Inequitable coverage of vitamin A supplementation in Nigeria and implications for childhood blindness

Vitamin A supplementation coverage and its associated factors among children 6-59 months of age in Ethiopia: a systematic review and meta-analysis

Background

Vitamin A supplementation is a key strategy for preventing the consequences of vitamin A deficiency and childhood illnesses, notably in countries where vitamin A deficiency is a public health issue. However, studies in Ethiopia are inconsistent. Hence, this meta-analysis assessed coverage of vitamin A supplementation and associated factors among children aged 6-59 months in Ethiopia.

Methods

A search of articles from databases (PubMed, Science Direct, African Index Medicus, and HINARI), and search engines (Google Scholar, Google, and Worldwide Science) was done. All observational studies that report vitamin A supplementation and/or associated factors among children were included. The Joana Brigs quality appraisal checklist was used. To estimate the pooled effect size a random effect model was used. Heterogeneity was evaluated using I 2-test and Cochrane Q statistics. Subgroup and sensitivity analyses were conducted. Publication bias was assessed using Egger's test and funnel plot.

Results

A total of 14 studies, involving 43,047 children aged 6-59 months, were included. The pooled vitamin A supplementation coverage was 54.88% (95% CI: 47.34-62.42). The lowest coverage 43.71%% (95% CI: 42.71-45.14) was among children 6-35 months. Four or more antenatal care (AOR: 1.79, 95%CI: 1.59-2.01), Postnatal care (AOR: 1.43, 95% CI: 1.24-1.66), delivery at health facilities (AOR: 1.14 95%CI: 1.02-1.28), media exposure (AOR: 1.19, 95% CI: 1.08-1.31), time to reach health facilities (AOR: 1.90, 95% CI: 1.11-3.24), information about VAS (AOR: 2.99, 95%CI: 1.72-5.20), maternal secondary education and above (AOR: 1.32, 95% CI: 1.07-1.64), and (AOR: 2.31, 95% CI: 1.31-4.09) respectively, and fathers education above secondary school (AOR:1.92, 95% CI: 1.13-3.26) were significant factors.

Conclusion

The pooled vitamin A supplementation coverage is significantly below the WHO's recommendation of 80%. Antenatal care, postnatal care, health facilities delivery, media exposure, time to reach health facilities, Information about VAS, maternal and paternal secondary education, and above increase VAS. Hence, the national nutritional program is better to increase awareness of the community about VAS, particularly targeting parents with low educational status and no antenatal and postnatal care through social media and community meetings. Additionally, the EPI program should strengthen outreach supplementations including door-to-door distribution to address older children and socio-economically disadvantaged populations.

Systematic review registration

identifier CRD42024576200.

Barriers and facilitators to the implementation of vitamin A supplementation programs in Africa: A systematic review

Background: Vitamin A deficiency (VAD) impacts over 50% of children aged 6-59 months in sub-Saharan Africa, causing severe health issues. Despite the importance of vitamin A supplementation (VAS) programs, barriers limit their effectiveness, making it essential to understand these factors for better outcomes. Aim: This systematic review aimed to identify the barriers and facilitators to VAS programs in Africa, using the Consolidated Framework for Implementation Research (CFIR) to conceptualize the findings. Methods: A comprehensive search was conducted across OVID Embase, OVID Medline, Web of Science Core Collection, Scopus, CINAHL and CAB Direct. Studies were excluded if they did not report VAS administration via capsules or droplets in large-scale programs or omitted discussions on implementation barriers and facilitators. Results: The search yielded 4377 citations, with 10 studies meeting eligibility criteria, published from 2002 to 2021 across 12 countries. The most frequently represented were Ethiopia and Zimbabwe. A total of nine barriers and seven facilitators to VAS programs were identified. The most frequently cited barriers were capsule stock-outs, limited resources and lack of incentive for staff, while the most frequently cited facilitators were Child Health Days and involvement of community-based health workers. The key CFIR constructs associated with these findings were Tailoring Strategies, Incentive Systems and Available Resources. Conclusion: The barriers and facilitators identified in this review offer valuable insights for improving VAS coverage and implementation in Africa. Tailoring implementation strategies based on these findings can enhance the effectiveness and coverage of VAS programs.

Coverage evaluation of Iron folic acid and vitamin A supplementation among children in rural Puducherry-A Mixed method study

Background

Despite many measures taken by the government, still the problem of Vitamin A deficiency and anaemia exists among children. This study focuses on coverage of iron and folic acid and Vitamin A supplementation among children aged between 9 months and 5 years and to find out the barriers in administrating these supplements to children.

Methods

An explanatory sequential mixed methodology was conducted in the field practice area of Thirubuvanai primary health centre. In the quantitative survey, a cross-sectional cluster sampling survey was conducted to find the coverage of IFA and Vitamin A supplementation among children (n = 215), followed by a qualitative interview (n = 14) to find out the barriers in administrating these supplements to children was conducted among the mothers.

Results

Our study found that Vitamin A supplementation coverage was taken only by 42% of the children in the last 6 months preceding the survey. IFA supplementation was taken by 31.2% of the children in the last 7 days preceding the survey. Lack of awareness, myths and misbeliefs, fear of adverse effects and lack of family support were found as barriers in administering the supplement to the children.

Conclusion

The study findings have highlighted the need for community health education to improve the coverage of supplement administration.

