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INTEGRATED ENVIRONMENTAL ASSESSMENT AND MANAGEMENT, 2026 (SCI-Expanded, Scopus)
Anemia remains a major global health concern with multifactorial causes and consequences across income levels. Evidence linking environmental factors, such as particulate matter (PM2.5) air pollution, to anemia is limited. This study examined longitudinal associations between PM2.5 air pollution and anemia prevalence across 185 countries from 1990 to 2021, focusing on sex and income-level differences. Secondary data on PM2.5 exposure, anemia prevalence, socioeconomic indices (Socio-demographic Index [SDI], Healthcare Access and Quality [HAQ], Sustainable Development Goals [SDGs]), and health-related factors (iron, vitamin A, calcium, zinc deficiencies, and kidney dysfunction) were analyzed using joinpoint regression and generalized estimating equations (GEEs). Globally, anemia prevalence rose by 8% in males and 9% in females over 32 years, with substantial variation by income group. Upper-middle-income countries achieved the greatest reductions in anemia disability-adjusted life years (DALYs), while low-income countries showed the largest PM2.5 declines (5%). Generalized estimating equation analysis found significant associations between anemia prevalence and PM2.5 pollution (beta = 2.18, p = .002), income level (beta = 1.25, p = .025), and female sex (beta = 1.14, p = .033). Particulate matter exposure rose most steeply in lower-middle-income countries (2008-2012) but declined in high-income countries (2015-2019). Despite declining PM2.5 exposure, global anemia prevalence has increased. Addressing air pollution alongside other health-related factors is essential, particularly in low-income countries. Key points From 1990 to 2021, global anemia prevalence increased in both males (8%) and females (9%) across 185 countries, with lower-middle-income countries showing the highest rates and upper-middle-income countries achieving the greatest reductions in anemia-related disability-adjusted life years.Generalized estimating equations (GEEs) analysis identified significant positive associations between PM2.5 exposure and anemia prevalence, country-level income, and female sex over the 32-year study period.Despite a global decline in PM2.5 air pollution exposure since 1990, anemia prevalence increased, underscoring the multifactorial nature of anemia and the insufficiency of environmental improvements alone to reverse population-level trends.Addressing the persistent anemia burden-especially in low-income countries and among females-requires integrated strategies combining air quality improvements, nutritional interventions, and gender-sensitive healthcare policies aligned with SDG and WHO targets.