The analysis of risk factors associated with multimorbidity of anaemia, malaria, and malnutrition among children aged 6- 59 months in Nigeria

In the last ten years multimorbidity in children under the age of five years has becoming an emerging health issue in developing countries. The absence of a proper understanding of the causes, risk factors, and prevention of these new health disorders (multimorbidity) in children is a significant cause for concern, if the sustainable development goal 3 of ensuring healthy lives and the promotion of well-being for all especially in the associated aim of ending preventable deaths of new-borns and children must be achieved by 2030. In the past, most studies conducted in Nigeria and some other least developed nations of the world focused on these multiple diseases by employing conventional analytical techniques to examine them separately as distinct disease entities. But the study of multimorbidity of anaemia, malaria, and malnutrition has not been done, especially in children. This study aims to investigate the multiple overlaps in the impact of individual and contextual variables on the prevalence of multimorbidity among children aged 6 to 59 months in Nigeria. The study used two nationally representative cross-sectional surveys, the 2018 Nigeria Demographic and Health Survey and the 2018 National Human Development Report. A series of multilevel mixed effect ordered logistic regression models were used to investigate the associations between child/parent/household variables (at level 1), community-related variables (at level 2) and area-related variables (at level 3), and the multimorbidity outcome (no disease, one disease only, two or more diseases). The interaction effects between child's sex, age, and household wealth quintiles and the outcome while accounting for some covariates in the model were also investigated. The result shows that 48.3% (4,917/10,184) of the sample of children aged 6-59 months cohabit with two or more of the disease outcomes. Child's sex, age, maternal education, mother’s anaemia status. household wealth quintiles, the proportion of community wealth status, states with high human development index, region, and place of residence, were among the significant predictors of MAMM (p<0.05). There was a significant interaction effect between a child's age and wealth status when some other covariates were accounted for. The prevalence of MAMM observed in the sample is large, with almost half of the children living with two or more of the diseases at the time of the survey and several potentially modifiable risk factors have been identified.  If suitable actions are not urgently taken, Nigeria’s ability to actualise the SDG 3 will be in grave danger. Therefore, possible actions to ameliorate this problem include developing and implementing a suitable policy that will pave the way for integrated care models to be developed. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study is an integral part of PEO's doctoral study at the School of Health and Related Research of the University of Sheffield, United Kingdom. The funding for the doctoral study was granted by TETFUND (Nigeria) with reference number TETF/ES/POLY/ZUNGERU/TSAS/2019. www.tetfund.gov.ng The University of Sheffield Postgraduate Research Services funded the manuscript for publication. The funders have no role in study design, data collection and analysis, the decision to publish, or preparation of the manuscript ### Author Declarations 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: The ethical approval to carry out this research study had been granted by the School of Health and Related Research (ScHARR) Ethics Committee of the University of Sheffield (Reference Number: 031534). This study is a secondary analysis of two nationally representative samples. Permission to use the data sets (2018 Nigeria Demographic and Health Survey and 2018 National Human Development Report) had been obtained from two organisations: the Inner City Fund (ICF)-International and the United Nations Development Programme (UNDP-Nigeria) 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 these findings are publicly available at the Demographic and Health Survey (DHS) https://dhsprogram.com/Data/ and the National Human Development Report (2018) of the United Nations Development Program UNDP-Nigeria. https://hdr.undp.org/content/national-human-development-report-2018-nigeria