Suboptimal micronutrient intake among children aged 6 to 23 months in Ethiopia: Further analysis of the demographic and health survey

BACKGROUND

The recommended essential micronutrient such as food rich in vitamin-A or iron, multiple micronutrient powder or iron supplement, routine daily consumption of iodine, and vitamin-A supplement are deficient among children in Ethiopia. This has been a significant public health problem despite the government efforts. Although few studies have examined the micronutrient intake among children, they are limited in scope and methodological measurements. Analyzing the micronutrient intake among children across all regions and leveraging all essential micronutrient elements are crucial for generating improved evidence to better inform policy. Thus, we examined the micronutrient intake among children aged 6 to 23 months in Ethiopia.

METHODS

We used data from the Ethiopian Demographic and Health Survey. A two-stage stratified sampling technique was employed, and 1392 children aged 6 to 23 months were included in our analysis. We conducted a multilevel mixed-effect binary logistic regression analysis to identify determinants of micronutrient intake. In the final model, we used a p-value of less than 0.05 and Adjusted Odds Ratio (AOR) with their 95% confidence interval (CI).

RESULTS

We found that only 27.6% (95% CI: 26.8-31.6) of children aged 6 to 23 months were received the recommended micronutrients in Ethiopia. We identified that maternal educational status (Educated mothers (AOR = 2.09, 95%CI:1.23-3.58)), health facility delivery (AOR = 2.14, 95%CI:1.42-2.98), household wealth status (middle quantile (AOR = 1.80, 95%CI:1.01-3.21)), children's age (12 to 23 months age (AOR = 2.36, 95% CI: 1.33-4.21)), and mother's exposure to media (AOR = 1.70, 95%CI: 1.42-2.04) were increased micronutrient intake, whereas residing in the rural communities (AOR = 0.27, 95%CI: 0.21-0.34) decreased micronutrient intake.

CONCLUSIONS

Nearly three-fourths of children aged 6 to 23 months did not receive the recommended essential micronutrients in Ethiopia. Therefore, there is a need to broaden strategies aimed at enhancing the intake by improving information and knowledge dissemination among mothers during facility visits and through media channels.

Employing advanced supervised machine learning approaches for predicting micronutrient intake status among children aged 6-23 months in Ethiopia

Background

Although micronutrients (MNs) are important for children's growth and development, their intake has not received enough attention. MN deficiency is a significant public health problem, especially in developing countries like Ethiopia. However, there is a lack of empirical evidence using advanced statistical methods, such as machine learning. Therefore, this study aimed to use advanced supervised algorithms to predict the micronutrient intake status in Ethiopian children aged 6-23 months.

Methods

A total weighted of 2,499 children aged 6-23 months from the Ethiopia Demographic and Health Survey 2016 data set were utilized. The data underwent preprocessing, with 80% of the observations used for training and 20% for testing the model. Twelve machine learning algorithms were employed. To select best predictive model, their performance was assessed using different evaluation metrics in Python software. The Boruta algorithm was used to select the most relevant features. Besides, seven data balancing techniques and three hyper parameter tuning methods were employed. To determine the association between independent and targeted feature, association rule mining was conducted using the a priori algorithm in R software.

Results

According to the 2016 Ethiopia Demographic and Health Survey, out of 2,499 weighted children aged 12-23 months, 1,728 (69.15%) had MN intake. The random forest, catboost, and light gradient boosting algorithm outperformed in predicting MN intake status among all selected classifiers. Region, wealth index, place of delivery, mothers' occupation, child age, fathers' educational status, desire for more children, access to media exposure, religion, residence, and antenatal care (ANC) follow-up were the top attributes to predict MN intake. Association rule mining was identified the top seven best rules that most frequently associated with MN intake among children aged 6-23 months in Ethiopia.

Conclusion

The random forest, catboost, and light gradient boosting algorithm achieved a highest performance and identifying the relevant predictors of MN intake. Therefore, policymakers and healthcare providers can develop targeted interventions to enhance the uptake of micronutrient supplementation among children. Customizing strategies based on identified association rules has the potential to improve child health outcomes and decrease the impact of micronutrient deficiencies in Ethiopia.

Vitamin A supplementation coverage and associated factors for children aged 6 to 59 months in integrated and campaign-based delivery systems in four sub-Saharan African countries

BACKGROUND

Vitamin A deficiency (VAD) is a leading contributor to the poor health and nutrition of young children in sub-Saharan Africa. Funding constraints are compelling many countries to shift from longstanding campaigns to integrating vitamin A supplementation (VAS) into routine health services. We assessed child VAS coverage and associated factors for integrated delivery systems in Mozambique, Senegal, and Sierra Leone and for a campaign-based delivery strategy in Tanzania.

METHODS

Data were obtained using representative household surveys administered to primary caregivers of N = 16,343 children aged 6-59 months (Mozambique: N = 1,659; Senegal: N = 7,254; Sierra Leone: N = 4,149; Tanzania: N = 3,281). Single-dose VAS coverage was assessed and bivariate and multivariable associations were examined for child VAS receipt with respect to rural or urban residence; child age and sex; maternal age, education, and VAS program knowledge; and household wealth.

RESULTS

VAS coverage for children aged 6-59 months was 42.8% (95% CI: 40.2, 45.6) in Mozambique, 46.1% (95% CI: 44.9, 47.4) in Senegal, 86.9% (95% CI: 85.8, 87.9) in Sierra Leone, and 42.4% (95% CI: 40.2, 44.6) in Tanzania and was significantly higher for children 6-11 vs. 24-59 months in Mozambique, Senegal, and Tanzania. In Sierra Leone, children aged 12-23 months (aOR = 1.86; 95% CI: 1.20, 2.86) and 24-59 months (aOR = 1.55; 95% CI: 1.07, 2.25) were more likely to receive VAS, compared to those 6-11 months. Maternal awareness of VAS programs was associated with higher uptake in Mozambique (aOR = 4.00; 95% CI: 2.81, 5.68), Senegal (aOR = 2.72; 95% CI: 2.35, 3.15), and Tanzania (aOR = 14.50; 95% CI: 10.98, 19.17). Increased household wealth was associated with a higher likelihood of child VAS in Senegal and Tanzania.

