- Email: [email protected]
Malnutrition and morbidity among children not reached by the national vitamin A capsule programme in urban slum areas of Indonesia
ARTICLE IN PRESS Public Health (2008) 122, 371–378
www.elsevierhealth.com/journals/pubh
Original Research
Malnutrition and morbidity among children not reached by the national vitamin A capsule programme in urban slum areas of Indonesia S.G. Bergera, S. de Peeb, M.W. Bloema,c, S. Halatid, R.D. Sembaa, a
Johns Hopkins School of Medicine, 550 N. Broadway, Suite 700, Baltimore, MD 21205, USA Helen Keller International Asia Pacific, Singapore c Nutrition Service, Policy, Strategy and Programme Support Division, World Food Programme, Rome, Italy d Helen Keller International, Jakarta, Indonesia b
Received 14 August 2006; received in revised form 22 May 2007; accepted 6 August 2007 Available online 28 January 2008
KEYWORDS Anaemia; Diarrhoea; Immunization; Malnutrition; Morbidity; Vitamin A; Indonesia
Summary Objective: To determine whether vitamin A capsule programmes fail to reach children who are at higher risk of malnutrition and morbidity. Although it has been suggested that there are health disparities between children who are reached or not reached by these programmes, little quantitative work has been undertaken to characterize this relationship. Study design: As part of a national surveillance system, nutritional status and other factors were compared in 138,956 children, aged 12–59 months, who had and had not received vitamin A supplementation in urban slum areas in Indonesia. Results: In total, 63.1% of children had received a vitamin A capsule within the previous 6 months. Among children who had and had not received vitamin A supplementation, respectively, the proportion with weight-for-age and height-forage Z scores o 3 were 7.8% vs 8.6% (Po0.0001) and 9.4% vs 10.7% (Po0.0001), and with a history of diarrhoea in the previous week was 8.1% vs 10.7% (Po0.0001). In families where a child had or had not received vitamin A supplementation, the proportion with a history of infant death o12 months was 5.2% vs 7.2% (Po0.0001) and child death o5 years was 6.7% vs 9.2%, respectively (Po0.0001). Children who had not received vitamin A supplementation were also significantly more likely to be anaemic and have diarrhoea or fever on the survey day compared with children who had received supplementation. Conclusions: In the urban slums of Indonesia, children who do not receive vitamin A supplementation tend to be slightly more malnourished and ill, and are more likely to come from families with higher child mortality than children who receive vitamin A. Higher rates of child mortality in non-participating households suggest that reaching preschoolers could yield a disproportionate survival benefit. Importantly, children who are not reached by the vitamin A programme are also unlikely to be
Corresponding author. Tel.: +1 410 955 3572; fax: +1 410 955 0629.
E-mail address: [email protected] (R.D. Semba). 0033-3506/$ - see front matter & 2007 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2007.08.003
ARTICLE IN PRESS 372
S.G. Berger et al. reached by vaccination and other services, emphasizing the need to identify and extend efforts to reach non-participants. & 2007 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction It is estimated that vitamin A deficiency affects 140 million children in the developing world1 and is a leading cause of child morbidity, mortality and paediatric blindness.2 Vitamin A is essential for normal cell differentiation, growth, maintenance of mucosal surfaces, reproduction, immunity and vision. Periodic high-dose vitamin A supplementation programmes have been established over the last 25 years in many developing countries in order to increase child survival and decrease the incidence of paediatric blindness. Vitamin A supplementation has proven to be a very cost-effective intervention,3 reducing all-cause mortality among 6–59-month-old children by 23%.4 It is estimated that if vitamin A coverage reached 99% of children in the 42 countries with the greatest burden of child mortality, 225,000 child deaths could be prevented annually.5 Vitamin A deficiency has been highly prevalent in Indonesia since at least the early 20th Century. In the 1970s, the prevalence of xerophthalmia was recorded at 1.33% and acute corneal disease affected one in 1000 infants and preschool children each year.6 In the early 1970s, with the introduction of vitamin A capsule pilot programmes, and later in the 1980s, with the initiation of a national programme, the