Coverage with vitamin A oil supplementation and factors infl uencing its uptake among children residing in an urban slum in Kolkata

Sain, et al.: Factors inluencing Vitamin A supplementation Int. J. Med. Public health [www.ijmedph.org] | October–December 2011 | Vol 1 | Issue 4 40 2. To identify the risk factors and adverse outcomes related to partial or non compliance of Vitamin A supplementation. MATERIALS AND METHODS Study design and sampling A community based descriptive type of study was conducted among 150 children aged between 60 months –72 months residing in an urban slum area in Chetla, Kolkata from March – May 2008. This area falls under the urban fi eld practice area of All India Institute of Hygiene and Public Health, Kolkata. It has an estimated total population of 1.34 lakhs (Urban Health Centre Statistics 2003–2004). This area is divided into four sectors and one sector was selected by simple random sampling which had a population of 25,000. The target population included all children aged between 60 months–72 months residing in that sector during the study period. The sample size was calculated to be 138 assuming a coverage with Vitamin A of 41.2% (West Bengal, NFHS III), 95% confi dence and 20% allowable error (N=Z 2 PQ/L 2 ). From the family folders maintained by the health centre, a sampling frame of all children between 60 months –72 months age group was prepared. It was found that 268 children in that slum belonged to the target age group. The required numbers of children were selected by simple random sampling from the family folder. Home visits were made and the purpose of the study was explained to the mothers/guardians and their informed verbal consent to participate in the study was obtained. Altogether 158 children were approached and the fi nal sample size came to be 150 children after excluding incomplete data and those who did not give consent.


INTRODUCTION
Vitamin A is an essential micronutrient necessary for important biological functions like maintaining normal vision, immune function, skeletal growth and integrity of glandular and epithelial tissue.Vitamin A defi ciency (VAD) still remains a public health concern in developing countries like India.Subclinical VAD is much more common, though the actual prevalence is uncertain owing to a paucity of reliable national level data. [ 1 ]Well designed scientifi c studies have clearly demonstrated the far reaching adverse health outcomes of Vitamin A defi ciency. [ 2 ]A survey in fi ve north-eastern states (Assam, Bihar, Orissa, West Bengal and Tripura) showed the 2. To identify the risk factors and adverse outcomes related to partial or non compliance of Vitamin A supplementation.

Study design and sampling
A community based descriptive type of study was conducted among 150 children aged between 60 months -72 months residing in an urban slum area in Chetla,

Data collection
Data collection was done using a pre-designed, pretested schedule containing questions pertaining to sociodemographic characteristics, immunization status, Vitamin A oil supplementation, nutritional status, morbidity profi le in last one month and intake of Vitamin A rich foods in last one week.The schedule was translated into local language (Bengali) and used to interview the mothers/guardians.Immunization status and Vitamin A supplementation was verifi ed from the immunization card of the child.Weights of the children were recorded by digital weighing machine and weight was categorized by Z score.Information on morbidity was collected by interviewing the mothers.A four-week history of morbidity symptoms including any episodes of acute respiratory infections, diarrhoea and history of measles in last 6 months was noted.In patients with a history of measles, the date of its occurrence was recorded.The children were clinically examined for signs and symptoms of Vitamin A defi ciency in eyes, skin.Systemic examination was done to exclude any cardio respiratory and abdominal pathology.
Mothers were enquired about their knowledge regarding plant and animal sources of Vitamin A rich foods, symptoms and signs of defi ciency and intake of prophylactic Vitamin A oil supplementation of their children.Data regarding vitamin A oil supplementation was verifi ed from immunization card.

Data analysis
Collected data were then analyzed and statistical test were done with the help of Microsoft Excel & Epi-info (3.5.1) software.Test for the statistical signifi cance was applied by using χ 2 test for analyzing the difference between two proportions ( P < 0.05 was considered signifi cant).
The proportion of children receiving incomplete doses of vitamin A oil was found to be higher in females and children belonging to joint family but was signifi cantly greater in families with per capita income below Rs 500 , illiterate mothers and malnourished children (Table 1).
Knowledge regarding plant & animal sources, defi ciency signs of vitamin A was found to be poorest in illiterate mothers and highest among mothers with secondary education and above.The association between maternal education and knowledge about at least one rich vegetarian (veg) and one rich non-vegetarian (non-veg) source of vitamin A was found to be statistically signifi cant (χ 2 = 15.88,p < 0.05).However knowledge about prevention of vitamin A defi ciency was very low among all the groups.(Table2).
Frequency of dietary intake of vitamin A rich foods was reported to be ≤4 days/week among majority (78.6%) of the respondents.However a statistically signifi cant association was observed between frequency of intake and awareness regarding dietary source of the vitamin (Table 3).
Occurrence of both acute respiratory infections (ARI) and malnutrition were signifi cantly higher in children with incomplete vitamin A oil supplementation.Malnutrition,   diarrhea and ARI were all signifi cantly associated with low frequency of dietary intake of vitamin A (Table 4).
Immunization schedule was upto date and completion of prophylactic doses of vitamin A supplementation was found to be higher in male children (Figure 1).
Diet survey by 24 hour recall method revealed inadequate level of vitamin A in diet in the majority (70.7%) (Figure 2) Inadequate supply of Vitamin A oil was stated to be the most common reason of non-compliance to prophylactic supplementation (Figure 3). 2 children were found to have suffered from measles in the last 6 months.2 children complained of night blindness, who were female children, malnourished, not immunized at all and migrated from the neighbouring state.