CONCLUSIONS

Our findings indicate routine delivery approaches for VAS are not achieving the level of coverage needed for public health impact in these settings. Intensive outreach efforts contributed to the higher coverage in Sierra Leone and highlight the importance of reducing the burdens associated with seeking supplementation at health facilities. As countries move towards incorporating VAS into routine health services, the essentiality of informed communities and potential losses for older children and socio-economically disadvantaged populations are key considerations in the sub-Saharan African context.

Home Gardening of Yellow Cassava and Orange Maize for the Prevention of Nutritional Blindness in Children: An Economic Evaluation and Value of Information Analysis

OBJECTIVES

Vitamin A deficiency is the leading cause of childhood blindness worldwide, affecting mostly Sub-Saharan Africa. We aimed to predict the cost-effectiveness of home gardening (HG) of yellow cassava and orange maize to prevent nutritional blindness in children below 5 years and to assess the likely value of obtaining additional information in reducing uncertainty surrounding its cost-effectiveness.

METHODS

We developed a Markov model and carried out probabilistic sensitivity analysis with a value of information analysis. We costed resources from a societal perspective and outcomes were measured in disability-adjusted life years (DALYs).

RESULTS

HG was estimated to cost an additional Intl$395.00 per DALY averted, with a 72.27% likelihood of being cost-effective at a threshold of Intl$2800 per DALY. The expected value of information was estimated to be Intl$29 843.50 for 1 child or Intl$925 billion for 31 million Nigerian children affected by the decision. Further research is only worthwhile for 1 parameter (relative risk of low serum retinol; expected value of perfect parameter information Intl$29 854.53 per child and Intl$925 billion for 31 million children).

CONCLUSION

HG of yellow cassava and orange maize is expected to be highly cost-effective in preventing nutritional blindness in Nigerian children. Worthwhile further research includes a cost analysis of the intervention and a high-quality randomized trial to assess the effectiveness of HG on serum retinol levels in young children.

COVID-19 concerns among caregivers and vitamin A supplementation coverage among children aged 6-59 months in four countries in Western sub-Saharan Africa

OBJECTIVE

To assess child vitamin A supplementation (VAS) coverage in 2019 and 2020 and explore key factors, including COVID-19 concerns, that influenced VAS status in four sub-Saharan African countries.

DESIGN

Data from eight representative household surveys were used to assess VAS coverage. Multivariable logistic regression models examined the effect of rural/urban residence, child sex and age, caregiver education, COVID-19 concern and household wealth on VAS status.

SETTING

Nine (2019) and 12 (2020) districts in Burkina Faso, Côte d'Ivoire, Guinea and Mali.

PARTICIPANTS

28 283 caregivers of children aged 6-59 months.

RESULTS

Between 2019 and 2020, VAS coverage increased in Burkina Faso (82·2-93·1 %), Côte d'Ivoire (90·3-93·3 %) and Mali (76·1-79·3 %) and decreased in Guinea (86·0 % to 81·7 %). Rural children had a higher likelihood of VAS uptake compared with urban children in Burkina Faso (adjusted OR (aOR) = 4·22; 95 % CI: 3·11, 5·72), Côte d'Ivoire (aOR = 5·19; 95 % CI: 3·10, 8·70) and Mali (aOR = 1·41; 95 % CI: 1·15, 1·74). Children aged 12-59 months had a higher likelihood of VAS uptake compared with children aged 6-11 months in Côte d'Ivoire (aOR = 1·67; 95 % CI: 1·12, 2·48) and Mali (aOR = 1·74; 95 % CI: 1·34, 2·26). Moderate-to-high COVID-19 concern was associated with a lower likelihood of VAS uptake in Côte d'Ivoire (aOR = 0·55; 95 % CI: 0·37, 0·80).

CONCLUSION

The increase in VAS coverage from 2019 to 2020 suggests that COVID-19 concerns may not have limited VAS uptake in some African countries, though geographic inequities should be considered.

Perennial malaria chemoprevention with and without malaria vaccination to reduce malaria burden in young children: a modelling analysis

BACKGROUND

A recent WHO recommendation for perennial malaria chemoprevention (PMC) encourages countries to adapt dose timing and number to local conditions. However, knowledge gaps on the epidemiological impact of PMC and possible combination with the malaria vaccine RTS,S hinder informed policy decisions in countries where malaria burden in young children remains high.

METHODS

The EMOD malaria model was used to predict the impact of PMC with and without RTS,S on clinical and severe malaria cases in children under the age of two years (U2). PMC and RTS,S effect sizes were fit to trial data. PMC was simulated with three to seven doses (PMC-3-7) before the age of eighteen months and RTS,S with three doses, shown to be effective at nine months. Simulations were run for transmission intensities of one to 128 infectious bites per person per year, corresponding to incidences of < 1 to 5500 cases per 1000 population U2. Intervention coverage was either set to 80% or based on 2018 household survey data for Southern Nigeria as a sample use case. The protective efficacy (PE) for clinical and severe cases in children U2 was calculated in comparison to no PMC and no RTS,S.

RESULTS

The projected impact of PMC or RTS,S was greater at moderate to high transmission than at low or very high transmission. Across the simulated transmission levels, PE estimates of PMC-3 at 80% coverage ranged from 5.7 to 8.8% for clinical, and from 6.1 to 13.6% for severe malaria (PE of RTS,S 10-32% and 24.6-27.5% for clinical and severe malaria, respectively. In children U2, PMC with seven doses nearly averted as many cases as RTS,S, while the combination of both was more impactful than either intervention alone. When operational coverage, as seen in Southern Nigeria, increased to a hypothetical target of 80%, cases were reduced beyond the relative increase in coverage.