prevalence of severe vitamin A deficiency began to decrease. By 1992, the prevalence of xerophthalmia had fallen by approximately 75–0.34% and acute corneal disease to 0.05 per 1000 among infants and preschool children.6 However, subclinical vitamin A deficiency is still common.7 Periodic high-dose vitamin A capsule distribution has been identified by the World Bank as one of the most cost-effective interventions to reduce child mortality in developing countries.8 In addition, the Copenhagen Consensus included vitamin A capsule distribution as one of the most effective measures to improve global health.9 Indonesia has had one of the strongest vitamin A capsule distribution programmes for child survival in the world,10 and the intended coverage is for all infants aged 6–12 months and all preschool children aged 12–59 months. The programme consists of biannual distribution of oral vitamin A, 60 mg retinol equiva-
lents, to children aged 12–59 months and half the dose for infants aged 6–12 months.11 The main site for distribution of vitamin A capsules to children is the subvillage health post (‘posyandu’). The effectiveness of vitamin A capsule distribution programmes for child survival is likely to be related to the extent of programme coverage. It has been suggested that vitamin A supplementation in developing countries may fail to reach the children who are at highest risk,12 but there are few recent quantitative data on the characteristics of children who do not receive vitamin A supplementation.13 It is not known whether children who are missed may actually be at greater risk of morbidity and mortality. To gain further insight into this issue, this study sought to characterize the demographic and health characteristics of preschool children who are reached and not reached by the national vitamin A capsule distribution programme in Indonesia. It was hypothesized that children who did not receive vitamin A supplementation were more likely: (i) to be stunted, wasted and underweight; (ii) to be at higher risk of diarrhoea, fever and anaemia; (iii) to have lower childhood immunization coverage; and (iv) to come from families with higher rates of infant and under5 child mortality than children who received vitamin A. In order to address these hypotheses, the characteristics of children who did and did not receive vitamin A supplementation in urban slum areas of Indonesia were examined.
Subjects and methods The study subjects were children from families that participated in a major nutritional surveillance system (NSS) in Indonesia that was established by the Ministry of Health, Government of Indonesia and Helen Keller International (HKI) in 1995.14 The NSS included five major urban slum areas of Indonesia in the cities of Jakarta, Surabaya, Semarang, Makassar and Padang. The subjects included in this analysis were surveyed between 1 January 1999 and 27 September 2003. The NSS was based upon UNICEF’s conceptual framework on the causes of malnutrition15 with the underlying principle to monitor public health problems and guide
ARTICLE IN PRESS Malnutrition and morbidity in children without vitamin A supplementation policy decisions.16 The NSS was based upon stratified multistage cluster sampling of households in subdistricts of administrative divisions of the country and in slum areas of large cities.14 A purposive sampling design was used to target poor households. Within specific slum areas, poor households were considered those in which the housing location was along train tracks, rivers/gutters/ swamps, underneath toll roads/highways, near ‘waste station/dump areas’, around small alleys and/or near the beach, and where housing conditions included ‘box house’ (composed of cardboard, galvanized tin, plywood and bamboo), house with soil/uncemented floor, house attached to other houses and house with wood floors. The NSS in Indonesia involved the collection of data from approximately 40,000 randomly selected urban households every quarter. New households were selected every round. Data were collected by two-person field teams. A structured coded questionnaire was used to record data on children aged 0–59 months, including anthropometric measurements, date of birth and sex. The mother of the child or another 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 the age of 6 months, the mother, father or guardian was asked whether the child had received a vitamin A capsule within the last 6 months and about receipt of diphtheriapertussis-tetanus (DPT), oral poliovirus vaccine (OPV) and measles vaccine. Axillary temperature was