Spatiotemporal Analysis of Anemia and Underweight Co-occurrence of Under Five Children in Ethiopia

Background Anemia and underweight are critical public health challenges for children under five years of age in Ethiopia, with significant implications for child development and long-term national productivity. Despite ongoing interventions, the coexistence and spatial distribution of these conditions remain inadequately understood. This study aimed to investigate the spatiotemporal variation and determinants of anemia and underweight co-occurrence among children under five years of age in Ethiopia. Methods A total of 17,477 children under five years of age were included and selected through a stratified two-stage cluster sampling design. Weighted analyses, spatial statistics including Global Moran’s I, and hotspot analyses were conducted to assess clustering patterns. Spatial bivariate binary logistic regression models were used to identify sociodemographic, maternal, and child health factors associated with the co-occurrence of anemia and underweight using SAS (V-9.4), and ArcGIS (V-10.8) was used for mapping. Results Anemia (50.89%) and underweight (28.15%) individuals exhibited significant geographic clustering, with persistent hotspots in the Afar (Zones 1–5), Tigray, and Somali regions. Emerging clusters in Wag Himra, Assosa, and West Wolega signal worsening conditions. Hotspots for anemia were consistently identified in Afar, Somali, Dire Dawa, and parts of Oromia across both survey years, whereas underweight hotspots were prominent in the Tigray, Amhara, Afar, and Oromia regions. Maternal anemia increased the odds of anemia in children and being underweight by 1.54 and 1.11 times, respectively. Other significant factors included the household wealth index, child age, birth size, stunting, wasting, recent illness (diarrhea, fever), and breastfeeding duration. Conclusions Anemia and underweight frequently coexist among under five Ethiopian children with geographic clustering, underscoring the role of environmental and structural barriers. Integrated interventions targeting maternal health, nutrition education, and healthcare access in hotspot regions are critical. Continued surveillance and targeted policies are essential to address these persistent public health challenges. Strengthening data-driven, spatially tailored strategies will mitigate Ethiopia’s dual burden of malnutrition and advance sustainable development goals.