CONCLUSIONS

PMC can substantially reduce clinical and severe cases in the first two years of life in areas with high malaria burden and perennial transmission. A better understanding of the malaria risk profile by age in early childhood and on feasible coverage by age, is needed for selecting an appropriate PMC schedule in a given setting.

Evaluating equity dimensions of infant and child vitamin A supplementation programmes using Demographic and Health Surveys from 49 countries

OBJECTIVES

Vitamin A deficiency affects an estimated 29% of all children under 5 years of age in low/middle-income countries, contributing to child mortality and exacerbating severity of infections. Biannual vitamin A supplementation (VAS) for children aged 6-59 months can be a low-cost intervention to meet vitamin A needs. This study aimed to present a framework for evaluating the equity dimensions of national VAS programmes according to determinants known to affect child nutrition and assist programming by highlighting geographical variation in coverage.

METHODS

We used open-source data from the Demographic and Health Survey for 49 countries to identify differences in VAS coverage between subpopulations characterised by various immediate, underlying and enabling determinants of vitamin A status and geographically. This included recent consumption of vitamin A-rich foods, access to health systems and services, administrative region of the country, place of residence (rural vs urban), socioeconomic position, caregiver educational attainment and caregiver empowerment.

RESULTS

Children who did not recently consume vitamin A-rich foods and who had poorer access to health systems and services were less likely to receive VAS in most countries despite potentially having a greater vitamin A need. Differences in coverage were also observed when disaggregated by administrative regions (88% of countries) and urban versus rural residence (35% of countries). Differences in vitamin A coverage between subpopulations characterised by other determinants of vitamin A status varied considerably between countries.

CONCLUSION

VAS programmes are unable to reach all eligible infants and children, and subpopulation differences in VAS coverage characterised by various determinants of vitamin A status suggest that VAS programmes may not be operating equitably in many countries.

Determinants of good vitamin A consumption in the 12 East Africa Countries using recent Demographic and health survey

BACKGROUND

Vitamin A one of the important micronutrients that it cannot be made in the human body and must be taken from outside the body through the diet. Ensuring that vitamin A is available in any form in sufficient quantities remains a challenge, especially in regions where access to vitamin A-containing foods and healthcare interventions is limited. As a result, vitamin A deficiency (VAD) becomes a common form of micronutrient deficiency. To the best of our knowledge, there is limited evidence on determinants of good Vitamin A consumption in East African countries. Therefore, this study aimed to assess the magnitude and determinants of good vitamin A consumption in East African countries.

METHODS

A recent Demographic and Health Survey (DHS) of twelve East African countries were included to determine the magnitude and determinants of good vitamin A consumption. A total of 32,275 study participants were included in this study. A multilevel logistic regression model was used to estimate the association between the likelihood of good vitamin A-rich food consumption. Both community and individual levels were used as independent variables. Adjusted odds ratio and its 95% confidence interval were used to see the strength of the association.

RESULT

The pooled magnitude of good vitamin A consumption was 62.91% with a 95% CI of 62.3 to 63.43. The higher proportion of good vitamin A consumption 80.84% was recorded in Burundi and the smallest good vitamin A consumption 34.12% was recorded in Kenya. From the multilevel logistic regression model, women's age, marital status, maternal education, wealth index, maternal occupation, children's age in a month, media exposure, literacy rate, and parity were significantly associated with good vitamin A consumption in East Africa.

CONCLUSION

The magnitude of good vitamin A consumption in twelve East African countries is low. To increase good vitamin A consumption health education through the mass media and enhancing the economic status of women is recommended. Planners and implementers should give attention and priority to identified determinants to enhance good vitamin A consumption.

Trends and inequalities in children aged 6-59 months who received Vitamin A supplementation: evidence from the 2003, 2008 and 2014 Ghana Demographic and Health Survey

BACKGROUND

Vitamin A deficiency is considered a public health issue, particularly among children under 5 years. Vitamin A supplementation is among the ten key essential nutrition actions put in place to tackle malnutrition in children and helps to reduce under-five mortality by almost a quarter in Vitamin A deficient areas. We, therefore, examined inequalities in Vitamin A uptake among children 6-59 months in Ghana.

METHODS

We used data from the 2003, 2008, and 2014 Ghana Demographic and Health Surveys. The WHO's HEAT version 3.1 software was used for all the analyses. We adopted six equity stratifiers (maternal age, economic status, level of education, place of residence, sex of the child, and region) to disaggregate Vitamin A supplementation among children 6-59 months. Four measures were used to compute inequality, namely, Difference (D), Population Attributable Risk (PAR), Population Attributable Fraction (PAF) and Ratio (R).

RESULTS

Over the 11-year period, the proportion of children who received Vitamin A supplementation declined from 78.6% to 65.2%. There were inequalities by maternal age, particularly in 2003 (D = 13.1, CI: 2.3, 23.9; PAF = 0.5, CI: - 12.3, 13.2). The widest inequality in Vitamin A supplementation by economic status was noted in 2003 (D = 8.8, CI: 3.3-14.2; PAF = 8.3, CI: 5, 11.5). In terms of sex, the indices revealed mild inequality in Vitamin A supplementation throughout the period studied. For education, the highest inequality was observed in 2014 (D = 11.6, CI: 6.0, 17.1), while the highest inequality in terms of place of residence was observed in 2003 (D = 4.0, CI: - 0.1-8.4). In the case of region, substantial inequality was noted in 2014 (D = 34.7, CI: 22.6, 46.8; PAF = 21.1, CI: 15.3, 27).