recorded. Haemoglobin was measured using a HemoCue instrument (HemoCue AB, Angelholm, Sweden). Morbidity histories were obtained for each child, including history of diarrhoea in the previous week and diarrhoea on the survey day. Data were collected on the history of any deaths in the household before 1 month of age, before 12 months of age and before 5 years of age. The field teams measured and recorded the weight of each child aged 0–59 months 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 (Centers for Disease Control and Prevention, Atlanta, GA, USA), which uses the reference population of the US National Center for Health Statistics. Children with Z-scores o 2 standard deviations (SD) for WHZ, WAZ or HAZ
373
were considered wasted, underweight or stunted.17 Severe wasting, underweight and stunting were defined by Z scores o 3 SD. Children who had a mid-upper arm circumference o125 mm were considered to be at high risk of malnutrition.18 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 days 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 of the Declaration of Helsinki.19 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. The research plan was reviewed by the Johns Hopkins School of Medicine Institutional Review Board and granted an exemption on 14 July 2006 under Department of Health and Human Services 45, Code of Federal Regulations 46.404. Data analyses were restricted to children aged 12–59 months at the start of the most recent vitamin A capsule distribution round because these were the children who were eligible to receive 60 mg retinol equivalents (200,000 International Units) every 6 months in the Indonesian vitamin A capsule programme. Children who were aged between 6 and 12 months 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 was being implemented during the period of this study. For families with more than one child, the youngest child aged 12–59 months was selected to represent each family. Continuous variables were compared using Student’s t-test, and variable transformations were used when necessary to normalize the data. Categorical variables were compared using Chisquared tests. Anaemia was defined as haemoglobin
ARTICLE IN PRESS 374 o11 g/dl, according to World Health Organization criteria.19 Population-based weighting was used to account for differences in population size of the various provinces, and population-weighted results are reported.
Results The study population included 138,956 children, aged 12–59 months, of whom 87,675 (63.1%) had received a vitamin A capsule within the last 6 months. Non-respondents accounted for only 612 children (0.4%). Table 1 shows the demographic and other characteristics of children who did and who did not receive vitamin A supplementation. Children who did not receive a vitamin A capsule were significantly more likely to be younger, male, have WAZ and HAZo 2, have WAZ, HAZ and WHZ o 3, have fever on the survey day, have diarrhoea on the survey day, have a history of diarrhoea in the previous week, and have anaemia compared with children who received a vitamin A capsule. Children who did not receive vitamin A supplementation were significantly more likely to have mothers who were younger and less educated and fathers who were less educated. The mean distance and time to walk from the house to the ‘posyandu’ were significantly higher for children who did not receive a vitamin A capsule compared with children who did receive a vitamin A capsule. Childhood immunization coverage was compared for children who did and did not receive vitamin A supplementation (Table 2). Children who did not receive a vitamin A capsule were significantly less likely to receive the first, second and third DPT immunization, the first, second, and third OPV immunization, and measles immunization. A history of child mortality was compared in households where the children did or did not receive vitamin A supplementation (Fig. 1). In households where the child did not receive a vitamin A capsule, the proportions of deaths before 1 month of age, before 12 months of age and before 5 years of age were significantly higher than in households where the child received a vitamin A capsule. The general reasons given for not visiting the ‘posyandu’ are shown in Table 3. The five main reasons were that the child was afraid of being weighed, that the parents usually took the child to other health facilities, that the family had just moved to the survey area, that the health post was not active, and that they thought the child was too old to attend the ‘posyandu’.
S.G. Berger et al.
