Childhood Anemia and Maternal Media Exposure in Sub-Saharan Africa: A Multi-Country Cross-Sectional Analysis Across Ghana, Nigeria, and Tanzania

Objectives

To examine the association between maternal media exposure and childhood anemia in three sub-Saharan African countries, and to develop a two-stage multiple imputation approach for substantial hemoglobin outcome missingness in Demographic and Health Survey (DHS) data.

Design

Multi-country cross-sectional analysis of nationally representative DHS data.

Setting

Community-based household surveys in Ghana (2022), Nigeria (2023–24), and Tanzania (2022).

Participants

42,944 children aged 6–59 months across 2,621 clusters.

Primary and secondary outcome measures

The primary outcome was anemia (altitude-adjusted hemoglobin <11.0 g/dL, WHO criteria); the primary exposure was a composite maternal media score (0–4 channels). Given 61.5% hemoglobin missingness, we imputed altitude-adjusted hemoglobin using multilevel Gaussian models and derived anemia deterministically, then estimated associations using population-averaged generalized estimating equations (pre-specified primary analysis), with six sensitivity analyses and exploratory mediation analysis.

Results

Media exposure was significantly associated with reduced anemia odds (OR 0.946, 95% CI 0.917 to 0.976, p<0.001; FMI 32.5%), a 5.4% reduction per additional weekly channel. Estimates were consistent across six sensitivity analyses (OR range 0.914–0.961), with no heterogeneity by country (I²=0%, p=0.482). Media exposure predicted antenatal care attendance and iron supplementation (both p<0.001), but neither mediated the anemia association.

Conclusions

Maternal media exposure was consistently associated with reduced childhood anemia across three sub-Saharan African settings. A two-stage multiple imputation approach addressed substantial (61.5%) outcome missingness while maintaining stable estimates, offering a transferable framework for DHS-based analyses. Prospective and intervention studies are needed before media-based communication can be recommended as a complementary anemia-control strategy.

Strengths and Limitations of This Study

• This is among the first multi-country analyses to directly examine maternal media exposure and childhood anemia using nationally representative biomarker data from three sub-Saharan African countries.

• A validated two-stage multiple imputation approach addressed substantial (61.5%) hemoglobin missingness, with robustness confirmed across six pre-specified sensitivity analyses.

• The cross-sectional design precludes establishing temporality and cannot rule out reverse causation or residual confounding from unmeasured household factors.

• Maternal media exposure was measured as frequency of channel use only, without capturing content, quality, or health-specific programming.

• Mediation analysis relied on a single imputed dataset with non-clustered models, limiting direct comparability with the primary GEE-based estimate.