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

BMC Public Health, Volume 20, No. 1, Year 2020

Ukuhunyushwa

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. This study was conducted in April 2016 in Humbo district, Southern Ethiopia. The district has 39 rural and 5 urban kebeles (the smallest administrative unit in Ethiopia having approximately 1000 households). Humbo has a total population of 157,073 of which children 6–59 months of age contribute to 11% of the population. In the district there are 6 health centres and 39 health posts. About 78 health extension workers (HEWs) are deployed in the health posts and are providing community-based service including distribution of VAS. HEWs are cadres of trained female community-based health workers who received at least 1 year of training after completing secondary education. In each kebele, on average 2 HEWs are deployed. In every kebele, a network of volunteers, called the Health Development Army (HDA) members support HEWs through community mobilization. In Ethiopia VAS is distributed through three strategies: Enhanced Outreach Strategy (EOS), Community Health Days (CHDs) and the routine Health Extension Program (HEP). The EOS is a makeshift strategy involving distribution of the supplement via centrally organized semi-annual or quarterly campaigns along with deworming and screening for malnutrition. The CHD is a similar modality as that of the EOS except that campaigns are organized at kebele level. The CHD is considered as a transitional stage to the ultimate integration of VAS into the HEP. In the third strategy, VAS is considered as the integral component of the HEP and the supplement is provided by HEWs through a mixture of static service, locally organized campaigns and home visits. In Humbo district, at the time of the survey VAS was mainly distributed via the third option – distribution through routine HEP. We implemented quantitative cross-sectional survey in April 2016 in Humbo district. The source population for the study was all children 6–59 months of age residing in the rural kebeles of the district; whereas, the study population was similar group of children residing in randomly selected six kebeles of Humbo district. A sample size of 840 was calculated using single population proportion formula with the inputs of 95% confidence level, 5% margin of error, 53.1% expected coverage of VAS [12] design effect of 2 and 10% compensation for possible non-response. The study subjects were identified using multistage cluster sampling approach. Initially, the 39 rural kebeles found in the district were categorized as accessible (30 kebeles) and non-accessible (9 kebeles) based on a cut-off distance of 10 kms from the nearest major all-weather roads. Then, accessible and non-accessible kebeles were separately listed and, four and two kebeles were randomly selected from the two strata, respectively. The total sample size of 840 was allotted to each of the six kebeles proportional to their population size and the sample size distributed per kebele ranged from 116 to 174 children. Ahead of the study, complete listing of eligible children was made and used as a sampling frame. Ultimately the required subjects were selected using systematic random sampling technique. Data were collected in April 2016 using pre-tested and structured questionnaire developed by the investigators specifically for the study. The questionnaire used in the study is provided as supplementary file with this manuscript (Supplementary File 1). The questionnaire was developed in English and translated to the local Wolaitigna language. Socio-demographic and economic related information were collected using questions extracted from the standard DHS questionnaire. The DHS questionnaire is a standard tool designed to collect demographic and health data consistently in multiple low-income countries. We collected the data using experienced and trained enumerators and supervisors. The VAS status of the selected child was determined by showing the mother/caregiver a VAS capsule and asking whether the child had received a similar one in the past 6 months. The dependent variable of the study was the recent (last 6 months) vitamin A supplementation status of the child. The independent variables were selected based on previous literature [5, 11, 12] and include socio-demographic variables (maternal age, maternal and paternal educational status, household wealth index, family size, age and sex of the child), type of the household (whether the household had been considered as model or non-model household by local HEWs), distance from the nearest health facility, whether the respondent received health education about vitamin A supplement in the last 12 months or not, knowledge about at least one benefit of vitamin A supplements to children, knowledge about at least one consequence of VAD and knowledge about dietary sources of vitamin A. According to the HEP of Ethiopia, model households are families that successfully implemented all the packages of the health extension program with the support of the community health workers. The data were entered, cleaned and analyzed using SPSS for windows, version 20. Frequencies, percentage, mean and standard deviation were used to summarize the data. Bivariable logistic regression analysis was performed to assess the association of each predictor with the outcome variable and multivariable logistic model was to control the effect of confounders. Variables with p-value less than 0.25 in the bivariable models were considered as candidate variables for the multivariable analysis [14]. In the multivariable analysis, proximate and distal variables were fitted separately in order to avoid over-adjustment bias [15]. The distal variables considered in the analysis were: household wealth index, maternal and paternal educational status, household type (being model or non-model household), sex and birth order of the baby. On the other hand, the proximate variables were: knowledge on vitamin A and VAS, physical access to the nearby health institution, exposure to VAS promotion activities and age of the child. Fitness of the logistic model was checked using Hosmer and Lemeshow statistic. Absence of multicollinearity was checked following standard approaches. The outputs of the analysis are presented using crude (COR) and adjusted odds ratio (AOR) with the 95% confidence interval (CI). Wealth index was constructed as an indicator of household economic status based on variables related to housing conditions, ownership of household assets, type of drinking water source, size of agricultural land, and number of livestock owned. Principal component analysis (PCA) was performed to generate a summary wealth index score and the score was ultimately categorized into three tertiles: poor, medium and rich. The study was approved by the ethics committee at Hawassa University, College of Medicine and Health Science. Data were collected after security informed verbal consent from the primary caregivers of the study children. Verbal, rather that written consent was used because significant proportion of the population in the area had no formal education. The same was approved by the ethics committee that reviewed the protocol.