Discussion The vitamin A capsule supplementation programme in Indonesia has proved to be highly effective over the last 25 years in decreasing rates of severe vitamin A deficiency and increasing overall coverage rates.6,10 However, these results, based on the most recent data from the NSS conducted in Indonesia, show that the programme may not be reaching the children who are at highest risk for malnutrition and infectious disease morbidity in urban Indonesia. The evidence shows that in urban slum areas, children, aged 12–59 months, who had not received vitamin A supplementation in the previous 6 months were at greater risk of underweight, stunting and severe wasting. They were also more likely to be anaemic and to have higher rates of diarrhoea on the survey day, fever on the survey day and a history of diarrhoea in the previous week than children who had received vitamin A supplementation. In addition, children who did not receive vitamin A were more likely to be more severely underweight, stunted and wasted (Z scores o 3) compared with children who did receive vitamin A. The difference in value of the above indicators between children who did and did not receive vitamin A supplementation was not exceptionally large and the statistical significance of these variables was probably influenced by the large sample size of the study. Nevertheless, consistent differences in anthropometric and health characteristics in both real and statistically significant terms offer compelling evidence that the children who were not reached by the vitamin A programme were at much greater risk for malnutrition and morbidity. This analysis also shows that children who did not receive vitamin A capsules were less likely to receive DPT, OPV and measles vaccine, thereby placing them at higher risk for infectious disease morbidity and mortality from vaccine-preventable diseases. Lack of vaccine protection as well as lack of vitamin A supplementation may place children at especially high risk, especially with regards to measles. Vitamin A deficiency is known to increase the risk of measles morbidity and measles-related pneumonia, blindness and mortality. These findings suggest that children who are not reached by the vitamin A programme are unlikely to benefit from other primary care and preventive care programmes. It is clear that efforts to increase participation in vitamin A programmes should also emphasize participation in childhood immunization and other primary care programmes. Barriers to access were also examined. Mothers reported the child’s fear of getting weighed and use
ARTICLE IN PRESS Malnutrition and morbidity in children without vitamin A supplementation
375
Table 1 Demographic and health characteristics of children, aged 12–59 months, who did and did not receive a vitamin A capsule. Characteristic
N
Child age (months) (%) 12–23 24–35 36–47 48–59 Gender, % male
19,516 14,248 10,509 7010 27,210
38.1 27.8 20.5 13.7 53.1
31,073 26,649 19,039 10,913 44,749
35.4 30.4 21.7 12.4 51.0
Maternal age (years) (%) p24 25–28 29–32 X33
9435 13,115 14,465 14,085
18.5 25.7 28.3 27.6
14,391 22,612 26,427 24,120
16.4 25.8 30.2 27.5
0.0001
Maternal education (years) (%) 0–6 7–9 X10
28,447 11,339 11,302
55.7 22.2 22.1
40,452 21,418 25,576
46.3 24.5 29.2
0.0001
Paternal education (years) (%) 0–6 7–9 X10
20,902 12,556 16,204
42.1 25.3 32.6
29,588 21,325 34,648
34.6 24.9 40.5
0.0001
Number of children o5 years in household 1 2 3 4+
23,944 8486 688 45
72.2 25.6 2.1 0.1
55,564 14,344 797 73
78.5 20.3 1.1 0.1
0.0001
Year in which interview was conducted 1999 2000 2001 2002 2003
17,456 18,930 8833 3710 2353
34.0 36.9 17.2 7.2 4.6
16,012 28,251 16,676 15,026 11,711
18.3 32.2 19.0 17.1 13.4
0.0001
Weight-for-age Z (WAZ) score (%) WAZ o 2 WAZ o 3
21,986 4371
43.2 8.6
37,016 6791
42.5 7.8
0.012 0.0001
Height-for-age Z (HAZ) score (%) HAZ o 2 HAZ o 3
19,345 5399
38.3 10.7
31,589 8149
36.4 9.4
0.0001 0.0001
Weight-for-height Z (WHZ) score (%) WHZ o 2 WHZ o 3
5786 603
11.4 1.2
9805 873
11.3 1.0
0.541 0.002
MUAC o125 mm (%) Diarrhoea on survey day (%) Fever on survey day (%) Diarrhoea last week (%) Anaemic (%)
1642 3246 1427 5448 5788
3.2 6.3 2.8 10.7 56.2
2705 4534 1618 7036 9622
3.1 5.2 1.9 8.1 53.9
0.237 0.0001 0.0001 0.0001 0.0001
Distance to the ‘posyandu’ Metresa Minutesa
MUAC, mid-upper arm circumference. Geometric mean (95% confidence intervals).
a
Did not receive vitamin A
50,710 35,204
N
Received vitamin A
264.5 86,279 (259.2–270.9) 5.11 82,508 (5.07–5.15)
78.7 (77.8–79.5) 4.66 (4.64–4.69)
P
0.0001
0.0001
0.0001 0.0001
ARTICLE IN PRESS 376 Table 2
S.G. Berger et al. Relationship of vitamin A capsule receipt with childhood vaccinations.
