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3 The Johns Hopkins Medical Institutions, Baltimore, MD 21287; 4 Helen Keller International Asia Pacific, Singapore; 5 Nutrition Service, Policy, Strategy and Programme Support Division, World Food Programme, 00148 Rome, Italy; and 6 Helen Keller International, Jakarta 12370, Indonesia
* To whom correspondence should be addressed. E-mail: rdsemba{at}jhmi.edu.
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ABSTRACT |
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 TOP ABSTRACT IntroductionSubjects and MethodsResultsDiscussionLITERATURE CITED |
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Introduction |
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TOPABSTRACTIntroductionSubjects and MethodsResultsDiscussionLITERATURE CITED |
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Vitamin A deficiency has long been recognized as a highly prevalent nutritional deficiency in women and children in Indonesia and a major cause of morbidity, mortality, and blindness (7–9). From 1973 to 1975, the government of Indonesia conducted a pilot program of dispensing high-dose vitamin A capsules every 6 mo to every preschool child in 20 selected subdistricts in the island of Java (10). The vitamin A capsule distribution program in Indonesia was more widely expanded in the 1980s (11). Indonesia has one of the strongest vitamin A capsule distribution programs for child survival and the intended coverage is for all infants 6–12 mo and all preschool children 12–59 mo of age. The program consists of biannual distribution of oral vitamin A, 60 mg retinol equivalents, to children aged 12–59 mo and one-half the dose for infants 6–12 mo (12). The subvillage level health post (posyandu) is the main site for distribution of vitamin A capsules to children.
The effectiveness of vitamin A capsule distribution programs for child survival is likely related to the extent of programmatic coverage (6). It has been suggested that vitamin A supplementation in developing countries may miss the children who are at highest risk (13), but little has been done to characterize nutritional status and infectious disease morbidity in children who are missed by vitamin A supplementation (14). It is not well known whether this important child survival program is missing children who may actually be at greater risk of morbidity and mortality. To gain further insight into this issue, we sought to characterize the demographic and health characteristics of preschool children who are reached and not reached by the national vitamin A capsule distribution program in rural Indonesia. We hypothesized that children who missed vitamin A supplementation were more likely: 1) to be stunted, wasted, and underweight; 2) to be at higher risk of diarrhea disease, fever, and anemia; 3) to have lower childhood immunization coverage; and 4) to come from families with higher rates of infant and under-5-y child mortality than children who received vitamin A. To address these hypotheses, we examined the characteristics of children who did and did not receive vitamin A capsules in rural families in Indonesia.
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Subjects and Methods |
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TOPABSTRACTIntroductionSubjects and MethodsResultsDiscussionLITERATURE CITED |
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40,000 randomly selected rural households every quarter. New households were selected every round. Data were collected by 2-person field teams. A structured, coded questionnaire was used to record data, including anthropometric measurements, date of birth, and sex, on children aged 0–59 mo. The mother of the child or other adult member of the household was asked to provide information on the household's composition, parental education, and weekly household expenditures, along with other socioeconomic, environmental sanitation, and health indicators. For each child over age 6 mo, the mother, father, or guardian was asked whether the child received a vitamin A capsule within the last 6 mo. Axillary temperature was recorded. Hemoglobin was measured using a HemoCue instrument (HemoCue AB). Morbidity histories were obtained for each child, including history of diarrhea in the previous week and current diarrhea. Data were collected on the history of any infant dying in the household <1 mo of age, <12 mo of age, and any child deaths <5 y of age. The field teams measured and recorded the weight of each child aged 0–59 mo to a precision of 0.1 kg and the length/height to a precision of 0.1 cm. Birth dates of the children were estimated using a calendar of local and national events and converted to the Gregorian calendar. Z scores of weight-for-height (WHZ) (wasting), weight-for-age (WAZ) (underweight), and height-for-age (HAZ) (stunting) were calculated using EpiInfo software (CDC), which uses the reference population of the U.S. National Center for Health Statistics. Children with Z scores less than <–2 SD for WHZ, WAZ, or HAZ were considered wasted, underweight, or stunted (18). Severe wasting, underweight, and stunting were defined by respective Z scores less than <–3 SD. Children who had a mid-upper arm circumference (MUAC) <125 mm were considered at high risk of malnutrition (19). HKI provided training to new field teams, field supervisors, and assistant field officers and refresher training prior to each new round of data collection. During each round, a monitoring team from HKI visited all field sites to check and calibrate the equipment and supervise data collection. A quality control team from HKI revisited 10% of households without prior warning within 2 d of data collection by the field teams and recollected data on selected indicators, including anthropometric measurements. Data collected by these quality control teams were later compared with the data collected by the field teams to check the accuracy of the data collection.
