Anaemia and associated factors in homeless children in the Paris region: the ENFAMS survey

Anaemia and associated factors in homeless children in the Paris region: the ENFAMS survey Abstract Background Food insecurity is a major concern in homeless population, however nutritional consequences remain poorly documented, especially for children. The objective of this study was to assess the prevalence of anaemia and to investigate the relation between both food insecurity and dietary intake to moderate-to-severe anaemia (MSA) in homeless sheltered children. Methods In 2013, a cross-sectional survey was conducted on a random sample of 801 sheltered homeless families in the Paris region. Haemoglobin concentration was measured in 630 mother/child dyads and questionnaires administrated to mothers collected socio-demographic, socioeconomic, health and dietary data. Factors associated with MSA were analysed in two stratified child age groups; 0.5–5 and 6–12 years old. Results Anaemia was detected in 39.9% of the children and 50.6% of the mothers, and MSA in 22.3% and 25.6%, respectively. In both age groups, MSA was positively associated with maternal MSA. In the 0.5–5 years group, it was also positively associated with child food insecurity, no cooking facilities and household monthly income. In the 6–12 years group, it was positively associated with household food insecurity and children’s age. Conclusion A higher food insecurity score was associated with greater prevalence of moderate-to-severe anaemia in children. Considering the high prevalence of anaemia among homeless mothers and their children, these findings highlight the need for reducing food insecurity in shelters so as to prevent anaemia in this vulnerable population. Introduction Anaemia, or low concentration of haemoglobin, is a worldwide public health issue1 due to multiple causes. Some of them are preventable, such as nutritional deficiencies including iron deficiency (ID). Anaemia can occur at any stage of life but is more frequent in pregnant women and children, due to their physiological vulnerability. In children, anaemia impairs cognitive, mental and psychomotor development.2 It affects child growth, damages the immune system and alters metabolism. In Europe and France, the 2008 prevalence anaemia for children aged 6 months to 4 years was 21.7% and 8.3%, respectively.1 In industrialized countries, disadvantaged population groups are more likely to suffer from anaemia: in 2002, in California, the prevalence of anaemia was 11, 1% in 12–36-month-old children from low-income families3 and 19% in homeless children under 3 years of age in New York in 2004.4 Alongside, diet quality is known to follow a socioeconomic gradient, 5 and food insecurity is associated with poorer nutritional quality of diet.6,7 Indeed, there is some evidence that household or child food insecurity result in suboptimal nutrient intake and increase the risk of iron deficiency anaemia in young, low-income children.8,9 In 2016, low-income infants living in low-food-secure households in Massachusetts were 42% more likely to develop anaemia at age 18 months than their food-secure counterparts.10 In France, about 30 000 children were living in homeless families in 2012.11 Studies from the ‘Observatoire du Samusocial de Paris’ have shown a large increase of homeless families in the Paris region since 1999.12 Despite this growing number of homeless families, little is known regarding their living conditions and associated health problems, including anaemia, especially for children. To fill this gap, the ‘Homeless children and families’ survey (‘Enfants et familles sans logement’, ENFAMS) was carried out in 2013.13 Given the alarming prevalence of food insecurity and anaemia in this population, we aimed to investigate the association between both food insecurity and dietary intake to moderate-to-severe anaemia in homeless sheltered children. Methods Study design and participants The ENFAMS survey, based on a three-stage random sampling design, had been described previously.13 The sample included 801 homeless families sheltered in emergency centres, long-term rehabilitation centres, social hostels and centres for asylum seekers in the Paris region. Eligibility criteria stipulated that families had to comprise at least one parent and at least one child less than 13 years, speak one of the 17 languages considered in the survey, and be able to provide informed consent for study participation. Participation rate was 79%. The interviews took place in the interviewee’s bedroom or in a private room provided by the accommodation service. The study protocol was approved by the national authority for the protection of personal data collected on individuals (CNIL, n°DR-2013-147) and by two Ethics Committees (CPP, Ref 2012 02 06, 22/08/2012, and CCTIRS, n°12.471, 17/09/2012). Measurements After obtaining consent, two face-to-face questionnaires were administered to one parent: the first focused on socio-demographic and socioeconomic characteristics, living conditions, health and use of healthcare at the parent and household levels; the second concerned the selected child’s health and behaviours according to the age bracket (0–5 or 6–12 years old). At a subsequent appointment, nurses performed anthropometric measures, and made an immediate measurement of haemoglobin concentration (Hb) from a capillary blood sample with a portable haemoglobinometer (HemoCue® Hb201+ System, Ängelholm, Sweden), as recommended by the WHO for population surveys determining the prevalence of anaemia.14–16 Stable, durable and convenient to use, this method provides instantaneous results. It is especially suitable for surveying homeless families who are more likely to undergo frequent moves.17 According to the Hb results, families were provided with information and dietary advice, and when needed, were referred to social services or healthcare and emergency services. Anaemia definition The following haemoglobin cut-off points were chosen according to the WHO guidelines:18 for anaemia, <11.0 g/dl for children from 0.5–4 years of age, <11.5 g/dl for children from 5 to 11 years of age and <12.0 g/dl for children of 12 years of age or older; for mild anaemia, 10.0–10.9, 11.0–11.4 and 11.0–11.9 g/dl, respectively; for moderate anaemia, 7.0–9.9, 8.0–10.9 and 8.0–10.9 g/dl; and for severe anaemia, <7.0, 8.0 and 8.0 g/dl. Because of lack of consensus regarding cut-offs for anaemia among children less than 6 months old, these children were excluded from the analyses.19,20 For mothers, the cut-off 12.0 g/dl was used to define anaemia (11.0 g/dl if pregnant).18 The degree of anaemia was defined as: 11.0–11.9 g/dl for mild anaemia, 8.0 –10.9 g/dl for moderate anaemia, and less than 8.0 g/dl for severe anaemia (10.0 –10.9 g/dl, 7.0 –9.9 g/dl, and less than 7.0 g/dl, respectively, for pregnant women). As a substantial proportion of children was anaemic, using the variable ‘anaemia’ (i.e. covering all degrees of anaemia) would not have been discriminant enough to identify associated factors. Accordingly, we chose to use ‘moderate-to-severe anaemia’ (MSA) as outcome in this analysis.21 Dietary data Breastfeeding duration (in months) was recorded in children aged ≤5 years only. Breastfeeding was defined as the consumption of breast-milk along with other sources of milk (e.g. formula), foods or drinks (if any). If a child was still being breastfed at the time of the survey, breastfeeding duration was censored to the age of the child at that moment. In children aged 6–12 years, dietary intake information was collected using a 15-item semi-quantitative food frequency questionnaire (FFQ). In order to prevent the FFQ from being too burdensome given the long (3 hours) and sometimes sensitive (e.g. questions on living food deprivation) interview, the 15 food items covered only part of the child’s diet, focussing mainly on core food groups (i.e. fruit and vegetables, dairies, starchy foods, animal products). For each food group, four possible responses ranging from ‘Every day’ to ‘Never’ were converted into weekly frequencies (‘Every day’ was coded as 7 per week, ‘Several times per week’ was replaced by a uniform random number in the interval [2–6], ‘Less often’ by a uniform random number in the interval [0.25–1] and ‘Never’ was coded as 0). Food insecurity Food insecurity was measured by the Household Food Security Scale Measure (HFSSM),22 screening by a preliminary item (similar to the ‘food sufficiency question’).23 The HFSSM questionnaire includes 10 adult and 8 child-referenced questions. Two scores equalling the total number of affirmative responses to the questions were calculated at household and child levels. The household score was divided into four categories defined by the usual thresholds: food security (score: 0–2), food insecurity without hunger (3–7), food insecurity with moderate hunger (8–12) and food insecurity with severe hunger (13–18).24,25 The child score was divided into three categories defined by the following thresholds: food security (<2), low food security (2–4), very low food security (>4).26 Other variables Socio-demographic factors included child’s sex, age and birth place; mother's age, birth place and highest educational certificate obtained. The variable ‘mother's birth place’ was categorised into: sickle cell disease-endemic countries in Africa and Asia, other African countries, Commonwealth of Independent States (i.e. former Soviet countries), Europe and America. Living conditions included mother's difficulty speaking French (evaluated using the set of questions: ‘In your daily life, do you have difficulty understanding French? speaking in French?’). Time living in France, duration of homelessness, residence status (i.e. legally resident in France or not), health cover, employment, monthly income (taking household composition into account (€/Consumption Unit)27), type of accommodation, and whether there were cooking facilities in the bedroom. Health: Anthropometric measures were collected by nurses. Child’s weight was measured using a calibrated SECA balance scale and child’s length or height by a sliding foot scale or a wall-mounted stadiometer respectively, depending on age. Body Mass Index (BMI) was calculated using the formula BMI = weight(kg)/height(m)2, and child's BMI categorised into four groups: underweight, normal, overweight, obese, according to the IOTF definition.28 Statistical analysis Dietary patterns were established for children aged 6–12 years using Principal Component Analysis (PCA) of the 15 standardised dietary variables. The number of components (or patterns) was selected considering eigenvalues > 1.0, the scree plot and their interpretability.29,30 To interpret the results and provide a label to a given pattern, we considered the items most strongly related to that component, i.e. those for which the absolute value of the loading coefficient was >0.25. The PCA scores for the dietary pattern selected were calculated at the individual level by summing the observed standardised frequencies of consumption per food group, weighted according to the PCA loadings. Descriptive analyses were performed to estimate the prevalence of MSA. The association between MSA and each factor studied was then assessed adjusted for sex and age. Variables associated with MSA (P < 0.25) were included in a multivariate regression. Fractional polynomials were used to deal with continuous variables.31 Poisson regressions were used to determine the factors independently associated with MSA and to estimate prevalence ratios.32 Analyses were stratified by age (0.5–5 and 6–12 years). Few variables known as risk factors for anaemia were forced into the multivariate models: child’s age and sex, mother's birth place, breastfeeding duration in children aged 0.5–5 years and dietary pattern scores in children aged 6–12 years. These analyses took the sampling design into account.33 All analyses were performed with Stata 12® (StataCorp, Texas, USA). The significance level was set at 5%. Results Population characteristics Hb concentration was measured in 673 children of 6 months of age and older and 716 mothers and the questionnaires were completed for 630 mother/child dyads (435 children aged 0.5–5 years and 195 children aged 6–12 years) (table 1). Mother/child dyads without complete measures and father/child dyads were excluded. Table 1 Characteristics of 0.5–12 year-old homeless children in the Paris region, 2013 Variables Sample size Estimated proportion (95% CI) Socio-demographic factors Sex     Male 301 46.8 (41.7, 52.0)     Female 329 53.2 (48.1, 58.3) Age     [0.5–1[a 74 8.9 (6.1, 12.8)     [1–3[ 197 29.2 (24.7, 34.1)     [3–6[ 164 27.0 (22.4, 32.2)     [6–11[ 151 27.6 (23.0, 32.7)     [11–13[ 44 7.3 (5.5, 9.6) Born in France     No 267 41.6 (35.5, 48.0)     Yes 359 58.4 (52.0, 64.5) Mother's age in years     [18–30[ 253 30.8 (25.9, 36.1)     [30–40[ 319 53.9 (49.0, 58.7)     ≥40 86 15.3 (11.6, 19.9) Mother's birthplace     SCD-endemic countries in Africa and Asia 318 53.9 (48.3, 59.4)     Other African countries 108 14.7 (10.9, 19.6)     Commonwealth of Independent States 118 17.0 (13.6, 21.0)     Europe, America 86 14.4 (10.9, 18.8) Mother's educational level     None 244 39.0 (33.9, 44.5)     Primary/junior high school certificate 142 28.4 (22.7, 34.9)     Senior high school certificate 135 19.3 (15.4, 23.8)     Tertiary-level certificate 96 13.3 (10.1, 17.3) Living conditions Mother's difficulty speaking/understanding French     No 210 36.6 (30.3, 43.4)     Yes 386 63.4 (56.6, 69.7) Duration of mother's time in France (years)     <1 90 13.5 (10.2, 17.6)     [1–2[ 124 14.7 (11.3, 18.9)     [2–4[ 166 26.7 (21.6, 32.5)     ≥4 217 45.1 (39.4, 51.0) Duration of mother’s homelessness in years     <1 147 23.3 (18.7, 28.7)     [1–2[ 177 23.3 (19.2, 28.0)     [2–4[ 174 26.7 (21.4, 32.7)     ≥4 132 26.7 (21.7, 32.4) Mother's administrative status     Awaiting regularisation 291 49.3 (43.2, 55.5)     Regularised 57 11.1 (7.6, 15.9)     Asylum seekers 108 10.8 (8.5, 13.7)     Residence permit 127 28.7 (23.8, 34.2) Mother's health cover     State health insurance 46 10.2 (6.6, 15.5)     Universal health insurance cover 297 42.6 (36.5, 49.0)     State health aid 162 27.8 (22.8, 33.4)     Pending response 61 8.9 (6.4, 12.2)     None 63 10.5 (7.9, 13.7) Mother is employed     No 511 78.5 (73.3, 82.9)     Yes 118 21.5 (17.1, 26.7) Household monthly income (€/CU)     None 126 20.4 (16.6, 24.8)     <250 231 30.8 (25.9, 36.1)     [250–500[ 119 19.6 (15.7, 24.2)     ≥500 135 29.2 (23.6, 35.5) Type of accommodation     Emergency centre/social hostel 435 78.8 (76.3, 81.1)     Centre for asylums seekers 106 5.6 (4.9, 6.4)     Long-term rehabilitation centre 89 15.6 (13.6, 17.8) Cooking facilities in the bedroom     No 375 52.7 (45.9, 59.5)     Yes 254 47.3 (40.5, 54.1) Health Household food insecurity     Food security 92 13.3 (10.1, 17.3)     Food insecurity without hunger 208 34.2 (28.9, 39.9)     Food insecurity with moderate hunger 241 41.9 (36.7, 47.2)     Food insecurity with severe hunger 74 10.6 (8.1, 14.0) Child food insecurity     Food security 200 27.3 (22.6, 32.7)     Low food security 367 63.7 (58.2, 68.9)     Very low food security 63 9.0 (6.7, 11.9) Children's weight status (BMI)     Underweight 49 9.8 (7.4, 12.9)     Normal 283 65.5 (58.9, 71.5)     Overweight 80 20.2 (14.4, 27.7)     Obese 18 4.5 (2.5, 8.0) Child's anaemia status     None 372 60.1 (54.3, 65.6)     Mild 129 17.7 (14.1, 22.0)     Moderate 128 22.2 (17.6, 27.6)     Severe 1 0.05 (0.01, 0.3)     Moderate+ Severe 129 22.3 (17.6, 27.7) Mother's anaemia status     None 299 49.4 (44.1, 54.8)     Mild 162 24.9 (20.8, 29.5)     Moderate 167 25.4 (21.4, 30.0)     Severe 2 0.2 (0.04, 1.0)     Moderate+ Severe 169 25.6 (21.5, 30.2) Dietary intake Breastfeeding duration (0.5–5 year-old children)     None 57 11.0 (7.9, 15.1)     <6 months 116 27.7 (21.0, 35.7)     [6–12[ 132 34.3 (27.9, 41.3)     [12–24[ 80 17.6 (13.4, 22.7)     ≥24 months 26 9.4 (5.8, 14.9) Dietary pattern mean score (SD) (6–12-year-old children) 190 0.08 (−0.92, 1.41) Variables Sample size Estimated proportion (95% CI) Socio-demographic factors Sex     Male 301 46.8 (41.7, 52.0)     Female 329 53.2 (48.1, 58.3) Age     [0.5–1[a 74 8.9 (6.1, 12.8)     [1–3[ 197 29.2 (24.7, 34.1)     [3–6[ 164 27.0 (22.4, 32.2)     [6–11[ 151 27.6 (23.0, 32.7)     [11–13[ 44 7.3 (5.5, 9.6) Born in France     No 267 41.6 (35.5, 48.0)     Yes 359 58.4 (52.0, 64.5) Mother's age in years     [18–30[ 253 30.8 (25.9, 36.1)     [30–40[ 319 53.9 (49.0, 58.7)     ≥40 86 15.3 (11.6, 19.9) Mother's birthplace     SCD-endemic countries in Africa and Asia 318 53.9 (48.3, 59.4)     Other African countries 108 14.7 (10.9, 19.6)     Commonwealth of Independent States 118 17.0 (13.6, 21.0)     Europe, America 86 14.4 (10.9, 18.8) Mother's educational level     None 244 39.0 (33.9, 44.5)     Primary/junior high school certificate 142 28.4 (22.7, 34.9)     Senior high school certificate 135 19.3 (15.4, 23.8)     Tertiary-level certificate 96 13.3 (10.1, 17.3) Living conditions Mother's difficulty speaking/understanding French     No 210 36.6 (30.3, 43.4)     Yes 386 63.4 (56.6, 69.7) Duration of mother's time in France (years)     <1 90 13.5 (10.2, 17.6)     [1–2[ 124 14.7 (11.3, 18.9)     [2–4[ 166 26.7 (21.6, 32.5)     ≥4 217 45.1 (39.4, 51.0) Duration of mother’s homelessness in years     <1 147 23.3 (18.7, 28.7)     [1–2[ 177 23.3 (19.2, 28.0)     [2–4[ 174 26.7 (21.4, 32.7)     ≥4 132 26.7 (21.7, 32.4) Mother's administrative status     Awaiting regularisation 291 49.3 (43.2, 55.5)     Regularised 57 11.1 (7.6, 15.9)     Asylum seekers 108 10.8 (8.5, 13.7)     