I-AI Digest

Study Justification:

The study aimed to assess the coverage and predictors of routine vitamin A supplementation (VAS) among preschool children in Humbo district, Southern Ethiopia. This is important because VAS is a key strategy for reducing vitamin A deficiency and mortality and morbidity in children, particularly in low- and middle-income countries. However, there was a lack of evidence regarding the level and determinants of VAS uptake in Ethiopia. Therefore, this study was conducted to fill this knowledge gap and provide valuable insights for improving VAS coverage in the district.

Highlights:

– The study found that the coverage of VAS in Humbo district was 75.0%, which was approaching the national target of 80%.
– Factors positively associated with the uptake of VAS included better knowledge of mothers about the importance of the supplement, obtaining VAS-related information from frontline community health workers, and being from households in the “rich” wealth tertile.
– The study highlights the importance of awareness creation and improving the socio-economic status of the community to enhance VAS uptake.

Recommendations:

Based on the findings of the study, the following recommendations can be made:

1. Strengthen health education programs on the importance of VAS for mothers and caregivers, emphasizing the benefits of the supplement for children’s health.
2. Enhance the role of frontline community health workers in providing VAS-related information and promoting the uptake of the supplement.
3. Implement interventions to improve the socio-economic status of the community, such as income-generating activities and poverty reduction programs, to increase access to VAS.
4. Conduct regular monitoring and evaluation of VAS coverage to track progress and identify areas for improvement.

Key Role Players:

1. Health Extension Workers (HEWs): These trained female community-based health workers play a crucial role in providing VAS and other health services to the community.
2. Health Development Army (HDA) members: These volunteers support HEWs through community mobilization and can help in raising awareness about VAS and promoting its uptake.
3. Community leaders and local authorities: Their support and involvement are essential in implementing VAS programs and ensuring community participation.
4. Non-governmental organizations (NGOs) and international partners: They can provide technical and financial support for VAS programs and interventions.

Cost Items for Planning Recommendations:

1. Training and capacity building for health workers and volunteers: This includes the cost of organizing training workshops, materials, and transportation.
2. Health education materials: Development and production of educational materials, such as brochures, posters, and audiovisual resources, to raise awareness about VAS.
3. Community mobilization activities: Costs associated with organizing community meetings, campaigns, and outreach programs to promote VAS uptake.
4. Socio-economic interventions: Implementation of income-generating activities, poverty reduction programs, and other initiatives to improve the socio-economic status of the community.
5. Monitoring and evaluation: Resources needed for regular monitoring and evaluation of VAS coverage, including data collection, analysis, and reporting.
Please note that the cost items mentioned above are for planning purposes and do not represent actual costs. The actual budget will depend on the specific context and implementation strategies.