CONCLUSIONS

We conclude that there is a need for the government of Ghana to deploy targeted interventions to enhance the uptake of Vitamin A supplementation among the most disadvantaged subpopulations. Interventions targeted at these disadvantaged populations should be pro-poor in nature. In addition, the inequalities in the dimension of place of residence were mixed, favoring both rural and urban children at different points. This calls for a comprehensive and all-inclusive approach that enhances Vitamin A supplementation uptake in an equitable manner in both areas of residence. Empowerment of women through formal education could be an important step toward improving Vitamin A supplementation among children in Ghana.

Corneal stromal repair and regeneration

The cornea is a specialized, transparent, avascular, immune-privileged, and heavily innervated tissue that affords 2/3rd of refraction to the eye. Ocular injuries, infections, and genetic factors affect corneal function and cause vision impairment. Presently, a variety of laser/non-laser surgeries, immunosuppressants, and/or corneal transplants are predominantly used to revive sight in human patients. The development of novel, precision-guided, and tissue-targeted non-surgical therapies promoting corneal repair and regeneration based on mechanistic understanding is of paramount importance to reduce the impact of global blindness. Research over the past decade revealed that modulation of pathological signaling pathways and factors by a variety of therapeutic delivery methods effectively treats corneal disorders including corneal scar/haze, inflammation, and angiogenesis in various pre-clinical animal models and are primed for human translation. This review discusses recent advances in the areas of corneal repair, restoration, and regeneration. Herein, we provide an overview of evolving approaches and therapeutic modalities that have shown great promise in reviving corneal transparency and function through the use of small drug molecules, gene therapy, nanomedicine, stem cells, trophic factors, exosomes, stromal equivalents, bioengineered stromal scaffolds, tissue adhesives, and 3D bioprinting.

Assessing the potential determinants of national vitamin A supplementation among children aged 6-35 months in Ethiopia: further analysis of the 2019 Ethiopian Mini Demographic and Health Survey

Background

Vitamin A is a nutrient that is required in a small amount for normal visual system function, growth and development, epithelia’s cellular integrity, immune function, and reproduction. Vitamin A has a significant and clinically important effect since it has been associated with a reduction in all-cause and diarrhea mortality. The aim of this study was to determine factors associated with national vitamin A supplementation among children aged 6–35 months.

Method

The data for this study was extracted from the 2019 Ethiopian Mini Demographic and Health Survey. A total weighted sample of 2242 women with children aged 6–35 months was included in the study. The analysis was performed using Stata version 14.2 software. Applying sampling weight for descriptive statistics and complex sample design for inferential statistics, a manual backward stepwise elimination approach was applied. Finally, statistical significance declared at the level of p value < 0.05.

Result

The overall coverage of vitamin A supplementation among children aged 6–35 months for the survey included was 44.4 95% CI (40.15, 48.74). In the multivariable analysis, mothers who had four or more antenatal visits [AOR = 2.02 (95% CI: 1.34, 3.04)] were two times more likely to receive vitamin A capsules for their children than mothers who had no antenatal visits. Children from middle-wealth quintiles had higher odds of receiving vitamin A capsules in comparison to children from the poorest wealth quintile [AOR = 1.77 (95% CI: 1.14, 2.73)]. Older children had higher odds of receiving vitamin A capsules than the youngest ones. Other factors that were associated with vitamin A supplementation were mode of delivery and region.

Conclusion

The coverage of vitamin A supplementation in Ethiopia remains low and it is strongly associated with antenatal visit, household wealth index and age of child. Expanding maternal health services like antenatal care visits should be prioritized.

Co-implementing vitamin A supplementation with seasonal malaria chemoprevention in Sokoto State, Nigeria: a feasibility and acceptability study

Background

Bi-annual high dose vitamin A supplements administered to children aged 6–59 months can significantly reduce child mortality, but vitamin A supplementation (VAS) coverage is low in Nigeria. The World Health Organization recommends that VAS be integrated into other public health programmes which are aimed at improving child survival. Seasonal malaria chemoprevention (SMC) provides a ready platform for VAS integration to improve health outcomes. This study explored the feasibility and acceptability of integrating VAS with SMC in one local government area in Sokoto State.

Methods

A concurrent QUAN-QUAL mixed methods study was used to assess the feasibility and acceptability of co-implementing VAS with SMC in one LGA of Sokoto state. Existing SMC implementation tools and job aids were revised and SMC and VAS were delivered using a door-to-door approach. VAS and SMC coverage were subsequently assessed using questionnaires administered to 188 and 197 households at baseline and endline respectively. The qualitative component involved key informant interviews and focus group discussions with policymakers, programme officials and technical partners to explore feasibility and acceptability. Thematic analysis was carried out on the qualitative data.

Results

At endline, the proportion of children who received at least one dose of VAS in the last six months increased significantly from 2 to 59% (p < 0.001). There were no adverse effects on the coverage of SMC delivery with 70% eligible children reached at baseline, increasing to 76% (p = 0.412) at endline. There was no significant change (p = 0.264) in the quality of SMC, measured by proportion of children receiving their first dose as directly observed treatment (DOT), at baseline (54%) compared to endline (68%). The qualitative findings are presented as two overarching themes relating to feasibility and acceptability of the integrated VAS-SMC strategy, and within each, a series of sub-themes describe study participants’ views of important considerations in implementing the strategy.

Conclusion

This study showed that it is feasible and acceptable to integrate VAS with SMC delivery in areas of high seasonal malaria transmission such as northern Nigeria, where SMC campaigns are implemented. SMC-VAS integrated campaigns can significantly increase vitamin A coverage but more research is required to demonstrate the feasibility of this integration in different settings and on a larger scale.

