District Effect Appraisal in East Sub-Saharan Africa: Combating Childhood Anaemia.

Background: Anaemia in children is a significant health problem that receives little attention. This study aimed at determining the factors significantly associated with anaemia in children aged 6 to 59 months in Kenya, Malawi, Tanzania, and Uganda while accounting for the spatial heterogeneity within and between the districts of the four countries. In addition, the performance of the districts with regard to their impact on anaemia was assessed and ranked.

Methods: A generalised additive mixed model with a spatial effect based on the geographical coordinates of the clusters was used. A district-level random effect was included to further account for the heterogeneity as well as to rank the performance of the districts based on the best linear unbiased prediction (BLUP).

Results: The results depicted significant spatial heterogeneity between and within the districts of the countries. After accounting for such spatial heterogeneity, child-level characteristics (gender, malaria test result, and mother's highest education level), household-level characteristics (household size, household's wealth index Z-score, the type of toilet facility available, and the type of place of residence), and the country of residence were found to be significantly associated with the child's anaemia status. There was a significant interaction between the type of place of residence and the country of residence. Based on the BLUP for the district-level random effect, the top 3 best- and worst-performing districts within each country were identified.

Conclusion: The ranking of the performance of the districts allows for the worst-performing districts to be targeted for further research in order to improve their anaemia control strategies, as well as for the best-performing districts to be identified to further determine why they are performing better and then to use these districts as role models in efforts to overcome childhood anaemia.