Amandla Obufakazi

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong because it presents the findings of a cross-sectional study conducted in Humbo district, Southern Ethiopia. The study used a multistage cluster sampling technique and collected data from 840 mothers/caregivers. The study identified predictors of uptake of routine vitamin A supplementation (VAS) among preschool children, such as knowledge of mothers about the importance of the supplement, obtaining VAS-related information from frontline community health workers, and being from households in the ‘rich’ wealth tertile. The study concludes that while the VAS coverage in the area is approaching the national target, it can be further enhanced through awareness creation and improving the socio-economic status of the community. To improve the evidence, future studies could consider using a longitudinal design to assess the long-term impact of VAS on vitamin A deficiency and mortality and morbidity of preschool children.

Abstract

This study was conducted in April 2016 in Humbo district, Southern Ethiopia. The district has 39 rural and 5 urban kebeles (the smallest administrative unit in Ethiopia having approximately 1000 households). Humbo has a total population of 157,073 of which children 6–59 months of age contribute to 11% of the population. In the district there are 6 health centres and 39 health posts. About 78 health extension workers (HEWs) are deployed in the health posts and are providing community-based service including distribution of VAS. HEWs are cadres of trained female community-based health workers who received at least 1 year of training after completing secondary education. In each kebele, on average 2 HEWs are deployed. In every kebele, a network of volunteers, called the Health Development Army (HDA) members support HEWs through community mobilization. In Ethiopia VAS is distributed through three strategies: Enhanced Outreach Strategy (EOS), Community Health Days (CHDs) and the routine Health Extension Program (HEP). The EOS is a makeshift strategy involving distribution of the supplement via centrally organized semi-annual or quarterly campaigns along with deworming and screening for malnutrition. The CHD is a similar modality as that of the EOS except that campaigns are organized at kebele level. The CHD is considered as a transitional stage to the ultimate integration of VAS into the HEP. In the third strategy, VAS is considered as the integral component of the HEP and the supplement is provided by HEWs through a mixture of static service, locally organized campaigns and home visits. In Humbo district, at the time of the survey VAS was mainly distributed via the third option – distribution through routine HEP. We implemented quantitative cross-sectional survey in April 2016 in Humbo district. The source population for the study was all children 6–59 months of age residing in the rural kebeles of the district; whereas, the study population was similar group of children residing in randomly selected six kebeles of Humbo district. A sample size of 840 was calculated using single population proportion formula with the inputs of 95% confidence level, 5% margin of error, 53.1% expected coverage of VAS [12] design effect of 2 and 10% compensation for possible non-response. The study subjects were identified using multistage cluster sampling approach. Initially, the 39 rural kebeles found in the district were categorized as accessible (30 kebeles) and non-accessible (9 kebeles) based on a cut-off distance of 10 kms from the nearest major all-weather roads. Then, accessible and non-accessible kebeles were separately listed and, four and two kebeles were randomly selected from the two strata, respectively. The total sample size of 840 was allotted to each of the six kebeles proportional to their population size and the sample size distributed per kebele ranged from 116 to 174 children. Ahead of the study, complete listing of eligible children was made and used as a sampling frame. Ultimately the required subjects were selected using systematic random sampling technique. Data were collected in April 2016 using pre-tested and structured questionnaire developed by the investigators specifically for the study. The questionnaire used in the study is provided as supplementary file with this manuscript (Supplementary File 1). The questionnaire was developed in English and translated to the local Wolaitigna language. Socio-demographic and economic related information were collected using questions extracted from the standard DHS questionnaire. The DHS questionnaire is a standard tool designed to collect demographic and health data consistently in multiple low-income countries. We collected the data using experienced and trained enumerators and supervisors. The VAS status of the selected child was determined by showing the mother/caregiver a VAS capsule and asking whether the child had received a similar one in the past 6 months. The dependent variable of the study was the recent (last 6 months) vitamin A supplementation status of the child. The independent variables were selected based on previous literature [5, 11, 12] and include socio-demographic variables (maternal age, maternal and paternal educational status, household wealth index, family size, age and sex of the child), type of the household (whether the household had been considered as model or non-model household by local HEWs), distance from the nearest health facility, whether the respondent received health education about vitamin A supplement in the last 12 months or not, knowledge about at least one benefit of vitamin A supplements to children, knowledge about at least one consequence of VAD and knowledge about dietary sources of vitamin A. According to the HEP of Ethiopia, model households are families that successfully implemented all the packages of the health extension program with the support of the community health workers. The data were entered, cleaned and analyzed using SPSS for windows, version 20. Frequencies, percentage, mean and standard deviation were used to summarize the data. Bivariable logistic regression analysis was performed to assess the association of each predictor with the outcome variable and multivariable logistic model was to control the effect of confounders. Variables with p-value less than 0.25 in the bivariable models were considered as candidate variables for the multivariable analysis [14]. In the multivariable analysis, proximate and distal variables were fitted separately in order to avoid over-adjustment bias [15]. The distal variables considered in the analysis were: household wealth index, maternal and paternal educational status, household type (being model or non-model household), sex and birth order of the baby. On the other hand, the proximate variables were: knowledge on vitamin A and VAS, physical access to the nearby health institution, exposure to VAS promotion activities and age of the child. Fitness of the logistic model was checked using Hosmer and Lemeshow statistic. Absence of multicollinearity was checked following standard approaches. The outputs of the analysis are presented using crude (COR) and adjusted odds ratio (AOR) with the 95% confidence interval (CI). Wealth index was constructed as an indicator of household economic status based on variables related to housing conditions, ownership of household assets, type of drinking water source, size of agricultural land, and number of livestock owned. Principal component analysis (PCA) was performed to generate a summary wealth index score and the score was ultimately categorized into three tertiles: poor, medium and rich. The study was approved by the ethics committee at Hawassa University, College of Medicine and Health Science. Data were collected after security informed verbal consent from the primary caregivers of the study children. Verbal, rather that written consent was used because significant proportion of the population in the area had no formal education. The same was approved by the ethics committee that reviewed the protocol.