Residence permit 127 28.7 (23.8, 34.2) Mother's health cover     State health insurance 46 10.2 (6.6, 15.5)     Universal health insurance cover 297 42.6 (36.5, 49.0)     State health aid 162 27.8 (22.8, 33.4)     Pending response 61 8.9 (6.4, 12.2)     None 63 10.5 (7.9, 13.7) Mother is employed     No 511 78.5 (73.3, 82.9)     Yes 118 21.5 (17.1, 26.7) Household monthly income (€/CU)     None 126 20.4 (16.6, 24.8)     <250 231 30.8 (25.9, 36.1)     [250–500[ 119 19.6 (15.7, 24.2)     ≥500 135 29.2 (23.6, 35.5) Type of accommodation     Emergency centre/social hostel 435 78.8 (76.3, 81.1)     Centre for asylums seekers 106 5.6 (4.9, 6.4)     Long-term rehabilitation centre 89 15.6 (13.6, 17.8) Cooking facilities in the bedroom     No 375 52.7 (45.9, 59.5)     Yes 254 47.3 (40.5, 54.1) Health Household food insecurity     Food security 92 13.3 (10.1, 17.3)     Food insecurity without hunger 208 34.2 (28.9, 39.9)     Food insecurity with moderate hunger 241 41.9 (36.7, 47.2)     Food insecurity with severe hunger 74 10.6 (8.1, 14.0) Child food insecurity     Food security 200 27.3 (22.6, 32.7)     Low food security 367 63.7 (58.2, 68.9)     Very low food security 63 9.0 (6.7, 11.9) Children's weight status (BMI)     Underweight 49 9.8 (7.4, 12.9)     Normal 283 65.5 (58.9, 71.5)     Overweight 80 20.2 (14.4, 27.7)     Obese 18 4.5 (2.5, 8.0) Child's anaemia status     None 372 60.1 (54.3, 65.6)     Mild 129 17.7 (14.1, 22.0)     Moderate 128 22.2 (17.6, 27.6)     Severe 1 0.05 (0.01, 0.3)     Moderate+ Severe 129 22.3 (17.6, 27.7) Mother's anaemia status     None 299 49.4 (44.1, 54.8)     Mild 162 24.9 (20.8, 29.5)     Moderate 167 25.4 (21.4, 30.0)     Severe 2 0.2 (0.04, 1.0)     Moderate+ Severe 169 25.6 (21.5, 30.2) Dietary intake Breastfeeding duration (0.5–5 year-old children)     None 57 11.0 (7.9, 15.1)     <6 months 116 27.7 (21.0, 35.7)     [6–12[ 132 34.3 (27.9, 41.3)     [12–24[ 80 17.6 (13.4, 22.7)     ≥24 months 26 9.4 (5.8, 14.9) Dietary pattern mean score (SD) (6–12-year-old children) 190 0.08 (−0.92, 1.41) SCD: sickle cell disease. CU: Consumption Unit. a Right bracket means ‘excluded’. Table 1 Characteristics of 0.5–12 year-old homeless children in the Paris region, 2013 Variables Sample size Estimated proportion (95% CI) Socio-demographic factors Sex     Male 301 46.8 (41.7, 52.0)     Female 329 53.2 (48.1, 58.3) Age     [0.5–1[a 74 8.9 (6.1, 12.8)     [1–3[ 197 29.2 (24.7, 34.1)     [3–6[ 164 27.0 (22.4, 32.2)     [6–11[ 151 27.6 (23.0, 32.7)     [11–13[ 44 7.3 (5.5, 9.6) Born in France     No 267 41.6 (35.5, 48.0)     Yes 359 58.4 (52.0, 64.5) Mother's age in years     [18–30[ 253 30.8 (25.9, 36.1)     [30–40[ 319 53.9 (49.0, 58.7)     ≥40 86 15.3 (11.6, 19.9) Mother's birthplace     SCD-endemic countries in Africa and Asia 318 53.9 (48.3, 59.4)     Other African countries 108 14.7 (10.9, 19.6)     Commonwealth of Independent States 118 17.0 (13.6, 21.0)     Europe, America 86 14.4 (10.9, 18.8) Mother's educational level     None 244 39.0 (33.9, 44.5)     Primary/junior high school certificate 142 28.4 (22.7, 34.9)     Senior high school certificate 135 19.3 (15.4, 23.8)     Tertiary-level certificate 96 13.3 (10.1, 17.3) Living conditions Mother's difficulty speaking/understanding French     No 210 36.6 (30.3, 43.4)     Yes 386 63.4 (56.6, 69.7) Duration of mother's time in France (years)     <1 90 13.5 (10.2, 17.6)     [1–2[ 124 14.7 (11.3, 18.9)     [2–4[ 166 26.7 (21.6, 32.5)     ≥4 217 45.1 (39.4, 51.0) Duration of mother’s homelessness in years     <1 147 23.3 (18.7, 28.7)     [1–2[ 177 23.3 (19.2, 28.0)     [2–4[ 174 26.7 (21.4, 32.7)     ≥4 132 26.7 (21.7, 32.4) Mother's administrative status     Awaiting regularisation 291 49.3 (43.2, 55.5)     Regularised 57 11.1 (7.6, 15.9)     Asylum seekers 108 10.8 (8.5, 13.7)     Residence permit 127 28.7 (23.8, 34.2) Mother's health cover     State health insurance 46 10.2 (6.6, 15.5)     Universal health insurance cover 297 42.6 (36.5, 49.0)     State health aid 162 27.8 (22.8, 33.4)     Pending response 61 8.9 (6.4, 12.2)     None 63 10.5 (7.9, 13.7) Mother is employed     No 511 78.5 (73.3, 82.9)     Yes 118 21.5 (17.1, 26.7) Household monthly income (€/CU)     None 126 20.4 (16.6, 24.8)     <250 231 30.8 (25.9, 36.1)     [250–500[ 119 19.6 (15.7, 24.2)     ≥500 135 29.2 (23.6, 35.5) Type of accommodation     Emergency centre/social hostel 435 78.8 (76.3, 81.1)     Centre for asylums seekers 106 5.6 (4.9, 6.4)     Long-term rehabilitation centre 89 15.6 (13.6, 17.8) Cooking facilities in the bedroom     No 375 52.7 (45.9, 59.5)     Yes 254 47.3 (40.5, 54.1) Health Household food insecurity     Food security 92 13.3 (10.1, 17.3)     Food insecurity without hunger 208 34.2 (28.9, 39.9)     Food insecurity with moderate hunger 241 41.9 (36.7, 47.2)     Food insecurity with severe hunger 74 10.6 (8.1, 14.0) Child food insecurity     Food security 200 27.3 (22.6, 32.7)     Low food security 367 63.7 (58.2, 68.9)     Very low food security 63 9.0 (6.7, 11.9) Children's weight status (BMI)     Underweight 49 9.8 (7.4, 12.9)     Normal 283 65.5 (58.9, 71.5)     Overweight 80 20.2 (14.4, 27.7)     Obese 18 4.5 (2.5, 8.0) Child's anaemia status     None 372 60.1 (54.3, 65.6)     Mild 129 17.7 (14.1, 22.0)     Moderate 128 22.2 (17.6, 27.6)     Severe 1 0.05 (0.01, 0.3)     Moderate+ Severe 129 22.3 (17.6, 27.7) Mother's anaemia status     None 299 49.4 (44.1, 54.8)     Mild 162 24.9 (20.8, 29.5)     Moderate 167 25.4 (21.4, 30.0)     Severe 2 0.2 (0.04, 1.0)     Moderate+ Severe 169 25.6 (21.5, 30.2) Dietary intake Breastfeeding duration (0.5–5 year-old children)     None 57 11.0 (7.9, 15.1)     <6 months 116 27.7 (21.0, 35.7)     [6–12[ 132 34.3 (27.9, 41.3)     [12–24[ 80 17.6 (13.4, 22.7)     ≥24 months 26 9.4 (5.8, 14.9) Dietary pattern mean score (SD) (6–12-year-old children) 190 0.08 (−0.92, 1.41) Variables Sample size Estimated proportion (95% CI) Socio-demographic factors Sex     Male 301 46.8 (41.7, 52.0)     Female 329 53.2 (48.1, 58.3) Age     [0.5–1[a 74 8.9 (6.1, 12.8)     [1–3[ 197 29.2 (24.7, 34.1)     [3–6[ 164 27.0 (22.4, 32.2)     [6–11[ 151 27.6 (23.0, 32.7)     [11–13[ 44 7.3 (5.5, 9.6) Born in France     No 267 41.6 (35.5, 48.0)     Yes 359 58.4 (52.0, 64.5) Mother's age in years     [18–30[ 253 30.8 (25.9, 36.1)     [30–40[ 319 53.9 (49.0, 58.7)     ≥40 86 15.3 (11.6, 19.9) Mother's birthplace     SCD-endemic countries in Africa and Asia 318 53.9 (48.3, 59.4)     Other African countries 108 14.7 (10.9, 19.6)     Commonwealth of Independent States 118 17.0 (13.6, 21.0)     Europe, America 86 14.4 (10.9, 18.8) Mother's educational level     None 244 39.0 (33.9, 44.5)     Primary/junior high school certificate 142 28.4 (22.7, 34.9)     Senior high school certificate 135 19.3 (15.4, 23.8)     Tertiary-level certificate 96 13.3 (10.1, 17.3) Living conditions Mother's difficulty speaking/understanding French     No 210 36.6 (30.3, 43.4)     Yes 386 63.4 (56.6, 69.7) Duration of mother's time in France (years)     <1 90 13.5 (10.2, 17.6)     [1–2[ 124 14.7 (11.3, 18.9)     [2–4[ 166 26.7 (21.6, 32.5)     ≥4 217 45.1 (39.4, 51.0) Duration of mother’s homelessness in years     <1 147 23.3 (18.7, 28.7)     [1–2[ 177 23.3 (19.2, 28.0)     [2–4[ 174 26.7 (21.4, 32.7)     ≥4 132 26.7 (21.7, 32.4) Mother's administrative status     Awaiting regularisation 291 49.3 (43.2, 55.5)     Regularised 57 11.1 (7.6, 15.9)     Asylum seekers 108 10.8 (8.5, 13.7)     Residence permit 127 28.7 (23.8, 34.2) Mother's health cover     State health insurance 46 10.2 (6.6, 15.5)     Universal health insurance cover 297 42.6 (36.5, 49.0)     State health aid 162 27.8 (22.8, 33.4)     Pending response 61 8.9 (6.4, 12.2)     None 63 10.5 (7.9, 13.7) Mother is employed     No 511 78.5 (73.3, 82.9)     Yes 118 21.5 (17.1, 26.7) Household monthly income (€/CU)     None 126 20.4 (16.6, 24.8)     <250 231 30.8 (25.9, 36.1)     [250–500[ 119 19.6 (15.7, 24.2)     ≥500 135 29.2 (23.6, 35.5) Type of accommodation     Emergency centre/social hostel 435 78.8 (76.3, 81.1)     Centre for asylums seekers 106 5.6 (4.9, 6.4)     Long-term rehabilitation centre 89 15.6 (13.6, 17.8) Cooking facilities in the bedroom     No 375 52.7 (45.9, 59.5)     Yes 254 47.3 (40.5, 54.1) Health Household food insecurity     Food security 92 13.3 (10.1, 17.3)     Food insecurity without hunger 208 34.2 (28.9, 39.9)     Food insecurity with moderate hunger 241 41.9 (36.7, 47.2)     Food insecurity with severe hunger 74 10.6 (8.1, 14.0) Child food insecurity     Food security 200 27.3 (22.6, 32.7)     Low food security 367 63.7 (58.2, 68.9)     Very low food security 63 9.0 (6.7, 11.9) Children's weight status (BMI)     Underweight 49 9.8 (7.4, 12.9)     Normal 283 65.5 (58.9, 71.5)     Overweight 80 20.2 (14.4, 27.7)     Obese 18 4.5 (2.5, 8.0) Child's anaemia status     None 372 60.1 (54.3, 65.6)     Mild 129 17.7 (14.1, 22.0)     Moderate 128 22.2 (17.6, 27.6)     Severe 1 0.05 (0.01, 0.3)     Moderate+ Severe 129 22.3 (17.6, 27.7) Mother's anaemia status     None 299 49.4 (44.1, 54.8)     Mild 162 24.9 (20.8, 29.5)     Moderate 167 25.4 (21.4, 30.0)     Severe 2 0.2 (0.04, 1.0)     Moderate+ Severe 169 25.6 (21.5, 30.2) Dietary intake Breastfeeding duration (0.5–5 year-old children)     None 57 11.0 (7.9, 15.1)     <6 months 116 27.7 (21.0, 35.7)     [6–12[ 132 34.3 (27.9, 41.3)     [12–24[ 80 17.6 (13.4, 22.7)     ≥24 months 26 9.4 (5.8, 14.9) Dietary pattern mean score (SD) (6–12-year-old children) 190 0.08 (−0.92, 1.41) SCD: sickle cell disease. CU: Consumption Unit. a Right bracket means ‘excluded’. Dietary intake in children Most of the children aged 0.5–5 years (89.0%) were being or had been breastfed. Of all the children in this age group 61.3% were fed with breastmilk for 6 months or more. In children aged 6–12 years, we retained the first component derived using PCA, which accounted for 17.8% of the explained variance (Supplementary table S1). This dietary pattern was positively correlated with intake of fresh fruit, fruit juices, meat and ham, dairy products, fish, cheese, raw vegetables, stewed fruit and French fries (in descending order of PCA loadings), and was labelled ‘Diversified’. Higher scores for this dietary pattern indicated greater adherence to a diversified diet. Noteworthy, ‘Diversified’ dietary pattern scores were inversely associated with household and child food insecurity (regression coefficient = −0.16 (95% CI: −0.22, −0.10), P < 10−3 and −0.38 (95% CI: −0.56, −0.20), P < 10−3, respectively). Prevalence and associated factors with MSA Anaemia prevalence was 39.9% (95% CI: 34.4, 45.7) in children: 38.1% (95% CI: 31.8, 44.7) in those aged 0.5–5 years, 43.5% (95% CI: 34.7, 52.6) in those aged 6–12 years, and 50.6% (95% CI: 45.2, 55.9) in mothers. MSA prevalence was estimated at 22.3% in children: 21.3% (95% CI: 16.3, 27.3) in those aged 0.5–5 years, 24.1% (95% CI: 14.8, 36.7) in those aged 6–12 years and 25.6% in mothers. The estimated prevalence of MSA according to the factors studied is shown in table 2. Hb concentration distributions according to age group and sex are illustrated in figure 1. Table 2 Estimated prevalence of moderate-to-severe anaemia and 95% confidence intervals (CI) among all children, among children aged 0.5–5 years, and among children aged 6–12 years according to various variables in the Paris region, France, 2013 All children 0.5–5 years 6–12 years Variables Sample size Estimated prevalence Sample size Estimated prevalence Sample size Estimated prevalence (95% CI) (95% CI) (95% CI) Socio-demographic factors Sex     Male 301 22.0 197 20.1 104 25.2 Female (16.0, 29.5) (12.1, 31.4) (17.3, 35.1) 329 22.5 238 22.2 91 23.0      (15.2, 31.9) (14.8, 32.0) (9.9, 44.8) Age in years     [0.5–1[a 74 42.8      (24.7, 63.1)     [1–3[ 197 15.5      (9.8, 23.5)     [3–6[ 164 20.4      (12.5, 31.6)     [6–11[ 151 22.6      (14.9, 32.8)     [11–13[ 44 29.6      (10.2, 60.8) Mother's birthplace  SCD-endemic countries in Africa and Asia 318 22.6 226 21.9 92 24.0      (15.6, 31.6) (14.8, 31.2) (10.0, 47.3)  Other African countries 108 36.7 85 36.4 23 37.3      (21.8, 54.5) (19.0, 58.2) (19.6, 59.3)  Commonwealth of Independent States 118 18.4 65 17.3 53 19.5      (10.9, 29.4) (8.9, 31.0) (10.6, 33.1)  Europe, America 86 10.6 59 8.1 27 17.9      (5.7, 18.8) (3.3, 18.7) (8.7, 33.4) Living conditions Mother's difficulty speaking/understanding French     No 210 27.6 156 23.8 54 35.9      (19.9, 36.9) (16.0, 33.8) (16.6, 61.0)     Yes 386 20.1 251 21.6 135 17.7      (14.5, 27.2) (14.1, 31.6) (11.8, 25.7) Duration of mother's time in France (years)     <1 90 20.6 65 23.2 25 15.6      (12.8, 31.5) (12.3, 39.2) (6.8, 32.1)     [1–2[ 124 11.9 93 10.3 31 16.6      (7.0, 19.5) (5.7, 17.8) (6.6, 35.9)     [2–4[ 166 23.1 120 25.7 46 15.7      (15.3, 33.4) (16.0, 38.7) (8.1, 28.4)     ≥4 217 26.8 130 24.9 87 29.1      (17.6, 38.5) (15.1, 38.1) (14.4, 50.2) Duration of mother's homelessness in years     <1 147 31.2 108 32.3 39 28.6      (20.4, 44.5) (18.7, 49.8) (18.8, 41.0)     [1–2[ 177 15.0 133 15.9 44 12.9      (9.6, 22.5) (9.3, 25.6) (6.4, 24.3)     [2–4[ 174 19.1 119 12.4 55 31.9      (10.6, 31.9) (6.5, 22.4) (11.4, 62.9)  ≥4 132 24.0 75 25.6 57 21.9 (14.3, 37.4) (12.6, 45.1) (11.1, 38.7) Household monthly income (€/CU)     None 126 21.4 88 20.3 38 23.9      (14.1, 31.2) (11.5, 33.3) (12.9, 39.9)     <250 231 17.6 169 12.6 62 29.0      (11.9, 25.3) (7.2, 21.2) (16.7, 45.4)     [250–500[ 119 18.1 79 22.0 40 12.4      (11.1, 28.2) (12.1, 36.6) (5.7, 25.0)     ≥500 135 30.3 88 29.7 47 31.3      (19.1, 44.5) (16.1, 48.3) (13.9, 56.2) Type of accommodation     Emergency centre/social hostel 435 20.5 304 21.2 131 19.0      (15.8, 26.0) (15.3, 28.5) (12.8, 27.2)     Centre for asylums seekers 106 26.2 79 27.1 27 24.5      (17.6, 37.1) (17.5, 39.5) (11.3, 45.4)     Long-term rehabilitation centre 89 29.9 52 19.3 37 39.9      (14.5, 51.6) (9.7, 37.9) (10.9, 78.4) Cooking facilities in the bedroom     No 375 26.8 274 25.8 101 29.0      (21.1, 33.3) (18.8, 34.5) (20.5, 39.5)     Yes 254 17.5 161 15.0 93 20.9      (10.5, 27.5) (8.4, 25.6) (8.4, 43.2) Health Household food insecurity     Food security 92 32.7 67 37.2 25 15.3      (18.7, 50.6) (20.5, 57.7) (5.0, 38.5)     Food insecurity without hunger 208 17.5 145 15.6 63 21.2      (9.8, 29.2) (7.4, 30.0) (7.4, 47.5)     Food insecurity with moderate hunger 241 22.2 164 19.9 77 26.0      (16.3, 29.4) (13.1, 28.9) (16.5, 38.4)     Food insecurity with severe hunger 74 26.9 52 21.4 22 36.5      (17.2, 39.4) (10.9, 37.8) (20.0, 57.0) Child food insecurity     Food security 200 21.0 150 24.1 50 12.6      (13.0, 32.2) (14.1, 37.9) (5.3, 27.0)     Low food security 367 21.3 243 19.7 124 26.5      (16.7, 28.9) (13.4, 27.9) (15.9, 40.6)     Very low food security 63 26.4 42 22.8 21 31.0      (15.7, 40.8) (10.1, 43.7) (15.8, 51.9) Mother has moderate-to-severe anaemia     No 461 18.6 306 16.7 155 21.6      (13.7, 24.7) (10.9, 24.7) (13.2, 33.3)     Yes 169 33.0 129 32.1 40 35.5      (23.1, 44.6) (20.7, 46.2) (19.6, 55.3) Dietary intake Breastfeeding duration     None 58 18.8      (9.5, 33.8)     <6 months 115 24.7      (13.8, 40.3)     [6–12[ months 132 25.4      (14.6, 40.2)     [12–24[ months 100 18.9      (11.3, 30.0)     ≥24 months 6 36.9      (6.2, 83, 8) All children 0.5–5 years 6–12 years Variables Sample size Estimated prevalence Sample size Estimated prevalence Sample size Estimated prevalence (95% CI) (95% CI) (95% CI) Socio-demographic factors Sex     Male 301 22.0 197 20.1 104 25.2 Female (16.0, 29.5) (12.1, 31.4) (17.3, 35.1) 329 22.5 238 22.2 91 23.0      (15.2, 31.9) (14.8, 32.0) (9.9, 44.8) Age in years     [0.5–1[a 74 42.8      (24.7, 63.1)     [1–3[ 197 15.5      (9.8, 23.5)     [3–6[ 164 20.4      (12.5, 31.6)     [6–11[ 151 22.6      (14.9, 32.8)     [11–13[ 44 29.6      (10.2, 60.8) Mother's birthplace  SCD-endemic countries in Africa and Asia 318 22.6 226 21.9 92 24.0      (15.6, 31.6) (14.8, 31.2) (10.0, 47.3)  Other African countries 108 36.7 85 36.4 23 37.3      (21.8, 54.5) (19.0, 58.2) (19.6, 59.3)  Commonwealth of Independent States 118 18.4 65 17.3 53 19.5      (10.9, 29.4) (8.9, 31.0) (10.6, 33.1)  Europe, America 86 10.6 59 8.1 27 17.9      (5.7, 18.8) (3.3, 18.7) (8.7, 33.4) Living conditions Mother's difficulty speaking/understanding French     No 210 27.6 156 23.8 54 35.9      (19.9, 36.9) (16.0, 33.8) (16.6, 61.0)     Yes 386 20.1 251 21.6 135 17.7      (14.5, 27.2) (14.1, 31.6) (11.8, 25.7) Duration of mother's time in France (years)     <1 90 20.6 65 23.2 25 15.6      (12.8, 31.5) (12.3, 39.2) (6.8, 32.1)     [1–2[ 124 11.9 93 10.3 31 16.6      (7.0, 19.5) (5.7, 17.8) (6.6, 35.9)     [2–4[ 166 23.1 120 25.7 46 15.7      (15.3, 33.4) (16.0, 38.7) (8.1, 28.4)     ≥4 217 26.8 130 24.9 87 29.1      (17.6, 38.5) (15.1, 38.1) (14.4, 50.2) Duration of mother's homelessness in years     <1 147 31.2 108 32.3 39 28.6      (20.4, 44.5) (18.7, 49.8) (18.8, 41.0)     [1–2[ 177 15.0 133 15.9 44 12.9      (9.6, 22.5) (9.3, 25.6) (6.4, 24.3)     [2–4[ 174 19.1 119 12.4 55 31.9      (10.6, 31.9) (6.5, 22.4) (11.4, 62.9)  ≥4 132 24.0 75 25.6 57 21.9 (14.3, 37.4) (12.6, 45.1) (11.1, 38.7) Household monthly income (€/CU)     None 126 21.4 88 20.3 38 23.9      (14.1, 31.2) (11.5, 33.3) (12.9, 39.9)     <250 231 17.6 169 12.6 62 29.0      (11.9, 25.3) (7.2, 21.2) (16.7, 45.4)     [250–500[ 119 18.1 79 22.0 40 12.4      (11.1, 28.2) (12.1, 36.6) (5.7, 25.0)     ≥500 135 30.3 88 29.7 47 31.3      (19.1, 44.5) (16.1, 48.3) (13.9, 56.2) Type of accommodation     Emergency centre/social hostel 435 20.5 304 21.2 131 19.0      (15.8, 26.0) (15.3, 28.5) (12.8, 27.2)     Centre for asylums seekers 106 26.2 79 27.1 27 24.5      (17.6, 37.1) (17.5, 39.5) (11.3, 