DISCUSSION
Reports from different trials conducted in vitamin A defi cient population indicate that vitamin A defi ciency (VAD) in children causes increased morbidity and mortality of infants and children, poor growth and possibly similar effects in infants infected with HIV. [ 5 , 6 ]Despite steady progress in controlling vitamin A defi ciency and an ) and nearly 20 million pregnant mothers (almost 10%) are vitamin A-defi cient in low-income countries. [ 7 ]At present the great majority of countries where VAD is known to be a major public health problem have policies supporting the regular supplementation of children, an approach of known large scale effectiveness that can reach the subpopulations affected by, or at risk of being affected by, VAD. [ 1 ]In Kolkata where the present study was conducted, the coverage with Vitamin A oil is only 18.7%. [ 4 ]Various nutritional and health-related parameters, such as socioeconomic indicators, vitamin A intake and co-morbidities, have to be considered to identify the factors responsible for vitamin A defi ciency. [ 8 ]In the present study, the risk factors identifi ed for incomplete dosage of vitamin A oil supplementation were lesser maternal educational status, families with low per capita income (PCI) and malnourished children.A survey in Bangladesh found higher birth order, female sex, poor socioeconomic status and low level of maternal education to be important sociodemographic risk factors for low coverage with vitamin A oil. [ 9 ] Sain, et al.: Factors inluencing Vitamin A supplementation The fact that a majority of the population subsists on inadequate diets, with vitamin A intakes less than half the recommended level and a signifi cant proportion of children having clinical and sub-clinical defi ciency is a matter of public health concern. [ 10 ]Maternal education is a key factor determining awareness regarding dietary sources and also in achieving high coverage with vitamin A oil of their children.Coverage was found to be lower among mothers who were illiterate or from lower educational status.For the majority, dietary assessment revealed inadequate intake of vitamin A rich foods.Frequency of dietary intake was signifi cantly poor among mothers who were unaware of the dietary sources.It is necessary to identify these vulnerable groups and educate mothers about the common, easily affordable rich dietary sources of the vitamin.Opportunity of visits to the immunization clinic may be utilized to counsel and motivate mothers regarding good dietary habits and completing vitamin A oil supplementation of their children.Promotion of family planning methods will enable couples to have small families and hereby provide more for their children.
Interestingly the present study revealed that though coverage with Vitamin A oil supplementation lagged behind considerably, immunization coverage was up-todate among a majority of the children in both sexes.In contrast studies in Bangladesh and Indonesia revealed a lower coverage with vitamin A among children who missed childhood immunizations. [ 11 ]The commonest reason for non compliance in this study was stated to be non availability.This issue needs to be addressed urgently.It showed that though mothers were motivated to accept the services willingly but failure to provide the same came as a setback to the national programme.
Association between vitamin A defi ciency and diseases is well documented.Studies have clearly shown that diarrhoeal disease and intestinal parasitoses affect vitamin A status by increasing loss of nutrients and reducing the absorption of nutrients. [ 12 ]Another large study found mild vitamin A defi ciency to be directly associated with at least 16% of all deaths in children aged from 1 to 6 years. [ 13 ]Malnourished children are more likely to suffer from vitamin A defi ciency disorders and have higher morbidity due to infectious diseases.A signifi cant difference in the proportion of malnutrition was observed between children who did and did not complete vitamin A supplementation.This fi nding re-emphasizes the fact that children who are most likely to benefi t from vitamin A supplementation are not being covered.
Vitamin A defi ciency persists as a global nutrition problem that merits short-term, medium term and longterm prevention.These include promotion of breast feeding, vitamin A supplementation, fortifi cation of dietary staples (commercial or food aid commodities), and homestead food production. [ 14 ]In recent years, confl icting reports have been obtained regarding continuation of the vitamin A supplementation programme in favour of dietary measures, especially in the context of a marked reduction in the prevalence of keratomalacia.The most promising strategies focus on increasing the vitamin A supply by improving the diet and the diversity of food supply, which seems to be the most thorough and durable method and by enriching common foodstuffs with vitamin A. [ 8 ] As observed in this study the dietary intake of vitamin A was inadequate in majority of the study participants.It has been opined that under these circumstances where Vitamin A intakes of children are less than half the RDA and a signifi cant proportion of them have clinical evidence of defi ciency, it is not wise or ethical to withdraw the benefi ts of supplementation. [ 10 ]ealth workers need to be trained to counsel mothers about dietary diversifi cation, identifi cation of early signs of vitamin A defi ciency and report adverse effects.They should also be monitored to prevent both under and overprescription with vitamin A oil.

Figure 1 :Figure 2 :Figure 3 :
Figure 1: Sexwise distribution of immunization status & vitamin A doses Kolkata from March -May 2008.This area falls under the urban fi eld practice area of All India Institute of Hygiene and Public Health, Kolkata.It has an estimated total population of 1.34 lakhs (Urban Health Centre Statistics2003-2004).This area is divided into four sectors and one sector was selected by simple random sampling which had a population of 25,000.The target population included all children aged between 60 months-72 months residing in that sector during the study period.The sample size was calculated to be 138 assuming a coverage with Vitamin A of 41.2% (West Bengal, NFHS III), 95% confi dence and 20% allowable error (N=Z 2 PQ/L 2 ).From the family folders maintained by the health centre, a sampling frame of all children between 60 months -72 months age group was prepared.It was found that 268 children in that slum belonged to the target age group.The required numbers of children were selected by simple random sampling from the family folder.Home visits were made and the purpose of the study was explained to the mothers/guardians and their informed verbal consent to participate in the study was obtained.Altogether 158 children were approached and the fi nal sample size came to be 150 children after excluding incomplete data and those who did not give consent.