Vitamin A supplementation among 9-59 month old children in India: geospatial perspectives and implications for targeted coverage

Introduction

Vitamin A supplementation (VAS) is yet to reach all Indian children aged 9–59 months, despite guidelines for universal coverage. This study mapped geospatial patterns underlying VAS coverage across two policy-relevant administrative unit levels (states and districts) in India. The relationship between spatial distribution of VAS coverage and vitamin A deficiency (VAD) prevalence was also investigated.

Methods

The study draws on nationally representative cross-sectional data collected during National Family and Health Survey 4 (NFHS-4) and Comprehensive National Nutritional Survey (CNNS). VAS coverage was estimated using information obtained during NFHS-4 from mothers about whether their children (n=204 645) had received VAS within 6 months of the survey. VAD prevalence estimates were based on serum retinol measurements during CNNS in under-five children (n=9563). State-level and district-level choropleth maps of VAS coverage were constructed. Spatial patterns were probed using Moran’s statistics, scatter plots and local indicators of spatial association (LISA). Relationship between VAS coverage (as an explanatory variable) and VAD prevalence was explored using spatial autoregressive models.

Results

VAS coverage in India (overall 60.5%) ranged from 29.5% (Nagaland) to 89.5% (Goa) across the various states/union territories. Among districts, it ranged from 12.8% (Longleng district, Nagaland) to 94.5% (Kolar district, Karnataka). The coverage exhibited positive spatial autocorrelation, more prominently at the district-level (univariate Moran’s I=0.638, z-value=25.614, pseudo p value=0.001). LISA maps identified spatial clusters of high coverage and low coverage districts. No significant spatial association was observed between VAS coverage and VAD prevalence in the states during spatial error (R²=0.07, λ=0.30, p value=0.14) and spatial lag (R²=0.05, ρ=0.25, p value=0.23) regression.

Conclusion

Two out of every five eligible Indian children were not supplemented with vitamin A. The coverage was geographically heterogeneous with discernible spatial patterns. Their consequences on vitamin A status and associated health effects in the community deserve close monitoring.

Trends in inequality in the coverage of vitamin A supplementation among children 6-59 months of age over two decades in Ethiopia: Evidence from demographic and health surveys

Objectives

There is a dearth of evidence on inequalities in vitamin A supplementation in Ethiopia. The goal of this study was to assess the magnitude and overtime changes of inequalities in vitamin A supplementation among children aged 6-59 months in Ethiopia.

Methods

We extracted data from four waves of the Ethiopia Demographic and Health Surveys (2000, 2005, 2011, and 2016). The analysis was carried out using the 2019 updated World Health Organization's Health Equity Assessment Toolkit software that facilitates the use of stored data from World Health Organization's Health Equity Monitor Database. We conducted analysis of inequality in vitamin A supplementation by five equity stratifiers: household economic status, educational status, place of residence, child's sex, and subnational region. Four summary measures-population attributable fraction, ratio, difference, and population attributable risk-were assessed. We computed 95% uncertainty intervals for each point estimate to ascertain statistical significance of the observed vitamin A supplementation inequalities and overtime disparities.

Results

The findings suggest marked absolute and relative pro-rich (population attributable fraction = 29.51, 95% uncertainty interval; 25.49-33.53, population attributable risk = 13.18, 95% uncertainty intervals; 11.38-14.98) and pro-urban (difference = 16.55, 95% uncertainty intervals; 11.23-21.87, population attributable fraction = 32.95, 95% uncertainty intervals; 32.12-33.78) inequalities. In addition, we found education-related (population attributable risk = 18.95, 95% uncertainty intervals; 18.22-19.67, ratio = 1.54, 95% uncertainty intervals; 1.37-1.71), and subnational regional (difference = 38.56, 95% uncertainty intervals; 29.57-47.54, ratio = 2.10, 95% uncertainty intervals; 1.66-2.54) inequalities that favored children from educated subgroups and those living in some regions such as Tigray. However, no sex-based inequalities were observed. While constant pattern was observed in subnational regional disparities, mixed but increasing patterns of socioeconomic and urban-rural inequalities were observed in the most recent surveys (2011-2016).

Conclusion

In this study, we found extensive socioeconomic and geographic-based disparities that favored children from advantaged subgroups such as those whose mothers were educated, lived in the richest/richer households, resided in urban areas, and from regions like Tigray. Government policies and programs should prioritize underprivileged subpopulations and empower women as a means to increase national coverage and achieve universal accessibility of vitamin A supplementation.

Cost-effectiveness of Vitamin A supplementation among children in three sub-Saharan African countries: An individual-based simulation model using estimates from Global Burden of Disease 2019

Background

Vitamin A Supplementation (VAS) is a cost-effective intervention to decrease mortality associated with measles and diarrheal diseases among children aged 6–59 months in low-income countries. Recently, experts have suggested that other interventions like large-scale food fortification and increasing the coverage of measles vaccination might provide greater impact than VAS. In this study, we conducted a cost-effectiveness analysis of a VAS scale-up in three sub-Saharan African countries.

Methods

We developed an individual-based microsimulation using the Vivarium simulation framework to estimate the cost and effect of scaling up VAS from 2019 to 2023 in Nigeria, Kenya, and Burkina Faso, three countries with different levels of baseline coverage. We calibrated the model with disease and risk factor estimates from the Global Burden of Disease 2019 (GBD 2019). We obtained baseline coverage, intervention effects, and costs from a systematic review. After the model was validated against GBD inputs, we modeled an alternative scenario where we scaled-up VAS coverage from 2019 to a level that halved the exposure to lack of VAS in 2023. Based on the simulation outputs for DALYs averted and intervention cost, we determined estimates for the incremental cost-effectiveness ratio (ICER) in USD/DALY.