45.4)     Long-term rehabilitation centre 89 29.9 52 19.3 37 39.9      (14.5, 51.6) (9.7, 37.9) (10.9, 78.4) Cooking facilities in the bedroom     No 375 26.8 274 25.8 101 29.0      (21.1, 33.3) (18.8, 34.5) (20.5, 39.5)     Yes 254 17.5 161 15.0 93 20.9      (10.5, 27.5) (8.4, 25.6) (8.4, 43.2) Health Household food insecurity     Food security 92 32.7 67 37.2 25 15.3      (18.7, 50.6) (20.5, 57.7) (5.0, 38.5)     Food insecurity without hunger 208 17.5 145 15.6 63 21.2      (9.8, 29.2) (7.4, 30.0) (7.4, 47.5)     Food insecurity with moderate hunger 241 22.2 164 19.9 77 26.0      (16.3, 29.4) (13.1, 28.9) (16.5, 38.4)     Food insecurity with severe hunger 74 26.9 52 21.4 22 36.5      (17.2, 39.4) (10.9, 37.8) (20.0, 57.0) Child food insecurity     Food security 200 21.0 150 24.1 50 12.6      (13.0, 32.2) (14.1, 37.9) (5.3, 27.0)     Low food security 367 21.3 243 19.7 124 26.5      (16.7, 28.9) (13.4, 27.9) (15.9, 40.6)     Very low food security 63 26.4 42 22.8 21 31.0      (15.7, 40.8) (10.1, 43.7) (15.8, 51.9) Mother has moderate-to-severe anaemia     No 461 18.6 306 16.7 155 21.6      (13.7, 24.7) (10.9, 24.7) (13.2, 33.3)     Yes 169 33.0 129 32.1 40 35.5      (23.1, 44.6) (20.7, 46.2) (19.6, 55.3) Dietary intake Breastfeeding duration     None 58 18.8      (9.5, 33.8)     <6 months 115 24.7      (13.8, 40.3)     [6–12[ months 132 25.4      (14.6, 40.2)     [12–24[ months 100 18.9      (11.3, 30.0)     ≥24 months 6 36.9      (6.2, 83, 8) SCD: sickle cell disease. CU: Consumption Unit. a Right bracket means ‘excluded’. Table 2 Estimated prevalence of moderate-to-severe anaemia and 95% confidence intervals (CI) among all children, among children aged 0.5–5 years, and among children aged 6–12 years according to various variables in the Paris region, France, 2013 All children 0.5–5 years 6–12 years Variables Sample size Estimated prevalence Sample size Estimated prevalence Sample size Estimated prevalence (95% CI) (95% CI) (95% CI) Socio-demographic factors Sex     Male 301 22.0 197 20.1 104 25.2 Female (16.0, 29.5) (12.1, 31.4) (17.3, 35.1) 329 22.5 238 22.2 91 23.0      (15.2, 31.9) (14.8, 32.0) (9.9, 44.8) Age in years     [0.5–1[a 74 42.8      (24.7, 63.1)     [1–3[ 197 15.5      (9.8, 23.5)     [3–6[ 164 20.4      (12.5, 31.6)     [6–11[ 151 22.6      (14.9, 32.8)     [11–13[ 44 29.6      (10.2, 60.8) Mother's birthplace  SCD-endemic countries in Africa and Asia 318 22.6 226 21.9 92 24.0      (15.6, 31.6) (14.8, 31.2) (10.0, 47.3)  Other African countries 108 36.7 85 36.4 23 37.3      (21.8, 54.5) (19.0, 58.2) (19.6, 59.3)  Commonwealth of Independent States 118 18.4 65 17.3 53 19.5      (10.9, 29.4) (8.9, 31.0) (10.6, 33.1)  Europe, America 86 10.6 59 8.1 27 17.9      (5.7, 18.8) (3.3, 18.7) (8.7, 33.4) Living conditions Mother's difficulty speaking/understanding French     No 210 27.6 156 23.8 54 35.9      (19.9, 36.9) (16.0, 33.8) (16.6, 61.0)     Yes 386 20.1 251 21.6 135 17.7      (14.5, 27.2) (14.1, 31.6) (11.8, 25.7) Duration of mother's time in France (years)     <1 90 20.6 65 23.2 25 15.6      (12.8, 31.5) (12.3, 39.2) (6.8, 32.1)     [1–2[ 124 11.9 93 10.3 31 16.6      (7.0, 19.5) (5.7, 17.8) (6.6, 35.9)     [2–4[ 166 23.1 120 25.7 46 15.7      (15.3, 33.4) (16.0, 38.7) (8.1, 28.4)     ≥4 217 26.8 130 24.9 87 29.1      (17.6, 38.5) (15.1, 38.1) (14.4, 50.2) Duration of mother's homelessness in years     <1 147 31.2 108 32.3 39 28.6      (20.4, 44.5) (18.7, 49.8) (18.8, 41.0)     [1–2[ 177 15.0 133 15.9 44 12.9      (9.6, 22.5) (9.3, 25.6) (6.4, 24.3)     [2–4[ 174 19.1 119 12.4 55 31.9      (10.6, 31.9) (6.5, 22.4) (11.4, 62.9)  ≥4 132 24.0 75 25.6 57 21.9 (14.3, 37.4) (12.6, 45.1) (11.1, 38.7) Household monthly income (€/CU)     None 126 21.4 88 20.3 38 23.9      (14.1, 31.2) (11.5, 33.3) (12.9, 39.9)     <250 231 17.6 169 12.6 62 29.0      (11.9, 25.3) (7.2, 21.2) (16.7, 45.4)     [250–500[ 119 18.1 79 22.0 40 12.4      (11.1, 28.2) (12.1, 36.6) (5.7, 25.0)     ≥500 135 30.3 88 29.7 47 31.3      (19.1, 44.5) (16.1, 48.3) (13.9, 56.2) Type of accommodation     Emergency centre/social hostel 435 20.5 304 21.2 131 19.0      (15.8, 26.0) (15.3, 28.5) (12.8, 27.2)     Centre for asylums seekers 106 26.2 79 27.1 27 24.5      (17.6, 37.1) (17.5, 39.5) (11.3, 45.4)     Long-term rehabilitation centre 89 29.9 52 19.3 37 39.9      (14.5, 51.6) (9.7, 37.9) (10.9, 78.4) Cooking facilities in the bedroom     No 375 26.8 274 25.8 101 29.0      (21.1, 33.3) (18.8, 34.5) (20.5, 39.5)     Yes 254 17.5 161 15.0 93 20.9      (10.5, 27.5) (8.4, 25.6) (8.4, 43.2) Health Household food insecurity     Food security 92 32.7 67 37.2 25 15.3      (18.7, 50.6) (20.5, 57.7) (5.0, 38.5)     Food insecurity without hunger 208 17.5 145 15.6 63 21.2      (9.8, 29.2) (7.4, 30.0) (7.4, 47.5)     Food insecurity with moderate hunger 241 22.2 164 19.9 77 26.0      (16.3, 29.4) (13.1, 28.9) (16.5, 38.4)     Food insecurity with severe hunger 74 26.9 52 21.4 22 36.5      (17.2, 39.4) (10.9, 37.8) (20.0, 57.0) Child food insecurity     Food security 200 21.0 150 24.1 50 12.6      (13.0, 32.2) (14.1, 37.9) (5.3, 27.0)     Low food security 367 21.3 243 19.7 124 26.5      (16.7, 28.9) (13.4, 27.9) (15.9, 40.6)     Very low food security 63 26.4 42 22.8 21 31.0      (15.7, 40.8) (10.1, 43.7) (15.8, 51.9) Mother has moderate-to-severe anaemia     No 461 18.6 306 16.7 155 21.6      (13.7, 24.7) (10.9, 24.7) (13.2, 33.3)     Yes 169 33.0 129 32.1 40 35.5      (23.1, 44.6) (20.7, 46.2) (19.6, 55.3) Dietary intake Breastfeeding duration     None 58 18.8      (9.5, 33.8)     <6 months 115 24.7      (13.8, 40.3)     [6–12[ months 132 25.4      (14.6, 40.2)     [12–24[ months 100 18.9      (11.3, 30.0)     ≥24 months 6 36.9      (6.2, 83, 8) All children 0.5–5 years 6–12 years Variables Sample size Estimated prevalence Sample size Estimated prevalence Sample size Estimated prevalence (95% CI) (95% CI) (95% CI) Socio-demographic factors Sex     Male 301 22.0 197 20.1 104 25.2 Female (16.0, 29.5) (12.1, 31.4) (17.3, 35.1) 329 22.5 238 22.2 91 23.0      (15.2, 31.9) (14.8, 32.0) (9.9, 44.8) Age in years     [0.5–1[a 74 42.8      (24.7, 63.1)     [1–3[ 197 15.5      (9.8, 23.5)     [3–6[ 164 20.4      (12.5, 31.6)     [6–11[ 151 22.6      (14.9, 32.8)     [11–13[ 44 29.6      (10.2, 60.8) Mother's birthplace  SCD-endemic countries in Africa and Asia 318 22.6 226 21.9 92 24.0      (15.6, 31.6) (14.8, 31.2) (10.0, 47.3)  Other African countries 108 36.7 85 36.4 23 37.3      (21.8, 54.5) (19.0, 58.2) (19.6, 59.3)  Commonwealth of Independent States 118 18.4 65 17.3 53 19.5      (10.9, 29.4) (8.9, 31.0) (10.6, 33.1)  Europe, America 86 10.6 59 8.1 27 17.9      (5.7, 18.8) (3.3, 18.7) (8.7, 33.4) Living conditions Mother's difficulty speaking/understanding French     No 210 27.6 156 23.8 54 35.9      (19.9, 36.9) (16.0, 33.8) (16.6, 61.0)     Yes 386 20.1 251 21.6 135 17.7      (14.5, 27.2) (14.1, 31.6) (11.8, 25.7) Duration of mother's time in France (years)     <1 90 20.6 65 23.2 25 15.6      (12.8, 31.5) (12.3, 39.2) (6.8, 32.1)     [1–2[ 124 11.9 93 10.3 31 16.6      (7.0, 19.5) (5.7, 17.8) (6.6, 35.9)     [2–4[ 166 23.1 120 25.7 46 15.7      (15.3, 33.4) (16.0, 38.7) (8.1, 28.4)     ≥4 217 26.8 130 24.9 87 29.1      (17.6, 38.5) (15.1, 38.1) (14.4, 50.2) Duration of mother's homelessness in years     <1 147 31.2 108 32.3 39 28.6      (20.4, 44.5) (18.7, 49.8) (18.8, 41.0)     [1–2[ 177 15.0 133 15.9 44 12.9      (9.6, 22.5) (9.3, 25.6) (6.4, 24.3)     [2–4[ 174 19.1 119 12.4 55 31.9      (10.6, 31.9) (6.5, 22.4) (11.4, 62.9)  ≥4 132 24.0 75 25.6 57 21.9 (14.3, 37.4) (12.6, 45.1) (11.1, 38.7) Household monthly income (€/CU)     None 126 21.4 88 20.3 38 23.9      (14.1, 31.2) (11.5, 33.3) (12.9, 39.9)     <250 231 17.6 169 12.6 62 29.0      (11.9, 25.3) (7.2, 21.2) (16.7, 45.4)     [250–500[ 119 18.1 79 22.0 40 12.4      (11.1, 28.2) (12.1, 36.6) (5.7, 25.0)     ≥500 135 30.3 88 29.7 47 31.3      (19.1, 44.5) (16.1, 48.3) (13.9, 56.2) Type of accommodation     Emergency centre/social hostel 435 20.5 304 21.2 131 19.0      (15.8, 26.0) (15.3, 28.5) (12.8, 27.2)     Centre for asylums seekers 106 26.2 79 27.1 27 24.5      (17.6, 37.1) (17.5, 39.5) (11.3, 45.4)     Long-term rehabilitation centre 89 29.9 52 19.3 37 39.9      (14.5, 51.6) (9.7, 37.9) (10.9, 78.4) Cooking facilities in the bedroom     No 375 26.8 274 25.8 101 29.0      (21.1, 33.3) (18.8, 34.5) (20.5, 39.5)     Yes 254 17.5 161 15.0 93 20.9      (10.5, 27.5) (8.4, 25.6) (8.4, 43.2) Health Household food insecurity     Food security 92 32.7 67 37.2 25 15.3      (18.7, 50.6) (20.5, 57.7) (5.0, 38.5)     Food insecurity without hunger 208 17.5 145 15.6 63 21.2      (9.8, 29.2) (7.4, 30.0) (7.4, 47.5)     Food insecurity with moderate hunger 241 22.2 164 19.9 77 26.0      (16.3, 29.4) (13.1, 28.9) (16.5, 38.4)     Food insecurity with severe hunger 74 26.9 52 21.4 22 36.5      (17.2, 39.4) (10.9, 37.8) (20.0, 57.0) Child food insecurity     Food security 200 21.0 150 24.1 50 12.6      (13.0, 32.2) (14.1, 37.9) (5.3, 27.0)     Low food security 367 21.3 243 19.7 124 26.5      (16.7, 28.9) (13.4, 27.9) (15.9, 40.6)     Very low food security 63 26.4 42 22.8 21 31.0      (15.7, 40.8) (10.1, 43.7) (15.8, 51.9) Mother has moderate-to-severe anaemia     No 461 18.6 306 16.7 155 21.6      (13.7, 24.7) (10.9, 24.7) (13.2, 33.3)     Yes 169 33.0 129 32.1 40 35.5      (23.1, 44.6) (20.7, 46.2) (19.6, 55.3) Dietary intake Breastfeeding duration     None 58 18.8      (9.5, 33.8)     <6 months 115 24.7      (13.8, 40.3)     [6–12[ months 132 25.4      (14.6, 40.2)     [12–24[ months 100 18.9      (11.3, 30.0)     ≥24 months 6 36.9      (6.2, 83, 8) SCD: sickle cell disease. CU: Consumption Unit. a Right bracket means ‘excluded’. Figure 1 View largeDownload slide Estimated distribution of haemoglobin (g/dl) in homeless women and children (stratified according to age group and sex) in the Paris region, France, 2013 Figure 1 View largeDownload slide Estimated distribution of haemoglobin (g/dl) in homeless women and children (stratified according to age group and sex) in the Paris region, France, 2013 Factors associated with MSA in children aged 0.5–5 years Among the variables included into the multivariate analysis (i.e. age, mother's birth place, mother duration of homelessness, household income, having cooking facilities in their bedroom, child food insecurity and mother having MSA), four variables remained significantly positively associated with MSA: household income, having no cooking facilities in their bedroom, child food insecurity and mother having MSA (table 3). The MSA prevalence increased with the household income. Children living in an accommodation with no facilities to cook in their bedroom were 1.6 times more likely to have MSA. Children with low and very low food security were, respectively, 1.8 and 2.6 times more likely to have MSA than children who were food secure. Children whose mother had MSA had an MSA prevalence 1.8 times higher than their counterparts. Table 3 Estimated prevalence ratios for the association with moderate-to-severe anaemia from a multivariate Poisson model in homeless children in the Paris region, France, 2013 0.5–5 years 6–12 years ref Adjusted prevalence ratio (95% CI) P value Adjusted prevalence ratio (95% CI) P value Sex     Male ref 1.31 (0.73, 2.34) 0.36     Female 1.15 (0.70, 1.93) 0.57 ref Age in monthsa 0.07     [6–12[b 9 1.67 (1.08, 2.59)     [12–36[ 24 ref     [36–72[ 55 1.30 (0.83, 2.03) Age in yearsa     [6–11[ 8 ref 0.042     [11–13[ 12 3.33 (1.03, 10.83) Mother's birthplace 0.14 0.13     SCD-endemic countries in Africa and Asia 2.15 (0.88, 5.27) 0.093 1.26 (0.48, 3.28) 0.63     Other African countries 3.24 (1.17, 8.93) 0.024 1.85 (0.92, 3.75) 0.085     Commonwealth of Independent States 2.66 (0.93, 7.62) 0.068 1.25 (0.52, 3.00) 0.61     Europe, America ref ref Household monthly income (€/CU)a 0.015     None 0 ref -     <250 100 1.03 (1.01, 1.05)     [250–500[ 384 1.79 (1.21, 2.65)     ≥500 666 2.09 (1.05, 4.16) Cooking facilities in the bedroom -     No 1.62 (1.03, 2.56) 0.038     Yes ref Household food insecuritya 0.013     Food security [0–2] 0 ref     Food insecurity without hunger [3–7] 6 1.30 (0.96, 1.77)     Food insecurity with moderate hunger [8–12] 10 1.92 (0.97, 3.80)     Food insecurity with severe hunger [13–18] 16 2.91 (1.35, 6.24) Child food insecuritya 0.05     Food security [0–1] 1 ref     Low food security [2–4] 3 1.81 (1.07, 3.07)     Very low food security [5–8] 7 2.56 (1.13, 5.81) Mother has moderate-to-severe anaemia     No ref ref     Yes 1.80 (1.09, 2.97) 0.021 1.68 (1.00, 2.81) 0.048 Breastfeeding durationa in months 0.58     < 6 3 ref     [6–12[ 9 1.05 (0.89, 1.25)     [12–24[ 24 1.19 (0.65, 2.15)     >24 months 38 1.33 (0.49, 3.59) Child dietary pattern 1.10 (0.91, 1.32) 0.32 0.5–5 years 6–12 years ref Adjusted prevalence ratio (95% CI) P value Adjusted prevalence ratio (95% CI) P value Sex     Male ref 1.31 (0.73, 2.34) 0.36     Female 1.15 (0.70, 1.93) 0.57 ref Age in monthsa 0.07     [6–12[b 9 1.67 (1.08, 2.59)     [12–36[ 24 ref     [36–72[ 55 1.30 (0.83, 2.03) Age in yearsa     [6–11[ 8 ref 0.042     [11–13[ 12 3.33 (1.03, 10.83) Mother's birthplace 0.14 0.13     SCD-endemic countries in Africa and Asia 2.15 (0.88, 5.27) 0.093 1.26 (0.48, 3.28) 0.63     Other African countries 3.24 (1.17, 8.93) 0.024 1.85 (0.92, 3.75) 0.085     Commonwealth of Independent States 2.66 (0.93, 7.62) 0.068 1.25 (0.52, 3.00) 0.61     Europe, America ref ref Household monthly income (€/CU)a 0.015     None 0 ref -     <250 100 1.03 (1.01, 1.05)     [250–500[ 384 1.79 (1.21, 2.65)     ≥500 666 2.09 (1.05, 4.16) Cooking facilities in the bedroom -     No 1.62 (1.03, 2.56) 0.038     Yes ref Household food insecuritya 0.013     Food security [0–2] 0 ref     Food insecurity without hunger [3–7] 6 1.30 (0.96, 1.77)     Food insecurity with moderate hunger [8–12] 10 1.92 (0.97, 3.80)     Food insecurity with severe hunger [13–18] 16 2.91 (1.35, 6.24) Child food insecuritya 0.05     Food security [0–1] 1 ref     Low food security [2–4] 3 1.81 (1.07, 3.07)     Very low food security [5–8] 7 2.56 (1.13, 5.81) Mother has moderate-to-severe anaemia     No ref ref     Yes 1.80 (1.09, 2.97) 0.021 1.68 (1.00, 2.81) 0.048 Breastfeeding durationa in months 0.58     < 6 3 ref     [6–12[ 9 1.05 (0.89, 1.25)     [12–24[ 24 1.19 (0.65, 2.15)     >24 months 38 1.33 (0.49, 3.59) Child dietary pattern 1.10 (0.91, 1.32) 0.32 SCD: sickle cell disease. CU: Consumption Unit. a Modelled using a fractional polynomial. The prevalence ratios of central values within each group (ref column) are presented. b Right bracket means ‘excluded’. Table 3 Estimated prevalence ratios for the association with moderate-to-severe anaemia from a multivariate Poisson model in homeless children in the Paris region, France, 2013 0.5–5 years 6–12 years ref Adjusted prevalence ratio (95% CI) P value Adjusted prevalence ratio (95% CI) P value Sex     Male ref 1.31 (0.73, 2.34) 0.36     Female 1.15 (0.70, 1.93) 0.57 ref Age in monthsa 0.07     [6–12[b 9 1.67 (1.08, 2.59)     [12–36[ 24 ref     [36–72[ 55 1.30 (0.83, 2.03) Age in yearsa     [6–11[ 8 ref 0.042     [11–13[ 12 3.33 (1.03, 10.83) Mother's birthplace 0.14 0.13     SCD-endemic countries in Africa and Asia 2.15 (0.88, 5.27) 0.093 1.26 (0.48, 3.28) 0.63     Other African countries 3.24 (1.17, 8.93) 0.024 1.85 (0.92, 3.75) 0.085     Commonwealth of Independent States 2.66 (0.93, 7.62) 0.068 1.25 (0.52, 3.00) 0.61     Europe, America ref ref Household monthly income (€/CU)a 0.015     None 0 ref -     <250 100 1.03 (1.01, 1.05)     [250–500[ 384 1.79 (1.21, 2.65)     ≥500 666 2.09 (1.05, 4.16) Cooking facilities in the bedroom -     No 1.62 (1.03, 2.56) 0.038     Yes ref Household food insecuritya 0.013     Food security [0–2] 0 ref     Food insecurity without hunger [3–7] 6 1.30 (0.96, 1.77)     Food insecurity with moderate hunger [8–12] 10 1.92 (0.97, 3.80)     Food insecurity with severe hunger [13–18] 16 2.91 (1.35, 6.24) Child food insecuritya 0.05     Food security [0–1] 1 ref     Low food security [2–4] 3 1.81 (1.07, 3.07)     Very low food security [5–8] 7 2.56 (1.13, 5.81) Mother has moderate-to-severe anaemia     No ref ref     Yes 1.80 (1.09, 2.97) 0.021 1.68 (1.00, 2.81) 0.048 Breastfeeding durationa in months 0.58     < 6 3 ref     [6–12[ 9 1.05 (0.89, 1.25)     [12–24[ 24 1.19 (0.65, 2.15)     >24 months 38 1.33 (0.49, 3.59) Child dietary pattern 1.10 (0.91, 1.32) 0.32 0.5–5 years 6–12 years ref Adjusted prevalence ratio (95% CI) P value Adjusted prevalence ratio (95% CI) P value Sex     Male ref 1.31 (0.73, 2.34) 0.36     Female 1.15 (0.70, 1.93) 0.57 ref Age in monthsa 0.07     [6–12[b 9 1.67 (1.08, 2.59)     [12–36[ 24 ref     [36–72[ 55 1.30 (0.83, 2.03) Age in yearsa     [6–11[ 8 ref 0.042     [11–13[ 12 3.33 (1.03, 10.83) Mother's birthplace 0.14 0.13     SCD-endemic countries in Africa and Asia 2.15 (0.88, 5.27) 0.093 1.26 (0.48, 3.28) 0.63     Other African countries 3.24 (1.17, 8.93) 0.024 1.85 (0.92, 3.75) 0.085     Commonwealth of Independent States 2.66 (0.93, 7.62) 0.068 1.25 (0.52, 3.00) 0.61     Europe, America ref ref Household monthly income (€/CU)a 0.015     None 0 ref -     <250 100 1.03 (1.01, 1.05)     [250–500[ 384 1.79 (1.21, 2.65)     ≥500 666 2.09 (1.05, 4.16) Cooking facilities in the bedroom -     No 1.62 (1.03, 2.56) 0.038     Yes ref Household food insecuritya 0.013     Food security [0–2] 0 ref     Food insecurity without hunger [3–7] 6 1.30 (0.96, 1.77)     Food insecurity with moderate hunger [8–12] 10 1.92 (0.97, 3.80)     Food insecurity with severe hunger [13–18] 16 2.91 (1.35, 6.24) Child food insecuritya 0.05     Food security [0–1] 1 ref     Low food security [2–4] 3 1.81 (1.07, 3.07)     Very low food security [5–8] 7 2.56 (1.13, 5.81) Mother has moderate-to-severe anaemia     No ref ref     Yes 1.80 (1.09, 2.97) 0.021 1.68 (1.00, 2.81) 0.048 Breastfeeding durationa in months 0.58     < 6 3 ref     [6–12[ 9 1.05 (0.89, 1.25)     [12–24[ 24 1.19 (0.65, 2.15)     >24 months 38 1.33 (0.49, 3.59) Child dietary pattern 1.10 (0.91, 1.32) 0.32 SCD: sickle cell disease. CU: Consumption Unit. a Modelled using a fractional polynomial. The prevalence ratios of central values within each group (ref column) are presented. b Right bracket means ‘excluded’. Factors associated with MSA in children aged 6–12 years The variables included in the multivariate analysis were age, mother’s birth place, mother’s difficulties speaking and understanding French, type of accommodation, household food insecurity and mother having MSA. Then children’s MSA prevalence was significantly higher when mothers suffered from MSA (prevalence ratio = 1.7) and when households experienced food insecurity (table 3). The prevalence of MSA was 3.3 times higher in children aged 11–12 years than in those aged 6–10 years. Discussion The ENFAMS survey is the first to describe the living conditions and health of homeless families in France.13 Our results provide original insights into the alarming prevalence of anaemia in this vulnerable population. These homeless families suffered considerably from food insecurity, as compared to the general population in the Paris metropolitan area in 2010 (6.3%),34 86.7% of the households and 72.7% of the children experiencing it. Overall vulnerability of our population may partly explain the factors associated with children having MSA, including living in an accommodation with no facilities to cook, mother having MSA, child and household food insecurity. Our findings suggest that food insecurity is the main factor associated with moderate-to-severe anaemia of the child. Even if our cross-sectional design did not allow causal inference regarding anaemia, our results are consistent with other studies that have suggested that food insecurity could affect nutritional quality of the diet.7,35 As expected, we did find an inverse link between food insecurity and the adherence to a diversified diet. Previous studies have shown that household food insecurity or food insufficiency is associated with suboptimal nutrient intakes, especially in women6,35–37 and that foods and nutrients are not allocated in proportion to individual family members’ needs.38 Poor women typically report that they deprive themselves of food in order to leave more for their children during periods of severe food shortages. Child MSA is associated with mothers having MSA, and anaemia is partially a result of dietary deficiency. Accordingly, our results are also consistent with those of McIntyre et al. who showed that low-income single mothers may compromise their own nutritional intake (as possibly indicated in our findings by their anaemia status) in order to preserve sufficient dietary intake for their child.39 Child food insecurity may therefore be considered as an indicator for more severe household food insecurity, given that adults might compromise their own food intake to minimize its effects on children. This assumption partly explains why only household food insecurity was found to be associated with MSA in children aged 6–12 years, whereas the association between child food insecurity and MSA among children of this age was not found to be significant. Moreover, the association between child food insecurity and MSA in children aged 0.5–5 years suggests that mothers might not be able to protect the latter as effectively as their older counterparts. Indeed, children this age have a different diet than adults, and baby food is likely to be too expensive. This assumption appears to partly be supported by a high proportion of children aged 0.5–5 years who were breastfed longer than 6 months (61.3%). Whereas this proportion is probably underestimated because of a right censored effect on breastfeeding, it remains much higher than among the general population (19.2%).40 This behaviour could be linked to mother’s attempt to compensate the lack of food. However, as mothers are anaemic, their breast-milk may be ironless and put children at risk for anaemia. The assumption that anaemia may partly be due to nutritional factors (e.g. iron, vitamins A, B2—riboflavin, B9—acid folic, B12, and C, protein, copper and other mineral) seems to be supported by the association between the MSA in young children and the provision of cooking facilities in the bedroom. This association was not observed in the 6–12-year-old children, which might be partly explained by their attendance to school canteen at lunch time, schooling being compulsory at this age. Above a certain threshold of income, families must contribute to the cost of their accommodation. The financial participation grows with their household income implying budget trade-offs to the expense of food supply,7 which could explain the positive association observed between 0.5 and 5 year-old children’s MSA and the household income. One limitation of the study is that dietary intakes in children aged 6–12 years were assessed based on a food questionnaire that did not contain all food types (especially non-core foods), limiting the ability of the food classification to cover the whole diet. The decision to restrict the number of food types was taken to reduce the time needed to complete the food-based survey. This limitation prevented us to identify unhealthy patterns and to test its association with anaemia. Thus, for our study, the indicator food insecurity, which retrospectively encompasses an individual’s physical, social and financial dimensions during the previous 12 months, is likely to be a better proxy for social disadvantage and malnutrition than the ‘diversified’ dietary pattern which we measured cross-sectionally, and consequently proves more useful for identifying epidemiological associations. Further, some variables known to be risk factors for childhood anaemia, such as parasitic infection or inflammation, could not be measured and controlled in the multivariate analysis. Despite these limitations, the ENFAMS survey is a unique source of information on nutritional health and anaemia related to social factors including food insecurity among homeless families. The questionnaire contained a wide range of variables on living conditions, including original factors specific to homelessness and social disadvantage such as child food insecurity, which is rarely studied in such population groups. This study shows that sheltered homeless children and mothers display a high prevalence of anaemia, the latter being mainly associated with food insecurity. It provides original and important insights into this extremely disadvantaged population whose have been growing exponentially in France in recent years and highlights the need for: ensure better healthcare support to identify anaemia’s origin and to treat it; improve availability and access to healthy foods, including iron-rich ones, by providing information about food aid organizations (localization, access conditions), organising food services in accommodation centres or establishing free distributions of ‘packed meal’ in social hostels; supplying dietary and cooking advice concerning food-aid products in order to encourage mothers to stock up on foods that they are not familiar with. Further research is also needed to evaluate the impact of such nutritional interventions on food insecurity, dietary intake and anaemia. Supplementary data Supplementary data are available at EURPUB online. Acknowledgements The authors gratefully acknowledge Françoise Riou, Emmanuelle Guyavarch, Erwan Le Méner, Carme Caum, Candy Jangal, Judith Martin-Fernandez and Florence Beauvallet. They thank interviewers, nurses and all the families involved in this study. They also thank Jude Sweeney for the English editorial assistance. Funding This study was funded by Agence Régionale de Santé d’Ile-de-France (ARS), Cancéropôle Ile-de-France, Caisse Nationale des Allocations Familiales (CNAF), Fondation de France, Fondation Macif, Fondation Sanofi Espoir, Institut National de Prévention et d’Éducation pour la Santé (INPES), Institut de Recherche en Santé Publique (IReSP), Institut de Veille Sanitaire (InVS), Ministère de l’Intérieur, Observatoire National de l’Enfance en Danger (ONED), Procter et Gamble and State Street. The HemoCue® equipment used in the survey was kindly supplied by HemoCue France. Conflicts of interest: None declared. Key points High prevalence of anaemia and moderate-to-severe anaemia among homeless children and their mothers. Children’s moderate-to-severe anaemia was positively associated with maternal moderate-to-severe anaemia and food insecurity. Need to ensure better healthcare and prevent food insecurity in the emergency shelter system. References 1 De Benoist B . World Health Organization, Centers for Disease Control and Prevention (U.S.). Worldwide Prevalence of Anaemia 1993–2005 of WHO Global Database of Anaemia . Geneva : World Health Organization ; 2008 . http://whqlibdoc.who.int/publications/2008/9789241596657_eng.pdf. Accessed June 18, 2015. 2 Grantham-McGregor S , Ani C . A review of studies on the effect of iron deficiency on cognitive development in children . J Nutr 2001 ; 131 : 649S – 66S . discussion 666S-668S. Google Scholar CrossRef Search ADS PubMed 3 Schneider JM , Fujii ML , Lamp CL , et al. Anemia, iron deficiency, and iron deficiency anemia in 12–36-mo-old children from low-income families . Am J Clin Nutr 2005 ; 82 : 1269 – 75 . Google Scholar CrossRef Search ADS PubMed 4 Grant R , Shapiro A , Joseph S , et al. The health of homeless children revisited . Adv Pediatr 2007 ; 54 : 173 – 87 . Google Scholar CrossRef Search ADS PubMed 5 Darmon N , Drewnowski A . Does social class predict diet quality? Am J Clin Nutr 2008 ; 87 : 1107 – 17 . Google Scholar CrossRef Search ADS PubMed 6 Dixon LB , Winkleby MA , Radimer KL . Dietary Intakes and Serum Nutrients Differ between Adults from Food-Insufficient and Food-Sufficient Families: Third National Health and Nutrition Examination Survey, 1988–1994 . J Nutr 2001 ; 131 : 1232 – 46 . Google Scholar CrossRef Search ADS PubMed 7 Bocquier A , Vieux F , Lioret S , et al. Socio-economic characteristics, living conditions and diet quality are associated with food insecurity in France . Public Health Nutr 2015 ; 18 : 2952 – 61 . Google Scholar CrossRef Search ADS PubMed 8 Skalicky A , Meyers AF , Adams WG , et al. Child food insecurity and iron deficiency anemia in low-income infants and toddlers in the United States . Matern Child Health J 2006 ; 10 : 177 – 85 . Google Scholar CrossRef Search ADS PubMed 9 Park K , Kersey M , Geppert J , et al. Household food insecurity is a risk factor for iron-deficiency anaemia in a multi-ethnic, low-income sample of infants and toddlers . Public Health Nutr 2009 ; 12 : 2120 – 8 . Google Scholar CrossRef Search ADS PubMed 10 Metallinos-Katsaras E , Colchamiro R , Edelstein S , Siu E . Household Food Security Status Is Associated with Anemia Risk at Age 18 Months among Low-Income Infants in Massachusetts . J Acad Nutr Diet 2016 ; 116 : 1760 – 6 . Google Scholar CrossRef Search ADS PubMed 11 Mordier B . Introduction de cadrage: les sans-domicile en France: caractéristiques et principales évolutions entre 2001 et 2012 . Économie Stat 2016 ; 488 : 25 – 35 . Google Scholar CrossRef Search ADS 12 FEANTSA. Changing Faces: Homelessness Among Children, Families and Young People. Homeless Eur. 2010 ;(Autumn/Winter). http://www.feantsa.org/spip.php? action=acceder_document&arg=337&cle=720c8a1da14daad5ddb4f1b9e8f9811ecf6b2932&file=pdf%2Fhomeless_in_europe_autumn2010_en_final.pdf.pdf. 13 Vandentorren S , Le Méner E , Oppenchaim N , Arnaud A , Jangal C , Caum C , et al. Characteristics and health of homeless families: the ENFAMS survey in the Paris region, France 2013 . Eur J Public Health 2016 ; 26 : 71 – 6 . Google Scholar CrossRef Search ADS PubMed 14 WHO . Iron deficiency anaemia: assessment, prevention and control: a guide for programme managers. 2001 . http://apps.who.int/iris/handle/10665/66914. Accessed March 11, 2014. 15 von Schenck H , Falkensson M , Lundberg B . Evaluation of “HemoCue,” a new device for determining hemoglobin . Clin Chem 1986 ; 32 : 526 – 9 . Google Scholar PubMed 16 Johns WL , Lewis SM . Primary health screening by haemoglobinometry in a tropical community . Bull World Health Organ 1989 ; 67 : 627 – 33 . Google Scholar PubMed 17 Rafferty Y , Shinn M . The impact of homelessness on children . Am Psychol 1991 ; 46 : 1170 – 9 . Google Scholar CrossRef Search ADS PubMed 18 WHO . Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. http://www.who.int/vmnis/indicators/haemoglobin/en/. Published 2011. Accessed August 19, 2015 . 19 Hercberg S , Dhur A , Mekki N , Galan P . [Comparison of 2 methods for evaluating the prevalence of anemia in young children] . Rev Dépidémiologie Santé Publique 1989 ; 37 : 319 – 25 . 20 De Pee S , Bloem MW , Sari M , et al. The high prevalence of low hemoglobin concentration among Indonesian infants aged 3–5 months is related to maternal anemia . J Nutr 2002 ; 132 : 2215 – 21 . Google Scholar CrossRef Search ADS PubMed 21 Stoltzfus RJ . Rethinking anaemia surveillance . Lancet 1997 ; 349 : 1764 – 6 . Google Scholar CrossRef Search ADS PubMed 22 Radimer KL , Radimer KL . Measurement of household food security in the USA and other industrialised countries . Public Health Nutr 2002 ; 5 : 859 – 64 . Google Scholar CrossRef Search ADS PubMed 23 Briefel RR , Woteki CE . Development of food sufficiency questions for the third national health and nutrition examination survey . J Nutr Educ 1992 ; 24 : 24S – 8S . Google Scholar CrossRef Search ADS 24 Bickel G , Nord M , Price C , et al. Guide to measuring household food security. 2000 . https://origin.drupal.fns.usda.gov/sites/default/files/FSGuide_0.pdf. Accessed May 6, 2015. 25 Wunderlich G , Norwood J . Food Insecurity and Hunger in the United States: An Assessment of the Measure . The National Academies Press . Washington DC ; 2006 . http://www.nap.edu/openbook.php? record_id=11578. Accessed June 30, 2015. 26 Government of Canada HC . Canadian Community Health Survey, Cycle 2.2, Nutrition (2004): Income-Related Food Security in Canada [Health Canada, 2007].; 2007 . http://www.hc-sc.gc.ca/fn-an/surveill/nutrition/commun/income_food_sec-sec_alim-eng.php#metho252. Accessed July 20, 2015. 27 Hagenaars A , de Vos K , Zaidi MA . Poverty Statistics in the Late 1980s: Research Based on Micro-Data . Luxembourg : Office for Official Publications of the European Communities ; 1994 . 28 Cole TJ , Bellizzi MC , Flegal KM , Dietz WH . Establishing a standard definition for child overweight and obesity worldwide: international survey . BMJ 2000 ; 320 : 1240 – 3 . Google Scholar CrossRef Search ADS PubMed 29 Cattell RB . The Scree test for the number of factors . Multivar Behav Res 1966 ; 1 : 245 – 76 . Google Scholar CrossRef Search ADS 30 Kline P . An Easy Guide to Factor Analysis . London : Routledge ; 1994 . http://trove.nla.gov.au/version/29227124. 31 Royston P , Sauerbrei W . Building multivariable regression models with continuous covariates in clinical epidemiology–with an emphasis on fractional polynomials . Methods Inf Med 2005 ; 44 : 561 – 71 . Google Scholar CrossRef Search ADS PubMed 32 Zou G . A Modified Poisson Regression Approach to Prospective Studies with Binary Data . Am J Epidemiol 2004 ; 159 : 702 – 6 . Google Scholar CrossRef Search ADS PubMed 33 Cochran WG . Sampling Techniques, 3rd Edition . Wiley ; 1977 . http://eu.wiley.com/WileyCDA/WileyTitle/productCd-047116240X.html. Accessed September 19, 2016. 34 Martin-Fernandez J , Grillo F , Parizot I , et al. Prevalence and socioeconomic and geographical inequalities of household food insecurity in the Paris region, France, 2010 . BMC Public Health 2013 ; 13 : 486 . Google Scholar CrossRef Search ADS PubMed 35 Rose D , Oliveira V . Nutrient intakes of individuals from food-insufficient households in the United States . Am J Public Health 1997 ; 87 : 1956 – 61 . Google Scholar CrossRef Search ADS PubMed 36 Tarasuk VS , Beaton GH . Women’s Dietary Intakes in the Context of Household Food Insecurity . J Nutr 1999 ; 129 : 672 – 9 . Google Scholar CrossRef Search ADS PubMed 37 Cristofar SP , Basiotis PP . Dietary intakes and selected characteristics of women ages 19–50 years and their children ages 1–5 years by reported perception of food sufficiency . J Nutr Educ 1992 ; 24 : 53 – 8 . Google Scholar CrossRef Search ADS 38 Government of Canada HC . ARCHIVED - Discussion Paper on Household and Individual Food Insecurity [Health Canada, 2001].; 2002 . http://www.hc-sc.gc.ca/fn-an/nutrition/pol/food_sec_entire-sec_aliments_entier-eng.php. Accessed March 14, 2016. 39 McIntyre L , Glanville NT , Raine KD , et al. Do low-income lone mothers compromise their nutrition to feed their children? CMAJ Can Med Assoc J 2003 ; 168 : 686 – 91 . 40 Wagner S , Kersuzan C , Gojard S , et al. [Breastfeeding duration in France according to parents and birth characteristics. Results from the ELFE longitudinal French study, 2011] . Bull Epidémiol Hebd 2015 ; 29 : 522 – 32 . © The Author 2017. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png The European Journal of Public Health Oxford University Press

Anaemia and associated factors in homeless children in the Paris region: the ENFAMS survey

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Oxford University Press
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© The Author 2017. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.