Characteristic
N
Did not receive vitamin A
N
Received vitamin A
P
DPT vaccine dose 1 Received, with record Received, no record Not received Does not know
7710 18,309 6402 418
23.5 55.8 19.5 1.2
28,683 36,439 5188 232
40.7 51.7 7.4 0.3
0.0001
DPT vaccine dose 2 Received, with record Received, no record Not received Does not know
7072 17,043 8284 448
21.5 51.9 25.2 1.3
27,579 35,070 7652 253
39.1 49.7 10.8 0.4
0.0001
DPT vaccine dose 3 Received, with record Received, no record Not received Does not know
6582 16,044 9716 482
20.0 48.9 29.6 1.5
26,482 33,784 9868 329
37.6 47.9 14.0 0.4
0.0001
OPV vaccine dose 1 Received, with record Received, no record Not received Does not know
7949 18,325 6235 330
24.2 55.8 19.0 1.0
29,122 36,493 4646 233
41.3 51.8 6.6 0.3
0.0001
OPV vaccine dose 2 Received, with record Received, no record Not received Does not know
7480 17,210 7790 371
22.8 52.4 23.7 1.1
28,372 35,355 6520 252
40.2 50.1 9.2 0.3
0.0001
OPV vaccine dose 3 Received, with record Received, no record Not received Does not know
6993 16,294 9161 398
21.3 49.6 27.9 1.2
27,392 34,303 8515 273
38.9 48.7 12.1 0.4
0.0001
Measles vaccine Received, with record Received, no record Not received Does not know
5972 14,294 12,030 530
18.2 43.5 36.6 1.6
24,809 31,737 13,401 504
35.2 45.0 19.0 0.7
0.0001
DPT, diphtheria-pertussis-tetanus; OPV, oral poliovirus vaccine.
of other health facilities as the main reasons why their children did not participate in the national vitamin A capsule programme. Other major reasons given were that the family had moved to the area recently and the ‘posyandus’ were not active. Less than 2% of respondents cited distance to the health post as a reason for non-participation. Most reasons given by the mothers suggested a lack of knowledge about the health benefits of vitamin A. Other studies in Indonesia have shown that limited knowledge of the importance of vitamin A is associated with lower rates of participation in the
national vitamin A programme.13,20 In addition, it is clear that general lack of access to health posts, and thus to primary care, is likely to be an additional determinant of the increased morbidity among children who are not reached by the vitamin A capsule programme. Two studies from the Philippines and Indonesia examined the characteristics of children who did and did not participate in vitamin A supplementation programmes. However, these studies focused mainly on socio-economic and family characteristics.12,13 Another recent study from Bangladesh
ARTICLE IN PRESS Malnutrition and morbidity in children without vitamin A supplementation 10 9
No capsule
8
Capsule
*
7
%
6
*
5 4
*
3 2 1 0
Infant Died <1 Month
Infant Died <12 Months
Child Died <5 Years
Figure 1 History of infant dying before 1 month of age, infant dying before 12 months of age, and under-5 child mortality in families where the child did and did not receive a vitamin A capsule (*Po0.0001).