Izinto zokwakha

https://efashare.b-cdn.net/materials/7c174f147610b4b6ec55b373494198df887d219742ca1a7d004da9ebd1b467d5/12889_2020_9617_MOESM1_ESM.docx

Emisha

Based on the provided information, here are some potential innovations that could improve access to maternal health:

1. Mobile Health (mHealth) Solutions: Implementing mobile health technologies, such as SMS reminders and mobile applications, to provide information and reminders about routine vitamin A supplementation (VAS) to mothers/caregivers. This can help increase awareness and improve adherence to VAS.

2. Community Health Worker Training: Enhancing the training of community health workers (CHWs) to provide accurate and comprehensive health education on VAS. This can empower CHWs to effectively communicate the importance of VAS to mothers/caregivers and address any misconceptions or concerns.

3. Integration of VAS into Antenatal Care: Integrating VAS services into antenatal care visits can ensure that pregnant women receive information and access to VAS early in their pregnancy. This can help improve coverage and uptake of VAS among pregnant women, leading to better maternal and child health outcomes.

4. Targeted Awareness Campaigns: Conducting targeted awareness campaigns in the community to raise awareness about the importance of VAS and address any barriers or misconceptions. These campaigns can utilize various communication channels, such as community meetings, radio broadcasts, and posters, to reach a wide audience.

5. Socio-economic Support: Implementing socio-economic support programs to improve the socio-economic status of the community. This can include initiatives to improve access to education, income-generating activities, and basic amenities. By addressing socio-economic factors, the uptake of VAS can be enhanced.

6. Strengthening Supply Chain Management: Improving the supply chain management of VAS to ensure consistent availability and accessibility of the supplement in health facilities and community settings. This can involve strengthening logistics systems, forecasting demand, and ensuring timely distribution of VAS.

7. Empowering Women: Promoting women’s empowerment and involvement in decision-making processes related to maternal and child health. This can include initiatives to improve women’s education, access to information, and participation in community health programs.

These innovations can help improve access to maternal health, specifically in relation to routine vitamin A supplementation, and contribute to better maternal and child health outcomes.