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1101-1262
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1464-360X
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10.1093/eurpub/ckx192
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Abstract

Abstract Background Food insecurity is a major concern in homeless population, however nutritional consequences remain poorly documented, especially for children. The objective of this study was to assess the prevalence of anaemia and to investigate the relation between both food insecurity and dietary intake to moderate-to-severe anaemia (MSA) in homeless sheltered children. Methods In 2013, a cross-sectional survey was conducted on a random sample of 801 sheltered homeless families in the Paris region. Haemoglobin concentration was measured in 630 mother/child dyads and questionnaires administrated to mothers collected socio-demographic, socioeconomic, health and dietary data. Factors associated with MSA were analysed in two stratified child age groups; 0.5–5 and 6–12 years old. Results Anaemia was detected in 39.9% of the children and 50.6% of the mothers, and MSA in 22.3% and 25.6%, respectively. In both age groups, MSA was positively associated with maternal MSA. In the 0.5–5 years group, it was also positively associated with child food insecurity, no cooking facilities and household monthly income. In the 6–12 years group, it was positively associated with household food insecurity and children’s age. Conclusion A higher food insecurity score was associated with greater prevalence of moderate-to-severe anaemia in children. Considering the high prevalence of anaemia among homeless mothers and their children, these findings highlight the need for reducing food insecurity in shelters so as to prevent anaemia in this vulnerable population. Introduction Anaemia, or low concentration of haemoglobin, is a worldwide public health issue1 due to multiple causes. Some of them are preventable, such as nutritional deficiencies including iron deficiency (ID). Anaemia can occur at any stage of life but is more frequent in pregnant women and children, due to their physiological vulnerability. In children, anaemia impairs cognitive, mental and psychomotor development.2 It affects child growth, damages the immune system and alters metabolism. In Europe and France, the 2008 prevalence anaemia for children aged 6 months to 4 years was 21.7% and 8.3%, respectively.1 In industrialized countries, disadvantaged population groups are more likely to suffer from anaemia: in 2002, in California, the prevalence of anaemia was 11, 1% in 12–36-month-old children from low-income families3 and 19% in homeless children under 3 years of age in New York in 2004.4 Alongside, diet quality is known to follow a socioeconomic gradient, 5 and food insecurity is associated with poorer nutritional quality of diet.6,7 Indeed, there is some evidence that household or child food insecurity result in suboptimal nutrient intake and increase the risk of iron deficiency anaemia in young, low-income children.8,9 In 2016, low-income infants living in low-food-secure households in Massachusetts were 42% more likely to develop anaemia at age 18 months than their food-secure counterparts.10 In France, about 30 000 children were living in homeless families in 2012.11 Studies from the ‘Observatoire du Samusocial de Paris’ have shown a large increase of homeless families in the Paris region since 1999.12 Despite this growing number of homeless families, little is known regarding their living conditions and associated health problems, including anaemia, especially for children. To fill this gap, the ‘Homeless children and families’ survey (‘Enfants et familles sans logement’, ENFAMS) was carried out in 2013.13 Given the alarming prevalence of food insecurity and anaemia in this population, we aimed to investigate the association between both food insecurity and dietary intake to moderate-to-severe anaemia in homeless sheltered children. Methods Study design and participants The ENFAMS survey, based on a three-stage random sampling design, had been described previously.13 The sample included 801 homeless families sheltered in emergency centres, long-term rehabilitation centres, social hostels and centres for asylum seekers in the Paris region. Eligibility criteria stipulated that families had to comprise at least one parent and at least one child less than 13 years, speak one of the 17 languages considered in the survey, and be able to provide informed consent for study participation. Participation rate was 79%. The interviews took place in the interviewee’s bedroom or in a private room provided by the accommodation service. The study protocol was approved by the national authority for the protection of personal data collected on individuals (CNIL, n°DR-2013-147) and by two Ethics Committees (CPP, Ref 2012 02 06, 22/08/2012, and CCTIRS, n°12.471, 17/09/2012). Measurements After obtaining consent, two face-to-face questionnaires were administered to one parent: the first focused on socio-demographic and socioeconomic characteristics, living conditions, health and use of healthcare at the parent and household levels; the second concerned the selected child’s health and behaviours according to the age bracket (0–5 or 6–12 years old). At a subsequent appointment, nurses performed anthropometric measures, and made an immediate measurement of haemoglobin concentration (Hb) from a capillary blood sample with a portable haemoglobinometer (HemoCue® Hb201+ System, Ängelholm, Sweden), as recommended by the WHO for population surveys determining the prevalence of anaemia.14–16 Stable, durable and convenient to use, this method provides instantaneous results. It is especially suitable for surveying homeless families who are more likely to undergo frequent moves.17 According to the Hb results, families were provided with information and dietary advice, and when needed, were referred to social services or healthcare and emergency services. Anaemia definition The following haemoglobin cut-off points were chosen according to the WHO guidelines:18 for anaemia, <11.0 g/dl for children from 0.5–4 years of age, <11.5 g/dl for children from 5 to 11 years of age and <12.0 g/dl for children of 12 years of age or older; for mild anaemia, 10.0–10.9, 11.0–11.4 and 11.0–11.9 g/dl, respectively; for moderate anaemia, 7.0–9.9, 8.0–10.9 and 8.0–10.9 g/dl; and for severe anaemia, <7.0, 8.0 and 8.0 g/dl. Because of lack of consensus regarding cut-offs for anaemia among children less than 6 months old, these children were excluded from the analyses.19,20 For mothers, the cut-off 12.0 g/dl was used to define anaemia (11.0 g/dl if pregnant).18 The degree of anaemia was defined as: 11.0–11.9 g/dl for mild anaemia, 8.0 –10.9 g/dl for moderate anaemia, and less than 8.0 g/dl for severe anaemia (10.0 –10.9 g/dl, 7.0 –9.9 g/dl, and less than 7.0 g/dl, respectively, for pregnant women). As a substantial proportion of children was anaemic, using the variable ‘anaemia’ (i.e. covering all degrees of anaemia) would not have been discriminant enough to identify associated factors. Accordingly, we chose to use ‘moderate-to-severe anaemia’ (MSA) as outcome in this analysis.21 Dietary data Breastfeeding duration (in months) was recorded in children aged ≤5 years only. Breastfeeding was defined as the consumption of breast-milk along with other sources of milk (e.g. formula), foods or drinks (if any). If a child was still being breastfed at the time of the survey, breastfeeding duration was censored to the age of the child at that moment. In children aged 6–12 years, dietary intake information was collected using a 15-item semi-quantitative food frequency questionnaire (FFQ). In order to prevent the FFQ from being too burdensome given the long (3 hours) and sometimes sensitive (e.g. questions on living food deprivation) interview, the 15 food items covered only part of the child’s diet, focussing mainly on core food groups (i.e. fruit and vegetables, dairies, starchy foods, animal products). For each food group, four possible responses ranging from ‘Every day’ to ‘Never’ were converted into weekly frequencies (‘Every day’ was coded as 7 per week, ‘Several times per week’ was replaced by a uniform random number in the interval [2–6], ‘Less often’ by a uniform random number in the interval [0.25–1] and ‘Never’ was coded as 0). Food insecurity Food insecurity was measured by the Household Food Security Scale Measure (HFSSM),22 screening by a preliminary item (similar to the ‘food sufficiency question’).23 The HFSSM questionnaire includes 10 adult and 8 child-referenced questions. Two scores equalling the total number of affirmative responses to the questions were calculated at household and child levels. The household score was divided into four categories defined by the usual thresholds: food security (score: 0–2), food insecurity without hunger (3–7), food insecurity with moderate hunger (8–12) and food insecurity with severe hunger (13–18).24,25 The child score was divided into three categories defined by the following thresholds: food security (<2), low food security (2–4), very low food security (>4).26 Other variables Socio-demographic factors included child’s sex, age and birth place; mother's age, birth place and highest educational certificate obtained. The variable ‘mother's birth place’ was categorised into: sickle cell disease-endemic countries in Africa and Asia, other African countries, Commonwealth of Independent States (i.e. former Soviet countries), Europe and America. Living conditions included mother's difficulty speaking French (evaluated using the set of questions: ‘In your daily life, do you have difficulty understanding French? speaking in French?’). Time living in France, duration of homelessness, residence status (i.e. legally resident in France or not), health cover, employment, monthly income (taking household composition into account (€/Consumption Unit)27), type of accommodation, and whether there were cooking facilities in the bedroom. Health: Anthropometric measures were collected by nurses. Child’s weight was measured using a calibrated SECA balance scale and child’s length or height by a sliding foot scale or a wall-mounted stadiometer respectively, depending on age. Body Mass Index (BMI) was calculated using the formula BMI = weight(kg)/height(m)2, and child's BMI categorised into four groups: underweight, normal, overweight, obese, according to the IOTF definition.28 Statistical analysis Dietary patterns were established for children aged 6–12 years using Principal Component Analysis (PCA) of the 15 standardised dietary variables. The number of components (or patterns) was selected considering eigenvalues > 1.0, the scree plot and their interpretability.29,30 To interpret the results and provide a label to a given pattern, we considered the items most strongly related to that component, i.e. those for which the absolute value of the loading coefficient was >0.25. The PCA scores for the dietary pattern selected were calculated at the individual level by summing the observed standardised frequencies of consumption per food group, weighted according to the PCA loadings. Descriptive analyses were performed to estimate the prevalence of MSA. The association between MSA and each factor studied was then assessed adjusted for sex and age. Variables associated with MSA (P < 0.25) were included in a multivariate regression. Fractional polynomials were used to deal with continuous variables.31 Poisson regressions were used to determine the factors independently associated with MSA and to estimate prevalence ratios.32 Analyses were stratified by age (0.5–5 and 6–12 years). Few variables known as risk factors for anaemia were forced into the multivariate models: child’s age and sex, mother's birth place, breastfeeding duration in children aged 0.5–5 years and dietary pattern scores in children aged 6–12 years. These analyses took the sampling design into account.33 All analyses were performed with Stata 12® (StataCorp, Texas, USA). The significance level was set at 5%. Results Population characteristics Hb concentration was measured in 673 children of 6 months of age and older and 716 mothers and the questionnaires were completed for 630 mother/child dyads (435 children aged 0.5–5 years and 195 children aged 6–12 years) (table 1). Mother/child dyads without complete measures and father/child dyads were excluded. Table 1 Characteristics of 0.5–12 year-old homeless children in the Paris region, 2013 Variables Sample size Estimated proportion (95% CI) Socio-demographic factors Sex     Male 301 46.8 (41.7, 52.0)     Female 329 53.2 (48.1, 58.3) Age     [0.5–1[a 74 8.9 (6.1, 12.8)     [1–3[ 197 29.2 (24.7, 34.1)     [3–6[ 164 27.0 (22.4, 32.2)     [6–11[ 151 27.6 (23.0, 32.7)     [11–13[ 44 7.3 (5.5, 9.6) Born in France     No 267 41.6 (35.5, 48.0)     Yes 359 58.4 (52.0, 64.5) Mother's age in years     [18–30[ 253 30.8 (25.9, 36.1)     [30–40[ 319 53.9 (49.0, 58.7)     ≥40 86 15.3 (11.6, 19.9) Mother's birthplace     SCD-endemic countries in Africa and Asia 318 53.9 (48.3, 59.4)     Other African countries 108 14.7 (10.9, 19.6)     Commonwealth of Independent States 118 17.0 (13.6, 21.0)     Europe, America 86 14.4 (10.9, 18.8) Mother's educational level     None 244 39.0 (33.9, 44.5)     Primary/junior high school certificate 142 28.4 (22.7, 34.9)     Senior high school certificate 135 19.3 (15.4, 23.8)     Tertiary-level certificate 96 13.3 (10.1, 17.3) Living conditions Mother's difficulty speaking/understanding French     No 210 36.6 (30.3, 43.4)     Yes 386 63.4 (56.6, 69.7) Duration of mother's time in France (years)     <1 90 13.5 (10.2, 17.6)     [1–2[ 124 14.7 (11.3, 18.9)     [2–4[ 166 26.7 (21.6, 32.5)     ≥4 217 45.1 (39.4, 51.0) Duration of mother’s homelessness in years     <1 147 23.3 (18.7, 28.7)     [1–2[ 177 23.3 (19.2, 28.0)     [2–4[ 174 26.7 (21.4, 32.7)     ≥4 132 26.7 (21.7, 32.4) Mother's administrative status     Awaiting regularisation 291 49.3 (43.2, 55.5)     Regularised 57 11.1 (7.6, 15.9)     Asylum seekers 108 10.8 (8.5, 13.7)     Residence permit 127 28.7 (23.8, 34.2) Mother's health cover     State health insurance 46 10.2 (6.6, 15.5)     Universal health insurance cover 297 42.6 (36.5, 49.0)     State health aid 162 27.8 (22.8, 33.4)     Pending response 61 8.9 (6.4, 12.2)     None 63 10.5 (7.9, 13.7) Mother is employed     No 511 78.5 (73.3, 82.9)     Yes 118 21.5 (17.1, 26.7) Household monthly income (€/CU)     None 126 20.4 (16.6, 24.8)     <250 231 30.8 (25.9, 36.1)     [250–500[ 119 19.6 (15.7, 24.2)     ≥500 135 29.2 (23.6, 35.5) Type of accommodation     Emergency centre/social hostel 435 78.8 (76.3, 81.1)     Centre for asylums seekers 106 5.6 (4.9, 6.4)     Long-term rehabilitation centre 89 15.6 (13.6, 17.8) Cooking facilities in the bedroom     No 375 52.7 (45.9, 59.5)     Yes 254 47.3 (40.5, 54.1) Health Household food insecurity     Food security 92 13.3 (10.1, 17.3)     Food insecurity without hunger 208 34.2 (28.9, 39.9)     Food insecurity with moderate hunger 241 41.9 (36.7, 47.2)     Food insecurity with severe hunger 74 10.6 (8.1, 14.0) Child food insecurity     Food security 200 27.3 (22.6, 32.7)     Low food security 367 63.7 (58.2, 68.9)     Very low food security 63 9.0 (6.7, 11.9) Children's weight status (BMI)     Underweight 49 9.8 (7.4, 12.9)     Normal 283 65.5 (58.9, 71.5)     Overweight 80 20.2 (14.4, 27.7)     Obese 18 4.5 (2.5, 8.0) Child's anaemia status     None 372 60.1 (54.3, 65.6)     Mild 