional study based on secondary analysis of the 2024 ZDHS. The study population comprised children aged 6–59 months with available haemoglobin measurements and information on selected explanatory variables. Of 8,673 children initially identified, 3,393 were eligible for the analytical dataset after exclusion of observations with missing or incomplete information; 3,300 children contributed to the final weighted analytical estimates. Descriptive and bivariate analyses were used to estimate prevalence and examine crude associations. A multilevel mixed-effects binary logistic regression model with a random intercept for enumeration areas was fitted to estimate adjusted odds ratios (AORs) and 95% confidence intervals (CIs). Statistical significance was assessed at a two-sided alpha level of 0.05. The hierarchical modelling strategy progressed from a null model to child-level, maternal-level, household/community-level and fully adjusted models. Model fit was assessed using AIC, BIC, likelihood-ratio testing, ICC and MOR. In the analytical sample, 52% of children aged 6–59 months were classified as anaemic. Children aged 24–59 months had lower odds of anaemia than children aged 6–23 months (AOR=0.55; 95% CI: 0.43–0.71). Children who had experienced fever in the preceding two weeks had higher odds of anaemia (AOR=1.64; 95% CI: 1.25–2.17), as did underweight children compared with children of normal weight (AOR=1.69; 95% CI: 1.13–2.54). Children who had received deworming medication had lower odds of anaemia (AOR=0.76; 95% CI: 0.58–1.00). Compared with children from the poorest households, those from poorer households had lower odds of anaemia (AOR=0.66; 95% CI: 0.49–0.90), while the association for the richest households was also in the lower-odds direction (AOR=0.53; 95% CI: 0.29–0.97). Rural residence was associated with lower odds of anaemia compared with urban residence (AOR=0.71; 95% CI: 0.52–0.97). The final model retained residual community-level clustering, with an ICC of 6.6% (95% CI: 2.7–15.4) and MOR of 1.59. Childhood anaemia remains common among children aged 6–59 months in Zambia. The findings indicate that age, recent fever, underweight status, deworming, household socioeconomic position and residence are associated with anaemia after adjustment for measured covariates. The persistence of community-level variation supports the use of multilevel approaches and indicates that prevention requires integrated child nutrition, infection prevention and socioeconomic interventions. Keywords: Anaemia; children aged 6–59 months; Zambia; Zambia Demographic and Health Survey; multilevel analysis; odds ratio; child nutrition; epidemiology.