Table 3 Reasons given for not taking children to the health post (‘posyandu’). Reason
n
%
Child afraid of being weighed Usually take child to another health facility Just moved to survey area Health clinic not active Child is too old Mother is too busy Do not know schedule Health clinic too far away Immunizations are complete Need to pay Child is too young Child is weighed at home No food supplementation programme Other reasons
14,039
36.4
5319 2525 2376 1879 1124 1057 661 552 118 94 57 42 8727
13.8 6.5 6.2 4.9 2.9 2.7 1.7 1.4 0.3 0.2 0.1 0.1 22.6
377
primary preventive care programmes in Indonesia. The study also emphasizes the substantial impact of formal maternal and paternal education on vitamin A supplementation in children. Further investigation is necessary to determine how coverage rates of vitamin A supplementation may be increased through improvements in formal and nutrition education among parents and primary caregivers. The International Vitamin A Consultative Group (IVACG) recently suggested that vitamin A deficiency may affect a disproportionate number of the poor who are also least likely to access public health services.8 IVACG recommended that vitamin A supplementation should achieve coverage over 80%, acknowledging that the averted morbidity and mortality would probably be greatest among the lowest one-fifth of the population.22 Little quantitative data have been available regarding those who are not reached, and the study findings confirm that non-participants in urban areas suffer poorer nutritional status and higher morbidity than participants in the vitamin A capsule programme. Periodic high-dose vitamin A supplementation remains one of the most cost-effective means of reducing child mortality in developing countries, and unless coverage is expanded to reach the children in greatest need, the international community will fall short of reaching the Millennium Development Goals for reducing child mortality by two-thirds between 1990 and 2015.3,23 Ethical approval Medical Ethical Committee of the Ministry of Health, Government of Indonesia; plan for secondary data analysis reviewed by Johns Hopkins School of Medicine Medical Institutional Review Board and granted an exemption on 14 July 2006 under the US Department of Health and Human Services 45, Code of Federal Regulations 46.404. Funding
described disparities in vitamin A supplementation among ethnic minorities in Bangladesh.21 To the authors’ knowledge, the present study is the first to examine the health and nutritional characteristics of children who are not reached by a vitamin A capsule supplementation programme. In addition, the study highlights that the programme coverage rate among children aged 12–59 months living in urban slum areas was 63.1%, falling below the Indonesian Government’s target coverage rate of 80%10 and below the World Bank’s recommendation of 85%.8 These findings suggest that strategies need to be developed to reach children who do not receive vitamin A supplementation and basic
Lew R. Wasserman Award from Research to Prevent Blindness. Competing interests None declared.
References 1. Sommer A, Davidson FR. Assessment and control of vitamin A deficiency: the Annecy Accords. J Nutr 2002;132(Suppl. 9): 2845S–50S. 2. West Jr KP, Darnton-Hill I. Vitamin A deficiency. In: Semba RD, Bloem MW, editors. Nutrition and health in developing countries. Totowa, NJ: Humana Press; 2001. p. 267–306.
ARTICLE IN PRESS 378 3. Edejer TTT, Aikins M, Black R, Wolfson L, Hutubessy R, Evans DB. Cost effectiveness analysis of strategies for child health in developing countries. Br Med J 2005;331:1177. 4. Beaton GH, Martorell R, L’Abbe KA, et al. Effectiveness of vitamin A supplementation in the control of young child morbidity and mortality in developing countries. ACC/SCN State-of-the-Art Nutrition Policy Discussion Paper No. 13. New York: United Nations; 1993. 5. Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS. Bellagio Child Survival Study Group. How many child deaths can we prevent this year? Lancet 2003;362:65–71. 6. Muhilal, Tarwotjo I, Kodyat B, Herman S, Permaesih D, Karyadi D, et al. Changing prevalence of xeropthalmia in Indonesia, 1977–1992. Eur J Clin Nutr 1994;48:708–14. 7. Soekarjo DD, de Pee S, Kusin JA, Schreurs WH, Schultink W, et al. Effectiveness of weekly vitamin A (10000 IU) and iron (60 mg) supplementation for adolescent boys and girls through schools in rural and urban East Java, Indonesia. Eur J Clin Nutr 2004;58:927–37. 8. World Bank. Vitamin A. 2004. Available at: (web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTHEALTHNUTRITIONANDPOPULATION/EXTPHAAG/0,,contentMDK:20800011menuPK:1314810pagePK:642298). Last accessed 8 May 2006. 9. Lomborg B. Global crises, global solutions. New York: Cambridge University Press; 2004. 10. Helen Keller International. Summary and accomplishments of the HKI/GOI collaboration for vitamin A, 1999–2005. Jakarta: Helen Keller International Indonesia; 2006. 11. Semba RD, Susatio B, Muhilal, Natadisastra G. The decline of admissions for xerophthalmia at Cicendo Eye Hospital, Indonesia, 1981–1992. Int Ophthalmol 1995;19:39–42. 12. Choi Y, Bishai D, Hill K. Socioeconomic differentials in supplementation of vitamin A: evidence from the Philippines. J Health Popul Nutr 2005;23:156–64. 13. Pangaribuan R, Scherbaum V, Erhardt JG, Sastroamidjojo S, Biesalski HK. Socioeconomic and familial characteristics influence caretakers’ adherence to the periodic vitamin A
S.G. Berger et al.
14.
15.