129 17.7 (14.1, 22.0)     Moderate 128 22.2 (17.6, 27.6)     Severe 1 0.05 (0.01, 0.3)     Moderate+ Severe 129 22.3 (17.6, 27.7) Mother's anaemia status     None 299 49.4 (44.1, 54.8)     Mild 162 24.9 (20.8, 29.5)     Moderate 167 25.4 (21.4, 30.0)     Severe 2 0.2 (0.04, 1.0)     Moderate+ Severe 169 25.6 (21.5, 30.2) Dietary intake Breastfeeding duration (0.5–5 year-old children)     None 57 11.0 (7.9, 15.1)     <6 months 116 27.7 (21.0, 35.7)     [6–12[ 132 34.3 (27.9, 41.3)     [12–24[ 80 17.6 (13.4, 22.7)     ≥24 months 26 9.4 (5.8, 14.9) Dietary pattern mean score (SD) (6–12-year-old children) 190 0.08 (−0.92, 1.41) Variables Sample size Estimated proportion (95% CI) Socio-demographic factors Sex     Male 301 46.8 (41.7, 52.0)     Female 329 53.2 (48.1, 58.3) Age     [0.5–1[a 74 8.9 (6.1, 12.8)     [1–3[ 197 29.2 (24.7, 34.1)     [3–6[ 164 27.0 (22.4, 32.2)     [6–11[ 151 27.6 (23.0, 32.7)     [11–13[ 44 7.3 (5.5, 9.6) Born in France     No 267 41.6 (35.5, 48.0)     Yes 359 58.4 (52.0, 64.5) Mother's age in years     [18–30[ 253 30.8 (25.9, 36.1)     [30–40[ 319 53.9 (49.0, 58.7)     ≥40 86 15.3 (11.6, 19.9) Mother's birthplace     SCD-endemic countries in Africa and Asia 318 53.9 (48.3, 59.4)     Other African countries 108 14.7 (10.9, 19.6)     Commonwealth of Independent States 118 17.0 (13.6, 21.0)     Europe, America 86 14.4 (10.9, 18.8) Mother's educational level     None 244 39.0 (33.9, 44.5)     Primary/junior high school certificate 142 28.4 (22.7, 34.9)     Senior high school certificate 135 19.3 (15.4, 23.8)     Tertiary-level certificate 96 13.3 (10.1, 17.3) Living conditions Mother's difficulty speaking/understanding French     No 210 36.6 (30.3, 43.4)     Yes 386 63.4 (56.6, 69.7) Duration of mother's time in France (years)     <1 90 13.5 (10.2, 17.6)     [1–2[ 124 14.7 (11.3, 18.9)     [2–4[ 166 26.7 (21.6, 32.5)     ≥4 217 45.1 (39.4, 51.0) Duration of mother’s homelessness in years     <1 147 23.3 (18.7, 28.7)     [1–2[ 177 23.3 (19.2, 28.0)     [2–4[ 174 26.7 (21.4, 32.7)     ≥4 132 26.7 (21.7, 32.4) Mother's administrative status     Awaiting regularisation 291 49.3 (43.2, 55.5)     Regularised 57 11.1 (7.6, 15.9)     Asylum seekers 108 10.8 (8.5, 13.7)     Residence permit 127 28.7 (23.8, 34.2) Mother's health cover     State health insurance 46 10.2 (6.6, 15.5)     Universal health insurance cover 297 42.6 (36.5, 49.0)     State health aid 162 27.8 (22.8, 33.4)     Pending response 61 8.9 (6.4, 12.2)     None 63 10.5 (7.9, 13.7) Mother is employed     No 511 78.5 (73.3, 82.9)     Yes 118 21.5 (17.1, 26.7) Household monthly income (€/CU)     None 126 20.4 (16.6, 24.8)     <250 231 30.8 (25.9, 36.1)     [250–500[ 119 19.6 (15.7, 24.2)     ≥500 135 29.2 (23.6, 35.5) Type of accommodation     Emergency centre/social hostel 435 78.8 (76.3, 81.1)     Centre for asylums seekers 106 5.6 (4.9, 6.4)     Long-term rehabilitation centre 89 15.6 (13.6, 17.8) Cooking facilities in the bedroom     No 375 52.7 (45.9, 59.5)     Yes 254 47.3 (40.5, 54.1) Health Household food insecurity     Food security 92 13.3 (10.1, 17.3)     Food insecurity without hunger 208 34.2 (28.9, 39.9)     Food insecurity with moderate hunger 241 41.9 (36.7, 47.2)     Food insecurity with severe hunger 74 10.6 (8.1, 14.0) Child food insecurity     Food security 200 27.3 (22.6, 32.7)     Low food security 367 63.7 (58.2, 68.9)     Very low food security 63 9.0 (6.7, 11.9) Children's weight status (BMI)     Underweight 49 9.8 (7.4, 12.9)     Normal 283 65.5 (58.9, 71.5)     Overweight 80 20.2 (14.4, 27.7)     Obese 18 4.5 (2.5, 8.0) Child's anaemia status     None 372 60.1 (54.3, 65.6)     Mild 129 17.7 (14.1, 22.0)     Moderate 128 22.2 (17.6, 27.6)     Severe 1 0.05 (0.01, 0.3)     Moderate+ Severe 129 22.3 (17.6, 27.7) Mother's anaemia status     None 299 49.4 (44.1, 54.8)     Mild 162 24.9 (20.8, 29.5)     Moderate 167 25.4 (21.4, 30.0)     Severe 2 0.2 (0.04, 1.0)     Moderate+ Severe 169 25.6 (21.5, 30.2) Dietary intake Breastfeeding duration (0.5–5 year-old children)     None 57 11.0 (7.9, 15.1)     <6 months 116 27.7 (21.0, 35.7)     [6–12[ 132 34.3 (27.9, 41.3)     [12–24[ 80 17.6 (13.4, 22.7)     ≥24 months 26 9.4 (5.8, 14.9) Dietary pattern mean score (SD) (6–12-year-old children) 190 0.08 (−0.92, 1.41) SCD: sickle cell disease. CU: Consumption Unit. a Right bracket means ‘excluded’. Table 1 Characteristics of 0.5–12 year-old homeless children in the Paris region, 2013 Variables Sample size Estimated proportion (95% CI) Socio-demographic factors Sex     Male 301 46.8 (41.7, 52.0)     Female 329 53.2 (48.1, 58.3) Age     [0.5–1[a 74 8.9 (6.1, 12.8)     [1–3[ 197 29.2 (24.7, 34.1)     [3–6[ 164 27.0 (22.4, 32.2)     [6–11[ 151 27.6 (23.0, 32.7)     [11–13[ 44 7.3 (5.5, 9.6) Born in France     No 267 41.6 (35.5, 48.0)     Yes 359 58.4 (52.0, 64.5) Mother's age in years     [18–30[ 253 30.8 (25.9, 36.1)     [30–40[ 319 53.9 (49.0, 58.7)     ≥40 86 15.3 (11.6, 19.9) Mother's birthplace     SCD-endemic countries in Africa and Asia 318 53.9 (48.3, 59.4)     Other African countries 108 14.7 (10.9, 19.6)     Commonwealth of Independent States 118 17.0 (13.6, 21.0)     Europe, America 86 14.4 (10.9, 18.8) Mother's educational level     None 244 39.0 (33.9, 44.5)     Primary/junior high school certificate 142 28.4 (22.7, 34.9)     Senior high school certificate 135 19.3 (15.4, 23.8)     Tertiary-level certificate 96 13.3 (10.1, 17.3) Living conditions Mother's difficulty speaking/understanding French     No 210 36.6 (30.3, 43.4)     Yes 386 63.4 (56.6, 69.7) Duration of mother's time in France (years)     <1 90 13.5 (10.2, 17.6)     [1–2[ 124 14.7 (11.3, 18.9)     [2–4[ 166 26.7 (21.6, 32.5)     ≥4 217 45.1 (39.4, 51.0) Duration of mother’s homelessness in years     <1 147 23.3 (18.7, 28.7)     [1–2[ 177 23.3 (19.2, 28.0)     [2–4[ 174 26.7 (21.4, 32.7)     ≥4 132 26.7 (21.7, 32.4) Mother's administrative status     Awaiting regularisation 291 49.3 (43.2, 55.5)     Regularised 57 11.1 (7.6, 15.9)     Asylum seekers 108 10.8 (8.5, 13.7)     Residence permit 127 28.7 (23.8, 34.2) Mother's health cover     State health insurance 46 10.2 (6.6, 15.5)     Universal health insurance cover 297 42.6 (36.5, 49.0)     State health aid 162 27.8 (22.8, 33.4)     Pending response 61 8.9 (6.4, 12.2)     None 63 10.5 (7.9, 13.7) Mother is employed     No 511 78.5 (73.3, 82.9)     Yes 118 21.5 (17.1, 26.7) Household monthly income (€/CU)     None 126 20.4 (16.6, 24.8)     <250 231 30.8 (25.9, 36.1)     [250–500[ 119 19.6 (15.7, 24.2)     ≥500 135 29.2 (23.6, 35.5) Type of accommodation     Emergency centre/social hostel 435 78.8 (76.3, 81.1)     Centre for asylums seekers 106 5.6 (4.9, 6.4)     Long-term rehabilitation centre 89 15.6 (13.6, 17.8) Cooking facilities in the bedroom     No 375 52.7 (45.9, 59.5)     Yes 254 47.3 (40.5, 54.1) Health Household food insecurity     Food security 92 13.3 (10.1, 17.3)     Food insecurity without hunger 208 34.2 (28.9, 39.9)     Food insecurity with moderate hunger 241 41.9 (36.7, 47.2)     Food insecurity with severe hunger 74 10.6 (8.1, 14.0) Child food insecurity     Food security 200 27.3 (22.6, 32.7)     Low food security 367 63.7 (58.2, 68.9)     Very low food security 63 9.0 (6.7, 11.9) Children's weight status (BMI)     Underweight 49 9.8 (7.4, 12.9)     Normal 283 65.5 (58.9, 71.5)     Overweight 80 20.2 (14.4, 27.7)     Obese 18 4.5 (2.5, 8.0) Child's anaemia status     None 372 60.1 (54.3, 65.6)     Mild 129 17.7 (14.1, 22.0)     Moderate 128 22.2 (17.6, 27.6)     Severe 1 0.05 (0.01, 0.3)     Moderate+ Severe 129 22.3 (17.6, 27.7) Mother's anaemia status     None 299 49.4 (44.1, 54.8)     Mild 162 24.9 (20.8, 29.5)     Moderate 167 25.4 (21.4, 30.0)     Severe 2 0.2 (0.04, 1.0)     Moderate+ Severe 169 25.6 (21.5, 30.2) Dietary intake Breastfeeding duration (0.5–5 year-old children)     None 57 11.0 (7.9, 15.1)     <6 months 116 27.7 (21.0, 35.7)     [6–12[ 132 34.3 (27.9, 41.3)     [12–24[ 80 17.6 (13.4, 22.7)     ≥24 months 26 9.4 (5.8, 14.9) Dietary pattern mean score (SD) (6–12-year-old children) 190 0.08 (−0.92, 1.41) Variables Sample size Estimated proportion (95% CI) Socio-demographic factors Sex     Male 301 46.8 (41.7, 52.0)     Female 329 53.2 (48.1, 58.3) Age     [0.5–1[a 74 8.9 (6.1, 12.8)     [1–3[ 197 29.2 (24.7, 34.1)     [3–6[ 164 27.0 (22.4, 32.2)     [6–11[ 151 27.6 (23.0, 32.7)     [11–13[ 44 7.3 (5.5, 9.6) Born in France     No 267 41.6 (35.5, 48.0)     Yes 359 58.4 (52.0, 64.5) Mother's age in years     [18–30[ 253 30.8 (25.9, 36.1)     [30–40[ 319 53.9 (49.0, 58.7)     ≥40 86 15.3 (11.6, 19.9) Mother's birthplace     SCD-endemic countries in Africa and Asia 318 53.9 (48.3, 59.4)     Other African countries 108 14.7 (10.9, 19.6)     Commonwealth of Independent States 118 17.0 (13.6, 21.0)     Europe, America 86 14.4 (10.9, 18.8) Mother's educational level     None 244 39.0 (33.9, 44.5)     Primary/junior high school certificate 142 28.4 (22.7, 34.9)     Senior high school certificate 135 19.3 (15.4, 23.8)     Tertiary-level certificate 96 13.3 (10.1, 17.3) Living conditions Mother's difficulty speaking/understanding French     No 210 36.6 (30.3, 43.4)     Yes 386 63.4 (56.6, 69.7) Duration of mother's time in France (years)     <1 90 13.5 (10.2, 17.6)     [1–2[ 124 14.7 (11.3, 18.9)     [2–4[ 166 26.7 (21.6, 32.5)     ≥4 217 45.1 (39.4, 51.0) Duration of mother’s homelessness in years     <1 147 23.3 (18.7, 28.7)     [1–2[ 177 23.3 (19.2, 28.0)     [2–4[ 174 26.7 (21.4, 32.7)     ≥4 132 26.7 (21.7, 32.4) Mother's administrative status     Awaiting regularisation 291 49.3 (43.2, 55.5)     Regularised 57 11.1 (7.6, 15.9)     Asylum seekers 108 10.8 (8.5, 13.7)     Residence permit 127 28.7 (23.8, 34.2) Mother's health cover     State health insurance 46 10.2 (6.6, 15.5)     Universal health insurance cover 297 42.6 (36.5, 49.0)     State health aid 162 27.8 (22.8, 33.4)     Pending response 61 8.9 (6.4, 12.2)     None 63 10.5 (7.9, 13.7) Mother is employed     No 511 78.5 (73.3, 82.9)     Yes 118 21.5 (17.1, 26.7) Household monthly income (€/CU)     None 126 20.4 (16.6, 24.8)     <250 231 30.8 (25.9, 36.1)     [250–500[ 119 19.6 (15.7, 24.2)     ≥500 135 29.2 (23.6, 35.5) Type of accommodation     Emergency centre/social hostel 435 78.8 (76.3, 81.1)     Centre for asylums seekers 106 5.6 (4.9, 6.4)     Long-term rehabilitation centre 89 15.6 (13.6, 17.8) Cooking facilities in the bedroom     No 375 52.7 (45.9, 59.5)     Yes 254 47.3 (40.5, 54.1) Health Household food insecurity     Food security 92 13.3 (10.1, 17.3)     Food insecurity without hunger 208 34.2 (28.9, 39.9)     Food insecurity with moderate hunger 241 41.9 (36.7, 47.2)     Food insecurity with severe hunger 74 10.6 (8.1, 14.0) Child food insecurity     Food security 200 27.3 (22.6, 32.7)     Low food security 367 63.7 (58.2, 68.9)     Very low food security 63 9.0 (6.7, 11.9) Children's weight status (BMI)     Underweight 49 9.8 (7.4, 12.9)     Normal 283 65.5 (58.9, 71.5)     Overweight 80 20.2 (14.4, 27.7)     Obese 18 4.5 (2.5, 8.0) Child's anaemia status     None 372 60.1 (54.3, 65.6)     Mild 129 17.7 (14.1, 22.0)     Moderate 128 22.2 (17.6, 27.6)     Severe 1 0.05 (0.01, 0.3)     Moderate+ Severe 129 22.3 (17.6, 27.7) Mother's anaemia status     None 299 49.4 (44.1, 54.8)     Mild 162 24.9 (20.8, 29.5)     Moderate 167 25.4 (21.4, 30.0)     Severe 2 0.2 (0.04, 1.0)     Moderate+ Severe 169 25.6 (21.5, 30.2) Dietary intake Breastfeeding duration (0.5–5 year-old children)     None 57 11.0 (7.9, 15.1)     <6 months 116 27.7 (21.0, 35.7)     [6–12[ 132 34.3 (27.9, 41.3)     [12–24[ 80 17.6 (13.4, 22.7)     ≥24 months 26 9.4 (5.8, 14.9) Dietary pattern mean score (SD) (6–12-year-old children) 190 0.08 (−0.92, 1.41) SCD: sickle cell disease. CU: Consumption Unit. a Right bracket means ‘excluded’. Dietary intake in children Most of the children aged 0.5–5 years (89.0%) were being or had been breastfed. Of all the children in this age group 61.3% were fed with breastmilk for 6 months or more. In children aged 6–12 years, we retained the first component derived using PCA, which accounted for 17.8% of the explained variance (Supplementary table S1). This dietary pattern was positively correlated with intake of fresh fruit, fruit juices, meat and ham, dairy products, fish, cheese, raw vegetables, stewed fruit and French fries (in descending order of PCA loadings), and was labelled ‘Diversified’. Higher scores for this dietary pattern indicated greater adherence to a diversified diet. Noteworthy, ‘Diversified’ dietary pattern scores were inversely associated with household and child food insecurity (regression coefficient = −0.16 (95% CI: −0.22, −0.10), P < 10−3 and −0.38 (95% CI: −0.56, −0.20), P < 10−3, respectively). Prevalence and associated factors with MSA Anaemia prevalence was 39.9% (95% CI: 34.4, 45.7) in children: 38.1% (95% CI: 31.8, 44.7) in those aged 0.5–5 years, 43.5% (95% CI: 34.7, 52.6) in those aged 6–12 years, and 50.6% (95% CI: 45.2, 55.9) in mothers. MSA prevalence was estimated at 22.3% in children: 21.3% (95% CI: 16.3, 27.3) in those aged 0.5–5 years, 24.1% (95% CI: 14.8, 36.7) in those aged 6–12 years and 25.6% in mothers. The estimated prevalence of MSA according to the factors studied is shown in table 2. Hb concentration distributions according to age group and sex are illustrated in figure 1. Table 2 Estimated prevalence of moderate-to-severe anaemia and 95% confidence intervals (CI) among all children, among children aged 0.5–5 years, and among children aged 6–12 years according to various variables in the Paris region, France, 2013 All children 0.5–5 years 6–12 years Variables Sample size Estimated prevalence Sample size Estimated prevalence Sample size Estimated prevalence (95% CI) (95% CI) (95% CI) Socio-demographic factors Sex     Male 301 22.0 197 20.1 104 25.2 Female (16.0, 29.5) (12.1, 31.4) (17.3, 35.1) 329 22.5 238 22.2 91 23.0      (15.2, 31.9) (14.8, 32.0) (9.9, 44.8) Age in years     [0.5–1[a 74 42.8      (24.7, 63.1)     [1–3[ 197 15.5      (9.8, 23.5)     [3–6[ 164 20.4      (12.5, 31.6)     [6–11[ 151 22.6      (14.9, 32.8)     [11–13[ 44 29.6      (10.2, 60.8) Mother's birthplace  SCD-endemic countries in Africa and Asia 318 22.6 226 21.9 92 24.0      (15.6, 31.6) (14.8, 31.2) (10.0, 47.3)  Other African countries 108 36.7 85 36.4 23 37.3      (21.8, 54.5) (19.0, 58.2) (19.6, 59.3)  Commonwealth of Independent States 118 18.4 65 17.3 53 19.5      (10.9, 29.4) (8.9, 31.0) (10.6, 33.1)  Europe, America 86 10.6 59 8.1 27 17.9      (5.7, 18.8) (3.3, 18.7) (8.7, 33.4) Living conditions Mother's difficulty speaking/understanding French     No 210 27.6 156 23.8 54 35.9      (19.9, 36.9) (16.0, 33.8) (16.6, 61.0)     Yes 386 20.1 251 21.6 135 17.7      (14.5, 27.2) (14.1, 31.6) (11.8, 25.7) Duration of mother's time in France (years)     <1 90 20.6 65 23.2 25 15.6      (12.8, 31.5) (12.3, 39.2) (6.8, 32.1)     [1–2[ 124 11.9 93 10.3 31 16.6      (7.0, 19.5) (5.7, 17.8) (6.6, 35.9)     [2–4[ 166 23.1 120 25.7 46 15.7      (15.3, 33.4) (16.0, 38.7) (8.1, 28.4)     ≥4 217 26.8 130 24.9 87 29.1      (17.6, 38.5) (15.1, 38.1) (14.4, 50.2) Duration of mother's homelessness in years     <1 147 31.2 108 32.3 39 28.6      (20.4, 44.5) (18.7, 49.8) (18.8, 41.0)     [1–2[ 177 15.0 133 15.9 44 12.9      (9.6, 22.5) (9.3, 25.6) (6.4, 24.3)     [2–4[ 174 19.1 119 12.4 55 31.9      (10.6, 31.9) (6.5, 22.4) (11.4, 62.9)  ≥4 132 24.0 75 25.6 57 21.9 (14.3, 37.4) (12.6, 45.1) (11.1, 38.7) Household monthly income (€/CU)     None 126 21.4 88 20.3 38 23.9      (14.1, 31.2) (11.5, 33.3) (12.9, 39.9)     <250 231 