title: Demographic and spatial predictors of anemia in women of reproductive age in Timor-Leste: implications for health program prioritization.
abstract: Anemia is a significant risk factor for poor health outcomes for both the mother and neonate; however, the determinants of anemia in many epidemiological settings are poorly understood. Using a subset of a nationally representative cluster survey (2010 Demographic and Health Survey) in combination with other non-contemporaneous survey data, the epidemiology of anemia among women of reproductive age in Timor-Leste has been explored. Logistic regression was used to identify risk factors, population-level impacts were estimated as population attributable fractions and spatial analytics were used to identify regions of highest risk. The DHS survey found that ∼ 21% of adult women in Timor-Leste are anemic (49,053; 95% CI: 37,095 to 61,035), with hemoglobin <12.0 g/dL. In this population, the main risk factors (adjusted odds ratio; 95% CI) are: currently abstaining from sex for any reason (2.25; 1.50 to 3.38); illiteracy (2.04; 1.49 to 2.80); giving birth within the previous year (1.80; 1.29 to 2.51); consumption of fruits/vegetables low in vitamin A (1.57; 1.13 to 2.20); and the district-level confirmed malaria incidence (1.31; 1.15 to 1.49). A review of prior soil-transmitted helminth surveys in Timor-Leste indicates low-to-moderate prevalence with generally low egg counts, suggesting a limited impact on anemia in this setting, although comprehensive survey data are lacking. Examination of the population-level effects highlights the impacts of both recent births and malaria on anemia, with more limited impacts from diet; the evidence does not suggest a large contribution from geohelminths within Timor-Leste. These patterns are divergent from some other settings in the Asia-Pacific region and highlight the need for further focused research. Targeting high-burden districts and by increasing access to pre/postnatal care, raising literacy levels, increasing access to family planning, and improving malaria control should be prioritized to maximize inherently limited health budgets in reaching these populations.
authors.affiliation: Saw Swee Hock School of Public Health, The National University of Singapore, Singapore.
authors.forename: Andrew A
authors.initials: AA
authors.lastname: Lover
authors.affiliation: Saw Swee Hock School of Public Health, The National University of Singapore, Singapore; Department of Surgery, The National University Hospital, Singapore; Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden.
authors.forename: Mikael
authors.initials: M
authors.lastname: Hartman
authors.affiliation: Saw Swee Hock School of Public Health, The National University of Singapore, Singapore.
authors.forename: Kee Seng
authors.initials: KS
authors.lastname: Chia
authors.affiliation: Public Health England, Department of Health, London, United Kingdom; Department of Infectious Disease Epidemiology, The London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: David L
authors.initials: DL
authors.lastname: Heymann
mesh_terms: D000293:Adolescent; D000328:Adult; D000740:Anemia / Q000453:epidemiology* / Q000209:etiology; D005260:Female; D006801:Humans; D007214:Indonesia / Q000453:epidemiology; D008875:Middle Aged; D012307:Risk Factors; D055815:Young Adult