16. 17.
18.
19.
20.
21.
22.
23.
capsule supplementation program in Central Java, Indonesia. J Trop Pediatr 2004;50:143–7. de Pee S, Bloem MW, Sari M, Kiess L, Yip R, Kosen S. High prevalence of low hemoglobin concentration among Indonesian infants aged 3–5 months is related to maternal anemia. J Nutr 2002;132:2115–221. de Pee S, Bloem MW. Assessing and communicating impact of nutrition and health programs. In: Semba RD, Bloem MW, editors. Nutrition and health in developing countries. Totowa, NJ: Humana Press; 2001. p. 483–506. Mason JB, Habicht JP, Tabatabai H, Valverde V. Nutritional surveillance. Geneva: World Health Organization; 1984. de Onis M. Child growth and development. In: Semba RD, Bloem MW, editors. Nutrition and health in developing countries. Totowa, NJ: Humana Press; 2001. p. 71–91. Dramaix M, Hennart P, Brasseur D, Bahwere P, Mudjene O, Tonglet R, et al. Serum albumin concentrations, arm circumference, and oedema and subsequent risk of dying in children in central Africa. Br Med J 1993;307: 710–3. World Medical Association. Declaration of Helsinki: ethical principles for medical research involving human subjects. Bull World Health Organ 2001;79:373–4. Pangaribuan R, Erhardt JG, Scherbaum V, Biesalski HK. Vitamin A capsule distribution to control vitamin A deficiency in Indonesia: effect of supplementation in pre-school children and compliance with the programme. Public Health Nutr 2003;6:209–16. Karim F, Rafi M, Begum SA. Inequitable access to immunization and vitamin A capsule services: a case of ethnic minorities in three hill districts of Bangladesh. Public Health 2005;119:743–6. Ross D. Recommendations for vitamin A supplementation. Proceedings of the XX international vitamin A consultative group meeting. J Nutr 2002;131:2902S–6S. Bryce J, el Arifeen S, Pariyo G, Lanata C, Gwatkin D, Habicht JP, et al. Reducing child mortality: can public health deliver? Lancet 2003;362:159–64.
www.elsevierhealth.com/journals/pubh
Original Research
Malnutrition and morbidity among children not reached by the national vitamin A capsule programme in urban slum areas of Indonesia S.G. Bergera, S. de Peeb, M.W. Bloema,c, S. Halatid, R.D. Sembaa, a
Johns Hopkins School of Medicine, 550 N. Broadway, Suite 700, Baltimore, MD 21205, USA Helen Keller International Asia Pacific, Singapore c Nutrition Service, Policy, Strategy and Programme Support Division, World Food Programme, Rome, Italy d Helen Keller International, Jakarta, Indonesia b
Received 14 August 2006; received in revised form 22 May 2007; accepted 6 August 2007 Available online 28 January 2008
KEYWORDS Anaemia; Diarrhoea; Immunization; Malnutrition; Morbidity; Vitamin A; Indonesia
Summary Objective: To determine whether vitamin A capsule programmes fail to reach children who are at higher risk of malnutrition and morbidity. Although it has been suggested that there are health disparities between children who are reached or not reached by these programmes, little quantitative work has been undertaken to characterize this relationship. Study design: As part of a national surveillance system, nutritional status and other factors were compared in 138,956 children, aged 12–59 months, who had and had not received vitamin A supplementation in urban slum areas in Indonesia. Results: In total, 63.1% of children had received a vitamin A capsule within the previous 6 months. Among children who had and had not received vitamin A supplementation, respectively, the proportion with weight-for-age and height-forage Z scores o 3 were 7.8% vs 8.6% (Po0.0001) and 9.4% vs 10.7% (Po0.0001), and with a history of diarrhoea in the previous week was 8.1% vs 10.7% (Po0.0001). In families where a child had or had not received vitamin A supplementation, the proportion with a history of infant death o12 months was 5.2% vs 7.2% (Po0.0001) and child death o5 years was 6.7% vs 9.2%, respectively (Po0.0001). Children who had not received vitamin A supplementation were also significantly more likely to be anaemic and have diarrhoea or fever on the survey day compared with children who had received supplementation. Conclusions: In the urban slums of Indonesia, children who do not receive vitamin A supplementation tend to be slightly more malnourished and ill, and are more likely to come from families with higher child mortality than children who receive vitamin A. Higher rates of child mortality in non-participating households suggest that reaching preschoolers could yield a disproportionate survival benefit. Importantly, children who are not reached by the vitamin A programme are also unlikely to be
Corresponding author. Tel.: +1 410 955 3572; fax: +1 410 955 0629.