17.6 169 12.6 62 29.0      (11.9, 25.3) (7.2, 21.2) (16.7, 45.4)     [250–500[ 119 18.1 79 22.0 40 12.4      (11.1, 28.2) (12.1, 36.6) (5.7, 25.0)     ≥500 135 30.3 88 29.7 47 31.3      (19.1, 44.5) (16.1, 48.3) (13.9, 56.2) Type of accommodation     Emergency centre/social hostel 435 20.5 304 21.2 131 19.0      (15.8, 26.0) (15.3, 28.5) (12.8, 27.2)     Centre for asylums seekers 106 26.2 79 27.1 27 24.5      (17.6, 37.1) (17.5, 39.5) (11.3, 45.4)     Long-term rehabilitation centre 89 29.9 52 19.3 37 39.9      (14.5, 51.6) (9.7, 37.9) (10.9, 78.4) Cooking facilities in the bedroom     No 375 26.8 274 25.8 101 29.0      (21.1, 33.3) (18.8, 34.5) (20.5, 39.5)     Yes 254 17.5 161 15.0 93 20.9      (10.5, 27.5) (8.4, 25.6) (8.4, 43.2) Health Household food insecurity     Food security 92 32.7 67 37.2 25 15.3      (18.7, 50.6) (20.5, 57.7) (5.0, 38.5)     Food insecurity without hunger 208 17.5 145 15.6 63 21.2      (9.8, 29.2) (7.4, 30.0) (7.4, 47.5)     Food insecurity with moderate hunger 241 22.2 164 19.9 77 26.0      (16.3, 29.4) (13.1, 28.9) (16.5, 38.4)     Food insecurity with severe hunger 74 26.9 52 21.4 22 36.5      (17.2, 39.4) (10.9, 37.8) (20.0, 57.0) Child food insecurity     Food security 200 21.0 150 24.1 50 12.6      (13.0, 32.2) (14.1, 37.9) (5.3, 27.0)     Low food security 367 21.3 243 19.7 124 26.5      (16.7, 28.9) (13.4, 27.9) (15.9, 40.6)     Very low food security 63 26.4 42 22.8 21 31.0      (15.7, 40.8) (10.1, 43.7) (15.8, 51.9) Mother has moderate-to-severe anaemia     No 461 18.6 306 16.7 155 21.6      (13.7, 24.7) (10.9, 24.7) (13.2, 33.3)     Yes 169 33.0 129 32.1 40 35.5      (23.1, 44.6) (20.7, 46.2) (19.6, 55.3) Dietary intake Breastfeeding duration     None 58 18.8      (9.5, 33.8)     <6 months 115 24.7      (13.8, 40.3)     [6–12[ months 132 25.4      (14.6, 40.2)     [12–24[ months 100 18.9      (11.3, 30.0)     ≥24 months 6 36.9      (6.2, 83, 8) All children 0.5–5 years 6–12 years Variables Sample size Estimated prevalence Sample size Estimated prevalence Sample size Estimated prevalence (95% CI) (95% CI) (95% CI) Socio-demographic factors Sex     Male 301 22.0 197 20.1 104 25.2 Female (16.0, 29.5) (12.1, 31.4) (17.3, 35.1) 329 22.5 238 22.2 91 23.0      (15.2, 31.9) (14.8, 32.0) (9.9, 44.8) Age in years     [0.5–1[a 74 42.8      (24.7, 63.1)     [1–3[ 197 15.5      (9.8, 23.5)     [3–6[ 164 20.4      (12.5, 31.6)     [6–11[ 151 22.6      (14.9, 32.8)     [11–13[ 44 29.6      (10.2, 60.8) Mother's birthplace  SCD-endemic countries in Africa and Asia 318 22.6 226 21.9 92 24.0      (15.6, 31.6) (14.8, 31.2) (10.0, 47.3)  Other African countries 108 36.7 85 36.4 23 37.3      (21.8, 54.5) (19.0, 58.2) (19.6, 59.3)  Commonwealth of Independent States 118 18.4 65 17.3 53 19.5      (10.9, 29.4) (8.9, 31.0) (10.6, 33.1)  Europe, America 86 10.6 59 8.1 27 17.9      (5.7, 18.8) (3.3, 18.7) (8.7, 33.4) Living conditions Mother's difficulty speaking/understanding French     No 210 27.6 156 23.8 54 35.9      (19.9, 36.9) (16.0, 33.8) (16.6, 61.0)     Yes 386 20.1 251 21.6 135 17.7      (14.5, 27.2) (14.1, 31.6) (11.8, 25.7) Duration of mother's time in France (years)     <1 90 20.6 65 23.2 25 15.6      (12.8, 31.5) (12.3, 39.2) (6.8, 32.1)     [1–2[ 124 11.9 93 10.3 31 16.6      (7.0, 19.5) (5.7, 17.8) (6.6, 35.9)     [2–4[ 166 23.1 120 25.7 46 15.7      (15.3, 33.4) (16.0, 38.7) (8.1, 28.4)     ≥4 217 26.8 130 24.9 87 29.1      (17.6, 38.5) (15.1, 38.1) (14.4, 50.2) Duration of mother's homelessness in years     <1 147 31.2 108 32.3 39 28.6      (20.4, 44.5) (18.7, 49.8) (18.8, 41.0)     [1–2[ 177 15.0 133 15.9 44 12.9      (9.6, 22.5) (9.3, 25.6) (6.4, 24.3)     [2–4[ 174 19.1 119 12.4 55 31.9      (10.6, 31.9) (6.5, 22.4) (11.4, 62.9)  ≥4 132 24.0 75 25.6 57 21.9 (14.3, 37.4) (12.6, 45.1) (11.1, 38.7) Household monthly income (€/CU)     None 126 21.4 88 20.3 38 23.9      (14.1, 31.2) (11.5, 33.3) (12.9, 39.9)     <250 231 17.6 169 12.6 62 29.0      (11.9, 25.3) (7.2, 21.2) (16.7, 45.4)     [250–500[ 119 18.1 79 22.0 40 12.4      (11.1, 28.2) (12.1, 36.6) (5.7, 25.0)     ≥500 135 30.3 88 29.7 47 31.3      (19.1, 44.5) (16.1, 48.3) (13.9, 56.2) Type of accommodation     Emergency centre/social hostel 435 20.5 304 21.2 131 19.0      (15.8, 26.0) (15.3, 28.5) (12.8, 27.2)     Centre for asylums seekers 106 26.2 79 27.1 27 24.5      (17.6, 37.1) (17.5, 39.5) (11.3, 45.4)     Long-term rehabilitation centre 89 29.9 52 19.3 37 39.9      (14.5, 51.6) (9.7, 37.9) (10.9, 78.4) Cooking facilities in the bedroom     No 375 26.8 274 25.8 101 29.0      (21.1, 33.3) (18.8, 34.5) (20.5, 39.5)     Yes 254 17.5 161 15.0 93 20.9      (10.5, 27.5) (8.4, 25.6) (8.4, 43.2) Health Household food insecurity     Food security 92 32.7 67 37.2 25 15.3      (18.7, 50.6) (20.5, 57.7) (5.0, 38.5)     Food insecurity without hunger 208 17.5 145 15.6 63 21.2      (9.8, 29.2) (7.4, 30.0) (7.4, 47.5)     Food insecurity with moderate hunger 241 22.2 164 19.9 77 26.0      (16.3, 29.4) (13.1, 28.9) (16.5, 38.4)     Food insecurity with severe hunger 74 26.9 52 21.4 22 36.5      (17.2, 39.4) (10.9, 37.8) (20.0, 57.0) Child food insecurity     Food security 200 21.0 150 24.1 50 12.6      (13.0, 32.2) (14.1, 37.9) (5.3, 27.0)     Low food security 367 21.3 243 19.7 124 26.5      (16.7, 28.9) (13.4, 27.9) (15.9, 40.6)     Very low food security 63 26.4 42 22.8 21 31.0      (15.7, 40.8) (10.1, 43.7) (15.8, 51.9) Mother has moderate-to-severe anaemia     No 461 18.6 306 16.7 155 21.6      (13.7, 24.7) (10.9, 24.7) (13.2, 33.3)     Yes 169 33.0 129 32.1 40 35.5      (23.1, 44.6) (20.7, 46.2) (19.6, 55.3) Dietary intake Breastfeeding duration     None 58 18.8      (9.5, 33.8)     <6 months 115 24.7      (13.8, 40.3)     [6–12[ months 132 25.4      (14.6, 40.2)     [12–24[ months 100 18.9      (11.3, 30.0)     ≥24 months 6 36.9      (6.2, 83, 8) SCD: sickle cell disease. CU: Consumption Unit. a Right bracket means ‘excluded’. Table 2 Estimated prevalence of moderate-to-severe anaemia and 95% confidence intervals (CI) among all children, among children aged 0.5–5 years, and among children aged 6–12 years according to various variables in the Paris region, France, 2013 All children 0.5–5 years 6–12 years Variables Sample size Estimated prevalence Sample size Estimated prevalence Sample size Estimated prevalence (95% CI) (95% CI) (95% CI) Socio-demographic factors Sex     Male 301 22.0 197 20.1 104 25.2 Female (16.0, 29.5) (12.1, 31.4) (17.3, 35.1) 329 22.5 238 22.2 91 23.0      (15.2, 31.9) (14.8, 32.0) (9.9, 44.8) Age in years     [0.5–1[a 74 42.8      (24.7, 63.1)     [1–3[ 197 15.5      (9.8, 23.5)     [3–6[ 164 20.4      (12.5, 31.6)     [6–11[ 151 22.6      (14.9, 32.8)     [11–13[ 44 29.6      (10.2, 60.8) Mother's birthplace  SCD-endemic countries in Africa and Asia 318 22.6 226 21.9 92 24.0      (15.6, 31.6) (14.8, 31.2) (10.0, 47.3)  Other African countries 108 36.7 85 36.4 23 37.3      (21.8, 54.5) (19.0, 58.2) (19.6, 59.3)  Commonwealth of Independent States 118 18.4 65 17.3 53 19.5      (10.9, 29.4) (8.9, 31.0) (10.6, 33.1)  Europe, America 86 10.6 59 8.1 27 17.9      (5.7, 18.8) (3.3, 18.7) (8.7, 33.4) Living conditions Mother's difficulty speaking/understanding French     No 210 27.6 156 23.8 54 35.9      (19.9, 36.9) (16.0, 33.8) (16.6, 61.0)     Yes 386 20.1 251 21.6 135 17.7      (14.5, 27.2) (14.1, 31.6) (11.8, 25.7) Duration of mother's time in France (years)     <1 90 20.6 65 23.2 25 15.6      (12.8, 31.5) (12.3, 39.2) (6.8, 32.1)     [1–2[ 124 11.9 93 10.3 31 16.6      (7.0, 19.5) (5.7, 17.8) (6.6, 35.9)     [2–4[ 166 23.1 120 25.7 46 15.7      (15.3, 33.4) (16.0, 38.7) (8.1, 28.4)     ≥4 217 26.8 130 24.9 87 29.1      (17.6, 38.5) (15.1, 38.1) (14.4, 50.2) Duration of mother's homelessness in years     <1 147 31.2 108 32.3 39 28.6      (20.4, 44.5) (18.7, 49.8) (18.8, 41.0)     [1–2[ 177 15.0 133 15.9 44 12.9      (9.6, 22.5) (9.3, 25.6) (6.4, 24.3)     [2–4[ 174 19.1 119 12.4 55 31.9      (10.6, 31.9) (6.5, 22.4) (11.4, 62.9)  ≥4 132 24.0 75 25.6 57 21.9 (14.3, 37.4) (12.6, 45.1) (11.1, 38.7) Household monthly income (€/CU)     None 126 21.4 88 20.3 38 23.9      (14.1, 31.2) (11.5, 33.3) (12.9, 39.9)     <250 231 17.6 169 12.6 62 29.0      (11.9, 25.3) (7.2, 21.2) (16.7, 45.4)     [250–500[ 119 18.1 79 22.0 40 12.4      (11.1, 28.2) (12.1, 36.6) (5.7, 25.0)     ≥500 135 30.3 88 29.7 47 31.3      (19.1, 44.5) (16.1, 48.3) (13.9, 56.2) Type of accommodation     Emergency centre/social hostel 435 20.5 304 21.2 131 19.0      (15.8, 26.0) (15.3, 28.5) (12.8, 27.2)     Centre for asylums seekers 106 26.2 79 27.1 27 24.5      (17.6, 37.1) (17.5, 39.5) (11.3, 45.4)     Long-term rehabilitation centre 89 29.9 52 19.3 37 39.9      (14.5, 51.6) (9.7, 37.9) (10.9, 78.4) Cooking facilities in the bedroom     No 375 26.8 274 25.8 101 29.0      (21.1, 33.3) (18.8, 34.5) (20.5, 39.5)     Yes 254 17.5 161 15.0 93 20.9      (10.5, 27.5) (8.4, 25.6) (8.4, 43.2) Health Household food insecurity     Food security 92 32.7 67 37.2 25 15.3      (18.7, 50.6) (20.5, 57.7) (5.0, 38.5)     Food insecurity without hunger 208 17.5 145 15.6 63 21.2      (9.8, 29.2) (7.4, 30.0) (7.4, 47.5)     Food insecurity with moderate hunger 241 22.2 164 19.9 77 26.0      (16.3, 29.4) (13.1, 28.9) (16.5, 38.4)     Food insecurity with severe hunger 74 26.9 52 21.4 22 36.5      (17.2, 39.4) (10.9, 37.8) (20.0, 57.0) Child food insecurity     Food security 200 21.0 150 24.1 50 12.6      (13.0, 32.2) (14.1, 37.9) (5.3, 27.0)     Low food security 367 21.3 243 19.7 124 26.5      (16.7, 28.9) (13.4, 27.9) (15.9, 40.6)     Very low food security 63 26.4 42 22.8 21 31.0      (15.7, 40.8) (10.1, 43.7) (15.8, 51.9) Mother has moderate-to-severe anaemia     No 461 18.6 306 16.7 155 21.6      (13.7, 24.7) (10.9, 24.7) (13.2, 33.3)     Yes 169 33.0 129 32.1 40 35.5      (23.1, 44.6) (20.7, 46.2) (19.6, 55.3) Dietary intake Breastfeeding duration     None 58 18.8      (9.5, 33.8)     <6 months 115 24.7      (13.8, 40.3)     [6–12[ months 132 25.4      (14.6, 40.2)     [12–24[ months 100 18.9      (11.3, 30.0)     ≥24 months 6 36.9      (6.2, 83, 8) All children 0.5–5 years 6–12 years Variables Sample size Estimated prevalence Sample size Estimated prevalence Sample size Estimated prevalence (95% CI) (95% CI) (95% CI) Socio-demographic factors Sex     Male 301 22.0 197 20.1 104 25.2 Female (16.0, 29.5) (12.1, 31.4) (17.3, 35.1) 329 22.5 238 22.2 91 23.0      (15.2, 31.9) (14.8, 32.0) (9.9, 44.8) Age in years     [0.5–1[a 74 42.8      (24.7, 63.1)     [1–3[ 197 15.5      (9.8, 23.5)     [3–6[ 164 20.4      (12.5, 31.6)     [6–11[ 151 22.6      (14.9, 32.8)     [11–13[ 44 29.6      (10.2, 60.8) Mother's birthplace  SCD-endemic countries in Africa and Asia 318 22.6 226 21.9 92 24.0      (15.6, 31.6) (14.8, 31.2) (10.0, 47.3)  Other African countries 108 36.7 85 36.4 23 37.3      (21.8, 54.5) (19.0, 58.2) (19.6, 59.3)  Commonwealth of Independent States 118 18.4 65 17.3 53 19.5      (10.9, 29.4) (8.9, 31.0) (10.6, 33.1)  Europe, America 86 10.6 59 8.1 27 17.9      (5.7, 18.8) (3.3, 18.7) (8.7, 33.4) Living conditions Mother's difficulty speaking/understanding French     No 210 27.6 156 23.8 54 35.9      (19.9, 36.9) (16.0, 33.8) (16.6, 61.0)     Yes 386 20.1 251 21.6 135 17.7      (14.5, 27.2) (14.1, 31.6) (11.8, 25.7) Duration of mother's time in France (years)     <1 90 20.6 65 23.2 25 15.6      (12.8, 31.5) (12.3, 39.2) (6.8, 32.1)     [1–2[ 124 11.9 93 10.3 31 16.6      (7.0, 19.5) (5.7, 17.8) (6.6, 35.9)     [2–4[ 166 23.1 120 25.7 46 15.7      (15.3, 33.4) (16.0, 38.7) (8.1, 28.4)     ≥4 217 26.8 130 24.9 87 29.1      (17.6, 38.5) (15.1, 38.1) (14.4, 50.2) Duration of mother's homelessness in years     <1 147 31.2 108 32.3 39 28.6      (20.4, 44.5) (18.7, 49.8) (18.8, 41.0)     [1–2[ 177 15.0 133 15.9 44 12.9      (9.6, 22.5) (9.3, 25.6) (6.4, 24.3)     [2–4[ 174 19.1 119 12.4 55 31.9      (10.6, 31.9) (6.5, 22.4) (11.4, 62.9)  ≥4 132 24.0 75 25.6 57 21.9 (14.3, 37.4) (12.6, 45.1) (11.1, 38.7) Household monthly income (€/CU)     None 126 21.4 88 20.3 38 23.9      (14.1, 31.2) (11.5, 33.3) (12.9, 39.9)     <250 231 17.6 169 12.6 62 29.0      (11.9, 25.3) (7.2, 21.2) (16.7, 45.4)     [250–500[ 119 18.1 79 22.0 40 12.4      (11.1, 28.2) (12.1, 36.6) (5.7, 25.0)     ≥500 135 30.3 88 29.7 47 31.3      (19.1, 44.5) (16.1, 48.3) (13.9, 56.2) Type of accommodation     Emergency centre/social hostel 435 20.5 304 21.2 131 19.0      (15.8, 26.0) (15.3, 28.5) (12.8, 27.2)     Centre for asylums seekers 106 26.2 79 27.1 27 24.5      (17.6, 37.1) (17.5, 39.5) (11.3, 45.4)     Long-term rehabilitation centre 89 29.9 52 19.3 37 39.9      (14.5, 51.6) (9.7, 37.9) (10.9, 78.4) Cooking facilities in the bedroom     No 375 26.8 274 25.8 101 29.0      (21.1, 33.3) (18.8, 34.5) (20.5, 39.5)     Yes 254 17.5 161 15.0 93 20.9      (10.5, 27.5) (8.4, 25.6) (8.4, 43.2) Health Household food insecurity     Food security 92 32.7 67 37.2 25 15.3      (18.7, 50.6) (20.5, 57.7) (5.0, 38.5)     Food insecurity without hunger 208 17.5 145 15.6 63 21.2      (9.8, 29.2) (7.4, 30.0) (7.4, 47.5)     Food insecurity with moderate hunger 241 22.2 164 19.9 77 26.0      (16.3, 29.4) (13.1, 28.9) (16.5, 38.4)     Food insecurity with severe hunger 74 26.9 52 21.4 22 36.5      (17.2, 39.4) (10.9, 37.8) (20.0, 57.0) Child food insecurity     Food security 200 21.0 150 24.1 50 12.6      (13.0, 32.2) (14.1, 37.9) (5.3, 27.0)     Low food security 367 21.3 243 19.7 124 26.5      (16.7, 28.9) (13.4, 27.9) (15.9, 40.6)     Very low food security 63 26.4 42 22.8 21 31.0      (15.7, 40.8) (10.1, 43.7) (15.8, 51.9) Mother has moderate-to-severe anaemia     No 461 18.6 306 16.7 155 21.6      (13.7, 24.7) (10.9, 24.7) (13.2, 33.3)     Yes 169 33.0 129 32.1 40 35.5      (23.1, 44.6) (20.7, 46.2) (19.6, 55.3) Dietary intake Breastfeeding duration     None 58 18.8      (9.5, 33.8)     <6 months 115 24.7      (13.8, 40.3)     [6–12[ months 132 25.4      (14.6, 40.2)     [12–24[ months 100 18.9      (11.3, 30.0)     ≥24 months 6 36.9      (6.2, 83, 8) SCD: sickle cell disease. CU: Consumption Unit. a Right bracket means ‘excluded’. Figure 1 View largeDownload slide Estimated distribution of haemoglobin (g/dl) in homeless women and children (stratified according to age group and sex) in the Paris region, France, 2013 Figure 1 View largeDownload slide Estimated distribution of haemoglobin (g/dl) in homeless women and children (stratified according to age group and sex) in the Paris region, France, 2013 Factors associated with MSA in children aged 0.5–5 years Among the variables included into the multivariate analysis (i.e. age, mother's birth place, mother duration of homelessness, household income, having cooking facilities in their bedroom, child food insecurity and mother having MSA), four variables remained significantly positively associated with MSA: household income, having no cooking facilities in their bedroom, child food insecurity and mother having MSA (table 3). The MSA prevalence increased with the household income. Children living in an accommodation with no facilities to cook in their bedroom were 1.6 times more likely to have MSA. Children with low and very low food security were, respectively, 1.8 and 2.6 times more likely to have MSA than children who were food secure. Children whose mother had MSA had an MSA prevalence 1.8 times higher than their counterparts. Table 3 Estimated prevalence ratios for the association with moderate-to-severe anaemia from a multivariate Poisson model in homeless children in the Paris region, France, 2013 0.5–5 years 6–12 years ref Adjusted prevalence ratio (95% CI) P value Adjusted prevalence