Vitamin A Supplementation Coverage and Ocular Signs among Children Aged 6-59 Months in Aleta Chuko Woreda, Sidama Zone, Southern Ethiopia

Background. Periodic vitamin A supplementation to children is a cost-effective strategy to avert vitamin A deficiency. However, few pieces of evidence are available about the coverage of vitamin A supplementation at the community level in the study area. Therefore, the aim of this study was to assess vitamin A supplementation coverage and prevalence of ocular signs of vitamin A deficiency among children aged 6-59 months. Methods. Community-based cross-sectional study design was conducted using a two-stage stratified random sampling method. Data were collected from mothers with children aged 6-59 months using a structured pretested questionnaire. A total of 665 children aged 6 to 59 months were examined for clinical signs and symptoms of vitamin A deficiency by trained clinical health professionals. Descriptive statistics and logistic regression were done. Result. Vitamin A supplementation coverage in the study area was 36.2% (95% CI: 32.6-39.9). Overall, the prevalence of xerophthalmia was 2.7%. Age group 6-23 months (AOR: 2.1, 95% CI: 1.4-2.9), good maternal knowledge (AOR: 1.5, 95% CI: 1.2-2.1), children with high wealth status (AOR: 2.3, 95% CI: 1.4-3.8), precampaign health education on vitamin A (AOR: 3.4,95% CI: 2.1-5.6), member of Health Development Army (AOR: 2.7, 95% CI: 1.7-4.2), and access to health facility within <30 minutes (AOR: 2.5, 95% CI: 1.6-3.8) were significantly associated with the receipt of vitamin A capsule. Conclusion. Vitamin A supplementation coverage of the study area was low as compared to the UNICEF threshold of 70%. Vitamin A deficiency is a public health problem in the study area. Increasing maternal level of knowledge, precampaign health education on vitamin A supplementation, and strengthening Health Development Army are recommended to increase the vitamin A supplementation coverage. Woreda is the third-level administrative division of Ethiopia and subdivided into several kebeles, which is the smallest unit of local government in Ethiopia. Aleta Chuko woreda is one of the 36 woredas in the Sidama administrative zone of Southern Nations, Nationalities, and Peoples' Regional State (SNNPRS) of Ethiopia. The zone is bordered on the north and east by Oromia region, on the south by the Oromia region and Gedeo Zone, and on the west by Bilate river, which separates it from Wolaita Zone. The projected population in 2019 was 203,142 being children of 6–59 months (28,317). The woreda has 24 rural and 5 urban kebeles. The main staple foods of the area are inset “false banana,” maize, fruits, and vegetables. Concerning the health care services, there are one woreda hospital, 7 health centers, 24 health posts, and 7 private clinics. VAS is conducted in the woreda through the Community Health Day (CHD) program by Health Extension Workers every six months. In CHDs, the Health Extension Workers (HEWs) mobilize the community with children under 5 years to come to the health post for malnutrition screening, deworming, and vitamin A capsule supplementation [16]. The last VAS was conducted in the area two months preceding this survey. A community-based cross-sectional study design was conducted between 15 December 2018 and 15 January 2019. Mothers with children aged 6–59 months that live in the area for at least six months prior to the survey were included in the study. Mothers with children aged 6–59 months who were sick, had a mental problem, and live in the area for less than six months were excluded. The sample size was calculated for vitamin supplementation coverage, associated factors, and prevalence of conjunctival xerosis with a child receiving vitamin A capsule using both single- and double-population formula. Finally, comparing the three objectives' sample size, the largest sample size 673 was taken, which was determined by using a single-proportion formula n = Z2 (1 − α) p (1 − p)/(se)2. Desired confidence interval = 95% (Z = 1.96), level of precision (marginal error) = 3%, non–response rate and missing data = 10%, design–effect = 1.5, and P=89.3% of vitamin A supplementation coverage were taken from the Southern Nations, Nationalities, and Peoples' Regional State health bureau report of 2017 [17]. A two-stage stratified sampling procedure was employed for sample selection. The woreda has been stratified by their administrative kebeles, and accordingly 4 rural and 2 urban kebeles were selected for the study by using lottery methods. The total numbers of children of 6–59 months living in these selected kebeles were obtained from the local administration. The proportional allocations to the size of each selected kebeles were conducted. After a proportional allocation to each kebele, kth or interval was calculated for each kebele and systematic sampling technique was employed to reach the study subjects. From each household, one study subject was selected, and where there is more than one