Findings

Our estimates for ICER are as follows: $860/DALY [95% UI; 320, 3530] in Nigeria, $550/DALY [240, 2230] in Kenya, and $220/DALY [80, 2470] in Burkina Faso. Examining the data for DALYs averted for the three countries over the time span, we found that the scale-up led to 21 [5, 56] DALYs averted per 100,000 person-years in Nigeria, 21 [5, 47] DALYs averted per 100,000 person-years in Kenya, and 14 [0, 37] DALYs averted per 100,000 person-years in Burkina Faso.

Conclusions

VAS may no longer be as cost-effective in low-income regions as it has been previously. Updated estimates in GBD 2019 for the effect of Vitamin A Deficiency on causes of death are an additional driver of this lower estimate of cost-effectiveness.

Geographical variation and associated factors of vitamin A supplementation among 6-59-month children in Ethiopia

Introduction

Vitamin A has been one of the most important micronutrients which are necessary for the health of the children. In developing countries, the supplementation of vitamins under a regular schedule had different constraints. Awareness, access, and resource limitations were usually the problem. In the current study, we analyzed the data from the demographic health survey (EDHS) 2016 to uncover the spatial distribution, predictors, and to provide additional information for policymaking and interventions.

Methods

In this analysis, we applied intra-community correlation to measure the random effect; global Moran’s I to test the nature of variance in the null model; proportional change in variance to check the variance of null and neighborhood in subsequent models. We used STATA 15 for prediction; ArcGIS 10.7 for the spatial distribution of vitamin A supplementation; SaTscan 9.6.1 to specify location of clustering were the applied soft wares. After confirming that the traditional logistic regression cannot explore the variances, we applied multilevel logistic regression to examine predictors where p-value <0.25 was used to include variables into the model and p-value<0.05 was used to declare associations. We presented the result using means, standard deviations, numbers, and proportions or percent, and AOR with 95% CI.

Result

The vitamin A coverage was 4,029.22 (44.90%) in Ethiopia in 2016. The distribution followed some spatial geo-locations where Afar, Somali were severely affected (RR = 1.46, P-value < 0.001), some pockets of Addis Ababa (RR = 1.47, p-value <0.001), and the poor distribution also affected all other regions partially. Place of delivery 1.2(1–1.34), primary and secondary education 1.3 (1–1.6), media exposure 1.2(1.1–1.4), having work 1.4(1.2–1.5), and all visits of ANC were positively influenced the distribution.

Conclusion

The distribution of vitamin A coverage was not random as per the EDHS 2016 data. Regions like Afar, Somali, and some pocket areas in Addis inquires immediate interventions. Pastoralist, agrarian, and city administrations were all involved from severe to the lesser coverage in order. Since factors like Place of delivery, education, ANC, media exposure, and having work were showed positive associations, interventions considering awareness, access, and availability of service need more attention than ever.

Primary health care facility readiness to implement primary eye care in Nigeria: equipment, infrastructure, service delivery and health management information systems

Background

Over two-thirds of Africans have no access to eye care services. To increase access, the World Health Organization (WHO) recommends integrating eye care into primary health care, and the WHO Africa region recently developed a package for primary eye care. However, there are limited data on the capacities needed for delivery, to guide policymakers and implementers on the feasibility of integration. The overall purpose of this study was to assess the technical capacity of the health system at primary level to deliver the WHO primary eye care package. Findings with respect to service delivery, equipment and health management information systems (HMIS) are presented in this paper.

Methods

This was a mixed-methods, cross sectional feasibility study in Anambra State, Nigeria. Methods included a desk review of relevant Nigerian policies; a survey of 48 primary health facilities in six districts randomly selected using two stage sampling, and semi-structured interviews with six supervisors and nine purposively selected facility heads. Quantitative study tools included observational checklists and questionnaires. Survey data were analysed descriptively using STATA V.15.1 (Statcorp, Texas). Differences between health centres and health posts were analysed using the z-test statistic. Interview data were analysed using thematic analysis assisted by Open Code Software V.4.02.

Results

There are enabling national health policies for eye care, but no policy specifically for primary eye care. 85% of facilities had no medication for eye conditions and one in eight had no vitamin A in stock. Eyecare was available in < 10% of the facilities. The services delivered focussed on maternal and child health, with low attendance by adults aged over 50 years with over 50% of facilities reporting ≤10 attendances per year per 1000 catchment population. No facility reported data on patients with eye conditions in their patient registers.

Conclusion

A policy for primary eye care is needed which aligns with existing eye health policies. There are currently substantial capacity gaps in service delivery, equipment and data management which will need to be addressed if eye care is to be successfully integrated into primary care in Nigeria.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07359-3.

Micronutrient intake status and associated factors among children aged 6-23 months in the emerging regions of Ethiopia: A multilevel analysis of the 2016 Ethiopia demographic and health survey

BACKGROUND

Micronutrient (MN) deficiency among children is recognised as a major public health problem in Ethiopia. The scarcity of MNs in Ethiopia, particularly in pastoral communities, might be severe due to poor diets mitigated by poor healthcare access, drought, and poverty. To reduce MNs deficiency, foods rich in vitamin A (VA) and iron were promoted and programs like multiple micronutrient powder (MNP), iron and vitamin A supplements (VAS) and or deworming have been implemented. Nationally for children aged 6-23 months, consumption of four or more food groups from diet rich in iron and VA within the previous 24 hours, MNP and iron supplementation within seven days, and VAS and >75% of deworming within the last 6 months is recommend; however, empirical evidence is scarce. Therefore, this study aimed to assess the recommended MN intake status of children aged 6-23 months in the emerging regions of Ethiopia.