ratio (95% CI) P value Sex     Male ref 1.31 (0.73, 2.34) 0.36     Female 1.15 (0.70, 1.93) 0.57 ref Age in monthsa 0.07     [6–12[b 9 1.67 (1.08, 2.59)     [12–36[ 24 ref     [36–72[ 55 1.30 (0.83, 2.03) Age in yearsa     [6–11[ 8 ref 0.042     [11–13[ 12 3.33 (1.03, 10.83) Mother's birthplace 0.14 0.13     SCD-endemic countries in Africa and Asia 2.15 (0.88, 5.27) 0.093 1.26 (0.48, 3.28) 0.63     Other African countries 3.24 (1.17, 8.93) 0.024 1.85 (0.92, 3.75) 0.085     Commonwealth of Independent States 2.66 (0.93, 7.62) 0.068 1.25 (0.52, 3.00) 0.61     Europe, America ref ref Household monthly income (€/CU)a 0.015     None 0 ref -     <250 100 1.03 (1.01, 1.05)     [250–500[ 384 1.79 (1.21, 2.65)     ≥500 666 2.09 (1.05, 4.16) Cooking facilities in the bedroom -     No 1.62 (1.03, 2.56) 0.038     Yes ref Household food insecuritya 0.013     Food security [0–2] 0 ref     Food insecurity without hunger [3–7] 6 1.30 (0.96, 1.77)     Food insecurity with moderate hunger [8–12] 10 1.92 (0.97, 3.80)     Food insecurity with severe hunger [13–18] 16 2.91 (1.35, 6.24) Child food insecuritya 0.05     Food security [0–1] 1 ref     Low food security [2–4] 3 1.81 (1.07, 3.07)     Very low food security [5–8] 7 2.56 (1.13, 5.81) Mother has moderate-to-severe anaemia     No ref ref     Yes 1.80 (1.09, 2.97) 0.021 1.68 (1.00, 2.81) 0.048 Breastfeeding durationa in months 0.58     < 6 3 ref     [6–12[ 9 1.05 (0.89, 1.25)     [12–24[ 24 1.19 (0.65, 2.15)     >24 months 38 1.33 (0.49, 3.59) Child dietary pattern 1.10 (0.91, 1.32) 0.32 0.5–5 years 6–12 years ref Adjusted prevalence ratio (95% CI) P value Adjusted prevalence ratio (95% CI) P value Sex     Male ref 1.31 (0.73, 2.34) 0.36     Female 1.15 (0.70, 1.93) 0.57 ref Age in monthsa 0.07     [6–12[b 9 1.67 (1.08, 2.59)     [12–36[ 24 ref     [36–72[ 55 1.30 (0.83, 2.03) Age in yearsa     [6–11[ 8 ref 0.042     [11–13[ 12 3.33 (1.03, 10.83) Mother's birthplace 0.14 0.13     SCD-endemic countries in Africa and Asia 2.15 (0.88, 5.27) 0.093 1.26 (0.48, 3.28) 0.63     Other African countries 3.24 (1.17, 8.93) 0.024 1.85 (0.92, 3.75) 0.085     Commonwealth of Independent States 2.66 (0.93, 7.62) 0.068 1.25 (0.52, 3.00) 0.61     Europe, America ref ref Household monthly income (€/CU)a 0.015     None 0 ref -     <250 100 1.03 (1.01, 1.05)     [250–500[ 384 1.79 (1.21, 2.65)     ≥500 666 2.09 (1.05, 4.16) Cooking facilities in the bedroom -     No 1.62 (1.03, 2.56) 0.038     Yes ref Household food insecuritya 0.013     Food security [0–2] 0 ref     Food insecurity without hunger [3–7] 6 1.30 (0.96, 1.77)     Food insecurity with moderate hunger [8–12] 10 1.92 (0.97, 3.80)     Food insecurity with severe hunger [13–18] 16 2.91 (1.35, 6.24) Child food insecuritya 0.05     Food security [0–1] 1 ref     Low food security [2–4] 3 1.81 (1.07, 3.07)     Very low food security [5–8] 7 2.56 (1.13, 5.81) Mother has moderate-to-severe anaemia     No ref ref     Yes 1.80 (1.09, 2.97) 0.021 1.68 (1.00, 2.81) 0.048 Breastfeeding durationa in months 0.58     < 6 3 ref     [6–12[ 9 1.05 (0.89, 1.25)     [12–24[ 24 1.19 (0.65, 2.15)     >24 months 38 1.33 (0.49, 3.59) Child dietary pattern 1.10 (0.91, 1.32) 0.32 SCD: sickle cell disease. CU: Consumption Unit. a Modelled using a fractional polynomial. The prevalence ratios of central values within each group (ref column) are presented. b Right bracket means ‘excluded’. Table 3 Estimated prevalence ratios for the association with moderate-to-severe anaemia from a multivariate Poisson model in homeless children in the Paris region, France, 2013 0.5–5 years 6–12 years ref Adjusted prevalence ratio (95% CI) P value Adjusted prevalence ratio (95% CI) P value Sex     Male ref 1.31 (0.73, 2.34) 0.36     Female 1.15 (0.70, 1.93) 0.57 ref Age in monthsa 0.07     [6–12[b 9 1.67 (1.08, 2.59)     [12–36[ 24 ref     [36–72[ 55 1.30 (0.83, 2.03) Age in yearsa     [6–11[ 8 ref 0.042     [11–13[ 12 3.33 (1.03, 10.83) Mother's birthplace 0.14 0.13     SCD-endemic countries in Africa and Asia 2.15 (0.88, 5.27) 0.093 1.26 (0.48, 3.28) 0.63     Other African countries 3.24 (1.17, 8.93) 0.024 1.85 (0.92, 3.75) 0.085     Commonwealth of Independent States 2.66 (0.93, 7.62) 0.068 1.25 (0.52, 3.00) 0.61     Europe, America ref ref Household monthly income (€/CU)a 0.015     None 0 ref -     <250 100 1.03 (1.01, 1.05)     [250–500[ 384 1.79 (1.21, 2.65)     ≥500 666 2.09 (1.05, 4.16) Cooking facilities in the bedroom -     No 1.62 (1.03, 2.56) 0.038     Yes ref Household food insecuritya 0.013     Food security [0–2] 0 ref     Food insecurity without hunger [3–7] 6 1.30 (0.96, 1.77)     Food insecurity with moderate hunger [8–12] 10 1.92 (0.97, 3.80)     Food insecurity with severe hunger [13–18] 16 2.91 (1.35, 6.24) Child food insecuritya 0.05     Food security [0–1] 1 ref     Low food security [2–4] 3 1.81 (1.07, 3.07)     Very low food security [5–8] 7 2.56 (1.13, 5.81) Mother has moderate-to-severe anaemia     No ref ref     Yes 1.80 (1.09, 2.97) 0.021 1.68 (1.00, 2.81) 0.048 Breastfeeding durationa in months 0.58     < 6 3 ref     [6–12[ 9 1.05 (0.89, 1.25)     [12–24[ 24 1.19 (0.65, 2.15)     >24 months 38 1.33 (0.49, 3.59) Child dietary pattern 1.10 (0.91, 1.32) 0.32 0.5–5 years 6–12 years ref Adjusted prevalence ratio (95% CI) P value Adjusted prevalence ratio (95% CI) P value Sex     Male ref 1.31 (0.73, 2.34) 0.36     Female 1.15 (0.70, 1.93) 0.57 ref Age in monthsa 0.07     [6–12[b 9 1.67 (1.08, 2.59)     [12–36[ 24 ref     [36–72[ 55 1.30 (0.83, 2.03) Age in yearsa     [6–11[ 8 ref 0.042     [11–13[ 12 3.33 (1.03, 10.83) Mother's birthplace 0.14 0.13     SCD-endemic countries in Africa and Asia 2.15 (0.88, 5.27) 0.093 1.26 (0.48, 3.28) 0.63     Other African countries 3.24 (1.17, 8.93) 0.024 1.85 (0.92, 3.75) 0.085     Commonwealth of Independent States 2.66 (0.93, 7.62) 0.068 1.25 (0.52, 3.00) 0.61     Europe, America ref ref Household monthly income (€/CU)a 0.015     None 0 ref -     <250 100 1.03 (1.01, 1.05)     [250–500[ 384 1.79 (1.21, 2.65)     ≥500 666 2.09 (1.05, 4.16) Cooking facilities in the bedroom -     No 1.62 (1.03, 2.56) 0.038     Yes ref Household food insecuritya 0.013     Food security [0–2] 0 ref     Food insecurity without hunger [3–7] 6 1.30 (0.96, 1.77)     Food insecurity with moderate hunger [8–12] 10 1.92 (0.97, 3.80)     Food insecurity with severe hunger [13–18] 16 2.91 (1.35, 6.24) Child food insecuritya 0.05     Food security [0–1] 1 ref     Low food security [2–4] 3 1.81 (1.07, 3.07)     Very low food security [5–8] 7 2.56 (1.13, 5.81) Mother has moderate-to-severe anaemia     No ref ref     Yes 1.80 (1.09, 2.97) 0.021 1.68 (1.00, 2.81) 0.048 Breastfeeding durationa in months 0.58     < 6 3 ref     [6–12[ 9 1.05 (0.89, 1.25)     [12–24[ 24 1.19 (0.65, 2.15)     >24 months 38 1.33 (0.49, 3.59) Child dietary pattern 1.10 (0.91, 1.32) 0.32 SCD: sickle cell disease. CU: Consumption Unit. a Modelled using a fractional polynomial. The prevalence ratios of central values within each group (ref column) are presented. b Right bracket means ‘excluded’. Factors associated with MSA in children aged 6–12 years The variables included in the multivariate analysis were age, mother’s birth place, mother’s difficulties speaking and understanding French, type of accommodation, household food insecurity and mother having MSA. Then children’s MSA prevalence was significantly higher when mothers suffered from MSA (prevalence ratio = 1.7) and when households experienced food insecurity (table 3). The prevalence of MSA was 3.3 times higher in children aged 11–12 years than in those aged 6–10 years. Discussion The ENFAMS survey is the first to describe the living conditions and health of homeless families in France.13 Our results provide original insights into the alarming prevalence of anaemia in this vulnerable population. These homeless families suffered considerably from food insecurity, as compared to the general population in the Paris metropolitan area in 2010 (6.3%),34 86.7% of the households and 72.7% of the children experiencing it. Overall vulnerability of our population may partly explain the factors associated with children having MSA, including living in an accommodation with no facilities to cook, mother having MSA, child and household food insecurity. Our findings suggest that food insecurity is the main factor associated with moderate-to-severe anaemia of the child. Even if our cross-sectional design did not allow causal inference regarding anaemia, our results are consistent with other studies that have suggested that food insecurity could affect nutritional quality of the diet.7,35 As expected, we did find an inverse link between food insecurity and the adherence to a diversified diet. Previous studies have shown that household food insecurity or food insufficiency is associated with suboptimal nutrient intakes, especially in women6,35–37 and that foods and nutrients are not allocated in proportion to individual family members’ needs.38 Poor women typically report that they deprive themselves of food in order to leave more for their children during periods of severe food shortages. Child MSA is associated with mothers having MSA, and anaemia is partially a result of dietary deficiency. Accordingly, our results are also consistent with those of McIntyre et al. who showed that low-income single mothers may compromise their own nutritional intake (as possibly indicated in our findings by their anaemia status) in order to preserve sufficient dietary intake for their child.39 Child food insecurity may therefore be considered as an indicator for more severe household food insecurity, given that adults might compromise their own food intake to minimize its effects on children. This assumption partly explains why only household food insecurity was found to be associated with MSA in children aged 6–12 years, whereas the association between child food insecurity and MSA among children of this age was not found to be significant. Moreover, the association between child food insecurity and MSA in children aged 0.5–5 years suggests that mothers might not be able to protect the latter as effectively as their older counterparts. Indeed, children this age have a different diet than adults, and baby food is likely to be too expensive. This assumption appears to partly be supported by a high proportion of children aged 0.5–5 years who were breastfed longer than 6 months (61.3%). Whereas this proportion is probably underestimated because of a right censored effect on breastfeeding, it remains much higher than among the general population (19.2%).40 This behaviour could be linked to mother’s attempt to compensate the lack of food. However, as mothers are anaemic, their breast-milk may be ironless and put children at risk for anaemia. The assumption that anaemia may partly be due to nutritional factors (e.g. iron, vitamins A, B2—riboflavin, B9—acid folic, B12, and C, protein, copper and other mineral) seems to be supported by the association between the MSA in young children and the provision of cooking facilities in the bedroom. This association was not observed in the 6–12-year-old children, which might be partly explained by their attendance to school canteen at lunch time, schooling being compulsory at this age. Above a certain threshold of income, families must contribute to the cost of their accommodation. The financial participation grows with their household income implying budget trade-offs to the expense of food supply,7 which could explain the positive association observed between 0.5 and 5 year-old children’s MSA and the household income. One limitation of the study is that dietary intakes in children aged 6–12 years were assessed based on a food questionnaire that did not contain all food types (especially non-core foods), limiting the ability of the food classification to cover the whole diet. The decision to restrict the number of food types was taken to reduce the time needed to complete the food-based survey. This limitation prevented us to identify unhealthy patterns and to test its association with anaemia. Thus, for our study, the indicator food insecurity, which retrospectively encompasses an individual’s physical, social and financial dimensions during the previous 12 months, is likely to be a better proxy for social disadvantage and malnutrition than the ‘diversified’ dietary pattern which we measured cross-sectionally, and consequently proves more useful for identifying epidemiological associations. Further, some variables known to be risk factors for childhood anaemia, such as parasitic infection or inflammation, could not be measured and controlled in the multivariate analysis. Despite these limitations, the ENFAMS survey is a unique source of information on nutritional health and anaemia related to social factors including food insecurity among homeless families. The questionnaire contained a wide range of variables on living conditions, including original factors specific to homelessness and social disadvantage such as child food insecurity, which is rarely studied in such population groups. This study shows that sheltered homeless children and mothers display a high prevalence of anaemia, the latter being mainly associated with food insecurity. It provides original and important insights into this extremely disadvantaged population whose have been growing exponentially in France in recent years and highlights the need for: ensure better healthcare support to identify anaemia’s origin and to treat it; improve availability and access to healthy foods, including iron-rich ones, by providing information about food aid organizations (localization, access conditions), organising food services in accommodation centres or establishing free distributions of ‘packed meal’ in social hostels; supplying dietary and cooking advice concerning food-aid products in order to encourage mothers to stock up on foods that they are not familiar with. Further research is also needed to evaluate the impact of such nutritional interventions on food insecurity, dietary intake and anaemia. Supplementary data Supplementary data are available at EURPUB online. Acknowledgements The authors gratefully acknowledge Françoise Riou, Emmanuelle Guyavarch, Erwan Le Méner, Carme Caum, Candy Jangal, Judith Martin-Fernandez and Florence Beauvallet. They thank interviewers, nurses and all the families involved in this study. They also thank Jude Sweeney for the English editorial assistance. Funding This study was funded by Agence Régionale de Santé d’Ile-de-France (ARS), Cancéropôle Ile-de-France, Caisse Nationale des Allocations Familiales (CNAF), Fondation de France, Fondation Macif, Fondation Sanofi Espoir, Institut National de Prévention et d’Éducation pour la Santé (INPES), Institut de Recherche en Santé Publique (IReSP), Institut de Veille Sanitaire (InVS), Ministère de l’Intérieur, Observatoire National de l’Enfance en Danger (ONED), Procter et Gamble and State Street. The HemoCue® equipment used in the survey was kindly supplied by HemoCue France. Conflicts of interest: None declared. 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[Breastfeeding duration in France according to parents and birth characteristics. Results from the ELFE longitudinal French study, 2011] . Bull Epidémiol Hebd 2015 ; 29 : 522 – 32 . © The Author 2017. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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The European Journal of Public HealthOxford University Press

Published: Nov 17, 2017

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