eligible study subject in the household only one child was included by a lottery method. In a situation where eligible study subject temporarily absent at the selected house, two repeated visits were done; otherwise, an adjacent house was substituted. Data were collected from mothers with children aged 6–59 months using a structured questionnaire. A total of 8 trained senior clinical health professionals and two supervisors who speak the local language fluently participated in data collection. At the time of the interview, the vitamin A capsule was demonstrated to the interviewer to facilitate recall of whether the child received or did not receive preceding the survey. The two-day training was given for data collectors by one principal investigator and one optometrist with field practice. Five percent of the questionnaire was pretested in the other kebeles that were not selected for the study. The pretest result was not included in the final analysis. Site selection for clinical assessments and a few frightened children were observed as a challenge during a pretest. To minimize these problems during the actual data collection, clinical assessments were done under an available shade with natural lightening and the examination was carried out after the frightened child calmed down. Eyes of eligible (665) children were examined by trained clinical health professionals for ocular signs of VAD such as Bitot's spot, conjunctival xerosis, corneal ulcers, corneal scar, and corneal xerosis, by using an ophthalmoscope, a pen torch, and magnifiers (fixed hand lens). History of the night blindness of children was obtained by asking mothers. To ensure the validity and reliability of the procedure, all children with ocular sign and symptoms were reexamined by a senior optometrist. And then, children with ocular sign of VAD were taken only for those children who were examined and confirmed by the senior optometrist. The pretest data were also entered to SPSS, and reliability test was done for nine items that were used for measuring maternal knowledge. The result showed a Cronbach's α of 0.77. Data were entered and analyzed using SPSS version 20. Data cleaning was performed to check for inconsistencies and missing values and variables. Data were checked daily for incompleteness and inconsistency by two field supervisors and one principal investigator. From the total houses included for an interview, five percent of them were randomly visited by field supervisors to check data quality. Descriptive analysis like mean and standard deviation were determined for continuous variables after checking the distribution of the data for its normality. The household wealth index was calculated using household properties. Principal component analysis (PCA) was used to compute the household wealth index and categorized into the lowest, middle, and highest. The overall knowledge level of mothers on VIT A was assessed using nine questions and each had one point with a total of nine marks. Each score for each question was calculated and summed up to give the overall knowledge. Pearson's chi-square test was also done to measure the association between vitamin A deficiency and ocular sign. Logistic regression was used to see the independent effect of predictors on outcome variables (VIT A utilization). Independent predictors that had a P value less than 0.25 at binary logistic regression were transferred to multivariable analysis. Crude odds ratio (COR) and the adjusted odds ratio (AOR) were presented at a confidence interval of 95%. Multicollinearity effect was checked by using a linear diagnostic test of mean-variance inflation factor (VIF) at cut-off point >10. The model goodness-of-fit was tested by using the Hosmer–Lemeshow test at P value>0.05 as the best fit. All tests were two-sided and variables with P < 0.05 in the final multivariable model were considered as independent predictors of vitamin A utilization. A child who was given vitamin A capsule in the preceding 6 months of the survey as reported by the mother (after the mother is shown the capsule) [18]. A child who was examined by a trained clinical health professional for ocular signs of VAD (Bitot's spot, conjunctival xerosis, corneal ulcer, corneal scar, and corneal xerosis) during data collection and unable to see in dim light or dark and has ocular symptoms of vitamin A deficiency as well. A respondent who correctly answered 6 (>60%) and above questions among nine knowledge-related questionnaires on VIT A [19]. A respondent who correctly answered ≤5 (<60%) questions among nine knowledge-related questions on VIT A [19]. It is a one to five networks of women volunteers organized to promote health and prevent disease through community participation and empowerment. It also helps to identify local salient bottlenecks that hinder families from utilizing maternally and child service [20]. It is a household measured in 18 health extension packages by Health Extension Workers (HEW) and verified as a model or non–model household.