The study protocol complied with the principles enunciated in the Helsinki Declaration (20). The field teams were instructed to explain the purpose of the NSS and data collection to each child's mother or caretaker, and, if present, the father and/or household head; data collection and phlebotomy proceeded only after written informed consent. Participation was voluntary and all subjects were free to withdraw at any stage of the interview. The protocol was approved by the Medical Ethical Committee of the Ministry of Health, Government of Indonesia.
Data analyses were restricted to children who were 12–59 mo of age at the start of the most recent vitamin A capsule distribution round, because these were the children who were eligible for receiving 60 mg retinol equivalent (200,000 IU) every 6 mo in the Indonesian vitamin A capsule program. Children who were 6 to <12 mo of age at the time of the last vitamin A capsule distribution round in the local area were not included in this analysis, because supplementation of children in this age range with a different dose and type of capsule had just been implemented at the beginning of the NSS data collection. The youngest child within 12–59 mo of age was selected to represent each family for families with more than 1 child. Continuous variables were compared using Student's t test and variable transformations were used when needed to normalize the data. Categorical variables were compared using chi-square tests. Anemia was defined as hemoglobin <11 g/dL, according to WHO criteria (21). Multivariate logistic regression models were used to examine the relation between separate outcomes of stunting and history of diarrhea in the last week and not receiving a vitamin A capsule and other factors. Population-based weighting was used to account for differences in population size of the various provinces. The level of significance in this study was P < 0.05.
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Results |
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TOPABSTRACTIntroductionSubjects and MethodsResultsDiscussionLITERATURE CITED |
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Health characteristics for children who did and did not receive vitamin A capsules are shown in Table 2. Children who did not receive a vitamin A capsule were significantly more likely to have WAZ, HAZ, and WHZ <–2, WAZ, HAZ, and WHZ <–3, have a MUAC <125 mm, current fever, current diarrhea, a history of diarrhea over the last week, and have anemia compared with children who received a vitamin A capsule. The frequency distribution of hemoglobin levels in children who did and did not receive a vitamin A capsule shows that the distribution of hemoglobin in children who did not receive a capsule was shifted to lower values compared with children who did receive a capsule (P < 0.0001) (Fig. 1).
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Childhood immunization coverage was compared for children who did and did not receive a vitamin A capsule (Table 3). Children who did not receive a vitamin A capsule were significantly less likely to receive diphtheria-pertussis-tetanus (DPT) immunizations 1, 2, and 3; oral poliovirus (OPV) immunizations 1, 2, and 3; and measles immunization. A history of child mortality was compared in households in which the children did or did not receive a vitamin A capsule. In the households in which the child did not receive a vitamin A capsule, the proportion of infants who died <1 mo of age, the proportion of infants who died <12 mo of age, and the under-5-y mortality rate were significantly higher than in households in which the child received a vitamin A capsule (Fig. 2).
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Discussion |
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TOPABSTRACTIntroductionSubjects and MethodsResultsDiscussionLITERATURE CITED |
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In developing countries, the relation between malnutrition and diarrheal diseases is often mutually reinforcing; children who are underweight, stunted, and wasted are at a higher risk of diarrheal morbidity and mortality (23) and diarrheal disease increases the risk of vitamin A deficiency (24). In addition, stunted and wasted children are at a higher risk of vitamin A deficiency (25–27), which in turn may lead to greater susceptibility to diarrheal diseases. Interventions such as vitamin A supplementation are considered a means of interrupting this cycle. The overall rate of vitamin A coverage in these children was 72.0% and the government's target rate was 80%. Our findings challenge the assumption that targeting only 80% of children is a sufficient intervention strategy, as the 28% of children who were not reached by Indonesia's vitamin A program demonstrated higher rates of child morbidity than children who were reached by the program. The coverage rate of the program in Indonesia was less than the 84% coverage in Bangladesh (28) but higher than the 34% coverage in Cambodia (28) during approximately the same time period. Ideally, vitamin A supplementation programs in developing countries should reach 85% of preschool children twice per year (29). Many programs have fallen short of this goal. An estimated 75% of children in sub-Saharan Africa and 46% of children in South Asia receive at least 1 dose of vitamin A annually (29).
