Drivers of anemia reduction among women of reproductive age in Uganda: a country case study

Background: In Uganda, anemia prevalence among women of reproductive age (WRA) decreased from 41% in 2006 to 32% in 2016. The factors associated with this reduction are uncertain. Objectives: We conducted a systematic in-depth assessment of the quantitative and qualitative determinants of anemia among WRA in Uganda between 2006 and 2016. Methods: Employing standard Exemplars in Global Health methodology, quantitative analyses were conducted using Uganda's Demographic and Health Surveys. Qualitative analyses included a comprehensive literature review, program analysis, and stakeholder interviews to identify and understand country-level enablers and barriers to WRA anemia decline in Uganda over the past 2 decades. A final Oaxaca–Blinder decomposition analysis (OBDA) evaluated the relative contribution of direct and indirect factors. Results: Among nonpregnant women (NPW), mean hemoglobin (Hb) increased from 12.3 g/dL in 2006 to 12.6 g/dL in 2016 (P < 0.01), corresponding to a 9%-point decline in anemia prevalence during this time (from 40% to 31%). However, inequities by geographical region, household wealth, and women's educational attainment persisted. Key programs over the study period included food fortification, the Uganda Anemia Policy, and the Uganda Nutrition Action Plan (UNAP). Stakeholders also identified malaria control, family planning programs, and continued strengthening of Uganda's health care system as key enablers of anemia decline. Our OBDA explained 89% of the observed change in mean Hb, with family planning (27%), increased access to bednets (26%), household sociodemographics (17%), and improvement in women's overall nutrition (body mass index [BMI]: 15%) emerging as the most critical drivers of anemia decline among NPW in Uganda, corroborating our qualitative and policy analyses. Conclusions: To protect the hard-fought gains and continue improvements, WRA anemia prevention efforts in Uganda should remain focused on improving health care access especially within antenatal care and malaria control programs. Additionally, multisectoral collaborations and investments to empower women and poverty alleviation strategies need to be enhanced.