METHODS

Data from the Ethiopia Demographic and Health Survey 2016 were used. A two-stage stratified sampling technique was used to identify 1009 children aged 6-23 months. MN intake status was assessed using six options: food rich in VA or iron consumed within the previous 24 hours, MNP or iron supplementation with the previous seven days, VAS or deworming within six months. A multilevel mixed-effect logistic regression analysis was computed, and a p-value of < 0.05 and Adjusted Odds Ratio (AOR) with 95% Confidence Interval (CI) were used to identify the individual and community-level factors.

RESULTS

In this analysis, 37.3% (95% CI: 34.3-40.3) of children aged 6-23 months had not received any to the recommended MNs sources. The recommended MNs resulted; VAS (47.2%), iron supplementation (6.0%), diet rich in VA (27.7%), diet rich in iron (15.6%), MNP (7.5%), and deworming (7.1%). Antenatal care visit (AOR: 1.9, 95% CI: 1.4-2.8), work in the agriculture (AOR: 2.2, 95% CI: 1.3-3.8) and children aged 13 to 23 months (AOR: 1.7, 95% CI: 1.2-2.4) were the individual-level factors and also Benishangul (AOR: 2.2, 95% CI: 1.3-4.9) and Gambella regions (AOR: 1.9, 95% CI: 1.0-3.4) were the community-level factors that increased micronutrient intake whereas residence in rural (AOR: 0.4, 95% CI: 0.1-0.9) was the community-level factors that decrease micronutrient intake.

CONCLUSIONS

Micronutrient intake among children aged 6-23 months in the pastoral community was low when compared to the national recommendation. After adjusting for individual and community level factors, women's occupational status, child's age, antenatal visits for recent pregnancy, residence and region were significantly associated with the MN intake status among children aged 6-23 months.

The Technical Feasibility of Integrating Primary Eye Care Into Primary Health Care Systems in Nigeria: Protocol for a Mixed Methods Cross-Sectional Study

Background

Approximately 90% of the 253 million blind or visually impaired people worldwide live in low- and middle-income countries. Lack of access to eye care is why most people remain or become blind. The World Health Organization Regional Office for Africa (WHO-AFRO) recently launched a primary eye care (PEC) package for sub-Saharan Africa—the WHO-AFRO PEC package—for integration into the health system at the primary health care (PHC) level. This has the potential to increase access to eye care, but feasibility studies are needed to determine the extent to which the health system has the capacity to deliver the package in PHC facilities.

Objective

Our objective is to assess the technical feasibility of integrating the WHO-AFRO PEC package in PHC facilities in Nigeria.

Methods

This study has several components, which include (1) a literature review of PEC in sub-Saharan Africa, (2) a Delphi exercise to reach consensus among experts regarding the technical complexity of the WHO-AFRO PEC package and the capacities needed to deliver it in PHC facilities, (3) development of PEC technical capacity assessment tools, and (4) data collection, including facility surveys and semistructured interviews with PHC staff and their supervisors and village health workers to determine the capacities available to deliver PEC in PHC facilities. Analysis will identify opportunities and the capacity gaps that need to be addressed to deliver PEC.

Results

Consensus was reached among experts regarding the technical complexity of the WHO-AFRO PEC package and the capacities needed to deliver it as part of PHC. Quantitative tools (ie, structured questionnaires, in-depth interviews, and observation checklists) and topic guides based on agreed-upon technical capacities have been developed and relevant stakeholders have been identified. Surveys in 48 PHC facilities and interviews with health professionals and supervisors have been undertaken. Capacity gaps are being analyzed.

Conclusions

This study will determine the capacity of PHC centers to deliver the WHO-AFRO PEC package as an integral part of the health system in Nigeria, with identification of capacity gaps. Although capacity assessments have to be context specific, the tools and findings will assist policy makers and health planners in Nigeria and similar settings, who are considering implementing the package, in making informed choices.

International Registered Report Identifier (IRRID)

DERR1-10.2196/17263

Uptake of routine vitamin A supplementation for children in Humbo district, southern Ethiopia: community-based cross-sectional study

Background

In low- and middle-income countries routine vitamin A supplementation (VAS) is a key strategy for reducing vitamin A deficiency and mortality and morbidity of preschool children. However, in Ethiopia, there is paucity of evidence regarding the level and determinants of the uptake of the supplement. This study was designed to assess the coverage and predictors of VAS among preschool children in Humbo district, Southern Ethiopia.

Methods

A cross-sectional study was conducted in April 2016. A total of 840 mothers/caregivers having children 6–59 months of age were selected using multistage cluster sampling technique from six rural villages implementing routine VAS program. Data were collected using interviewer administered questionnaire. Possible predictors considered in the study include distance from the nearby health facility, household socio-economic status, type of the household (model vs non-model), maternal access to health education on VAS, and knowledge on vitamin A and VAS. Multivariable logistic regression analysis was performed to identify predictors of uptake of VAS. The outputs are presented using adjusted odds ratio (AOR) with the respective 95% confidence interval (CI).

Results

The coverage of VAS was 75.0% (95% CI: 72.1–77.9). Better knowledge of mothers about the importance of the supplement (AOR: 1.49, 1.02–2.17), obtaining VAS related information from frontline community health workers (AOR: 1.51, 1.34–2.72) than health professionals and being from households in the “rich” wealth tertile (AOR: 1.80, 95% CI: 1.07–3.03) were positively associated with uptake VAS.

Conclusion

The VAS coverage of the area was approaching the expected national target of 80%. However, the uptake can be enhanced though awareness creation and improving socio-economic status of the community.