AI Innovations Description

The study titled “Uptake of routine vitamin A supplementation for children in Humbo district, southern Ethiopia: Community-based cross-sectional study” aimed to assess the coverage and predictors of vitamin A supplementation (VAS) among preschool children in Humbo district, Southern Ethiopia. The study found that the coverage of VAS in the area was 75.0%. Factors positively associated with the uptake of VAS included better knowledge of mothers about the importance of the supplement, obtaining VAS-related information from frontline community health workers, and being from households in the “rich” wealth tertile.

Based on the findings of the study, the following recommendations can be made to improve access to maternal health:

1. Awareness creation: Implement awareness campaigns to educate mothers and caregivers about the importance of routine vitamin A supplementation for children. This can be done through community health workers, health extension workers, and other frontline health professionals.

2. Strengthening health education: Provide regular and comprehensive health education on vitamin A supplementation to mothers and caregivers. This can include information on the benefits of VAS, consequences of vitamin A deficiency, and dietary sources of vitamin A.

3. Improving socio-economic status: Implement interventions to improve the socio-economic status of the community, particularly targeting households in lower wealth tertiles. This can include income-generating activities, livelihood support, and poverty reduction programs.

4. Enhancing community-based services: Strengthen the capacity of community health workers, health extension workers, and volunteers to provide VAS and other maternal health services. This can be done through training, supervision, and supportive supervision.

5. Integration of VAS into routine health services: Integrate VAS into the routine Health Extension Program (HEP) to ensure regular and sustainable access to the supplement. This can include providing VAS through static service, locally organized campaigns, and home visits.

By implementing these recommendations, it is expected that the uptake of routine vitamin A supplementation for children in Humbo district, Southern Ethiopia, and access to maternal health services in general, can be improved.

AI Innovations Methodology

Based on the provided information, here are some potential recommendations to improve access to maternal health:

1. Strengthen Health Education: Increase awareness and knowledge among mothers/caregivers about the importance of routine vitamin A supplementation (VAS) for children. This can be done through community-based health education programs, involving frontline community health workers and volunteers.

2. Improve Socio-economic Status: Implement interventions to improve the socio-economic status of the community. This can include income-generating activities, livelihood support, and poverty reduction programs. Addressing socio-economic factors can help remove barriers to accessing maternal health services.

3. Enhance Distribution Strategies: Explore innovative distribution strategies for VAS, such as integrating it into routine health services, organizing community health days, and utilizing community health workers for distribution. This can improve the reach and coverage of VAS in remote areas.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the indicators: Identify key indicators to measure the impact of the recommendations, such as VAS coverage rate, knowledge level of mothers/caregivers, socio-economic status, and distance to health facilities.

2. Collect baseline data: Conduct a baseline survey to collect data on the current status of VAS coverage, knowledge, socio-economic status, and other relevant factors. This can be done through interviews, questionnaires, and data collection tools.

3. Implement interventions: Implement the recommended interventions, such as health education programs, socio-economic support initiatives, and improved distribution strategies for VAS. Ensure proper implementation and monitoring of these interventions.

4. Collect post-intervention data: After implementing the interventions, collect post-intervention data using the same indicators and data collection methods as the baseline survey. This will help assess the impact of the interventions on improving access to maternal health.

5. Analyze the data: Analyze the collected data to compare the baseline and post-intervention results. Use statistical methods, such as logistic regression analysis, to assess the association between the interventions and the outcomes.

6. Evaluate the impact: Evaluate the impact of the interventions by comparing the pre- and post-intervention data. Calculate the changes in VAS coverage, knowledge level, socio-economic status, and other relevant indicators. Assess the statistical significance of the changes.

7. Draw conclusions and make recommendations: Based on the results of the impact evaluation, draw conclusions about the effectiveness of the interventions in improving access to maternal health. Make recommendations for further improvements or modifications to the interventions based on the findings.

It is important to note that this is a general methodology and the specific details and steps may vary depending on the context and resources available for the study.

Ababhali & Co-Ababhali

Statistics:

Citations: 9

Authors: 3

Identifiers:

DOI: 10.1186/s12889-020-09617-1

Research Areas:

Community Interventions, Environmental, Food Security, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Social Determinants, Workforce

Study Countries:

Ethiopia

Study Design:

Case-Control Study, Cross Sectional Study

Study Approach:

Quantitative

Participants Gender:

Female

Yabelana ngalokhu: