Background Anemia is a condition characterized by nutritional deficiencies and blood disorders, predominantly affecting children aged 6 to 59 months and women of reproductive age, especially in low and middle-income countries. In Zambia, anemia is a public health problem. This study aims to assess the spatial patterns and determine factors associated with anemia severity in Zambia over six years (2018 to 2024).

Method The study included a total of 19,362 WRA from the two waves of the ZDHS, 2018 and 2024. The ZDHS is a periodic national survey that uses multistage sampling. We adopted an analytical cross-sectional design, and the three-level multivariable ordinal logistic regression model was used to identify variables (individual, household, and community level) associated with anemia severity. Global Moran’s I, Local Moran’s I, and Getis-Ord Gi* statistics were used to determine the hotspots and spatial patterns, while spatial scan statistics were used to detect primary and secondary clusters and their distribution over the two cycles.

Results The prevalence of anemia among women of reproductive age in Zambia was 31.0% (n=3,946) and 30.4% (n=2,015) in 2018 and 2024, respectively. The factors associated with higher odds of anemia severity were HIV status (HIV-positive: AOR=2.63, 95% CI:2.25,3.09), pregnancy (AOR=1.96, 95% CI:1.67,2.31), and rural residency (AOR=1.21, 95% CI:1.08,1.35). While being in a union was protective compared to never being in a union (AOR=0.66, 95% CI:0.57,0.77), not having financial barriers for medical assistance was equally protective. Spatial analysis showed geographic disparities and a non-random distribution of anemia (Global Moran’s I, 2018: I=0.147, p<0.001; 2024: I=0.130, p<0.001). the Hotspot analysis depicted an expansion of high-risk areas Western in 2018 to the North-Western and Luapula in 2024. Spatial scan analysis identified the south-west region (Western, Southern and North-Western) as the significant primary cluster of anemia consistently for both waves.

Conclusion Anemia among women of reproductive age remains a persistent and significant moderate public health problem among WRA in Zambia. Anemia severity is influenced by complex interactions at the individual, household, and community levels. Subtle changes in the effects of predictors were observed over the study period. These finding suggest the need for subnational (provincial and district) targeted interventions, especially in the persistent hotspot regions such as Western and emergine high-risk areas like Luapula, where integrated malaria control, nutritional supplementation, and improved healthcare access should be a priority.

The authors have declared no competing interest.

The author(s) received no specific funding for this work.

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

Yes

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

National Health Research Authority Lot No. 18961/M in Chalala, off Kasama Road Lusaka Email: znhrasecnhra.org.zm www.nhra.org.zm

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

Yes

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

Yes

I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

Yes

The data underlying the results presented in the study are available from https://dhsprogram.com/

https://dhsprogram.com/