Two previous studies characterized children who are missed by vitamin A capsule programs. In a sample of 677 children aged 1–5 y in Central Java, Indonesia, children who were not participating in the vitamin A capsule program were more likely to be <36 mo of age and from families with more than 1 preschool child (14). In the Philippines, a study of over 13,000 children showed that those who were not reached by vitamin A capsule distribution in 1993 and 1998 had mothers with lower education level and lower socioeconomic status compared with those who received vitamin A (13). The investigators concluded that the vitamin A program in the Philippines was missing some of the most vulnerable children.
In our study, children who were missed by the vitamin A capsule distribution program were less likely to have received DPT, OPV, and measles immunization, and the lack of immunization places these children at an even higher risk of infectious disease morbidity and mortality from vaccine-preventable diseases. Vitamin A deficiency increases the risk of measles morbidity, including the severity of diarrheal disease, measles-related pneumonia, blindness, and mortality (30). These findings suggest that demographic factors that impact a child's participation in vitamin A supplementation programs may also impact participation in other public health interventions. The leading cause for not taking a child to the posyandu was that the posyandu was not active. Because these health posts provide basic primary care, it seems that children who are missing vitamin A supplementation may also be missed by other critical child survival interventions. It is evident that strategies need to be developed to reach children who are missed by basic primary preventive care programs in developing countries.
The lack of receipt of a vitamin A capsule was associated with an increased risk of stunting and an increased risk of a history of diarrhea in the previous week. Although vitamin A supplementation is associated with a reduction in diarrhea morbidity, it cannot be determined from these cross-sectional data whether the children had higher risk of diarrhea because they did not receive a vitamin A capsule or that children who did not receive a vitamin A capsule came from households where diarrheal morbidity was generally higher. The relation between vitamin A supplementation and stunting has not been consistent between studies (31). These findings suggest that children missed by vitamin A supplementation are more stunted, but, similar to the association between vitamin A capsule receipt and diarrhea, causality cannot be determined.
Distance and nonfunctioning of the posyandus appeared to be important barriers to the utilization of these rural health posts. This study also suggests that the parents did not take their children to the posyandu because they thought immunizations were complete or that the child was too old. Formal parental education was 1 of the most significant determinants of receipt of vitamin A capsules. Paternal education significantly influenced the likelihood of the child receiving a vitamin A capsule, although the strength of the correlation was not as great as that of maternal education. Little research has been done on the impact of paternal education on child health. Greater research in this area would therefore be beneficial for informing strategies for health programming. Further work is also needed to determine whether the parents have adequate knowledge of the purpose and benefits of the vitamin A capsule program and how public health promotion campaigns could be used to increase attendance at the posyandu.
In September 2000, 189 countries endorsed the goals set forth by the United Nations millennium declaration to reduce under-5-y child mortality by two-thirds between 1990 and 2015 (2). Periodic high-dose vitamin A supplementation has been shown to reduce preschool child mortality, primarily from diarrheal disease, by about one-quarter (32). Given that children who are missed by the vitamin A programs are at higher risk of malnutrition and morbidity, the extent of mortality reduction by periodic vitamin A supplementation is unclear. It has been argued that vitamin A supplementation should be targeted to high-risk children; however, analyses have shown that universal supplementation is most cost effective (33). Universal periodic high-dose vitamin A supplementation is known as an effective intervention to increase child survival in developing countries. Further work is needed to expand coverage of existing programs to reach children who are at higher risk of dying.
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FOOTNOTES |
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2 Author disclosures: S. G. Berger, no conflicts of interest; S. de Pee, no conflicts of interest; M. W. Bloem, no conflicts of interest; S. Halati, no conflicts of interest; R. D. Semba, no conflicts of interest.
7 Abbreviations used: DPT, diphtheria-pertussis-tetanus; HAZ, height-for-age Z score; HKI, Helen Keller International; MUAC, mid-upper arm circumference; NSS, Nutrition Surveillance System; OPV, oral poliovirus; O.R., odds ration; WAZ, weight-for-age Z score; WHZ, weight-for-height Z score.
Manuscript received 20 December 2006. Initial review completed 9 January 2007. Revision accepted 24 February 2007.
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