E-mail address: [email protected] (R.D. Semba). 0033-3506/$ - see front matter & 2007 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2007.08.003
ARTICLE IN PRESS 372
S.G. Berger et al. reached by vaccination and other services, emphasizing the need to identify and extend efforts to reach non-participants. & 2007 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction It is estimated that vitamin A deficiency affects 140 million children in the developing world1 and is a leading cause of child morbidity, mortality and paediatric blindness.2 Vitamin A is essential for normal cell differentiation, growth, maintenance of mucosal surfaces, reproduction, immunity and vision. Periodic high-dose vitamin A supplementation programmes have been established over the last 25 years in many developing countries in order to increase child survival and decrease the incidence of paediatric blindness. Vitamin A supplementation has proven to be a very cost-effective intervention,3 reducing all-cause mortality among 6–59-month-old children by 23%.4 It is estimated that if vitamin A coverage reached 99% of children in the 42 countries with the greatest burden of child mortality, 225,000 child deaths could be prevented annually.5 Vitamin A deficiency has been highly prevalent in Indonesia since at least the early 20th Century. In the 1970s, the prevalence of xerophthalmia was recorded at 1.33% and acute corneal disease affected one in 1000 infants and preschool children each year.6 In the early 1970s, with the introduction of vitamin A capsule pilot programmes, and later in the 1980s, with the initiation of a national programme, the prevalence of severe vitamin A deficiency began to decrease. By 1992, the prevalence of xerophthalmia had fallen by approximately 75–0.34% and acute corneal disease to 0.05 per 1000 among infants and preschool children.6 However, subclinical vitamin A deficiency is still common.7 Periodic high-dose vitamin A capsule distribution has been identified by the World Bank as one of the most cost-effective interventions to reduce child mortality in developing countries.8 In addition, the Copenhagen Consensus included vitamin A capsule distribution as one of the most effective measures to improve global health.9 Indonesia has had one of the strongest vitamin A capsule distribution programmes for child survival in the world,10 and the intended coverage is for all infants aged 6–12 months and all preschool children aged 12–59 months. The programme consists of biannual distribution of oral vitamin A, 60 mg retinol equiva-
lents, to children aged 12–59 months and half the dose for infants aged 6–12 months.11 The main site for distribution of vitamin A capsules to children is the subvillage health post (‘posyandu’). The effectiveness of vitamin A capsule distribution programmes for child survival is likely to be related to the extent of programme coverage. It has been suggested that vitamin A supplementation in developing countries may fail to reach the children who are at highest risk,12 but there are few recent quantitative data on the characteristics of children who do not receive vitamin A supplementation.13 It is not known whether children who are missed may actually be at greater risk of morbidity and mortality. To gain further insight into this issue, this study sought to characterize the demographic and health characteristics of preschool children who are reached and not reached by the national vitamin A capsule distribution programme in Indonesia. It was hypothesized that children who did not receive vitamin A supplementation were more likely: (i) to be stunted, wasted and underweight; (ii) to be at higher risk of diarrhoea, fever and anaemia; (iii) to have lower childhood immunization coverage; and (iv) to come from families with higher rates of infant and under5 child mortality than children who received vitamin A. In order to address these hypotheses, the characteristics of children who did and did not receive vitamin A supplementation in urban slum areas of Indonesia were examined.
Subjects and methods The study subjects were children from families that participated in a major nutritional surveillance system (NSS) in Indonesia that was established by the Ministry of Health, Government of Indonesia and Helen Keller International (HKI) in 1995.14 The NSS included five major urban slum areas of Indonesia in the cities of Jakarta, Surabaya, Semarang, Makassar and Padang. The subjects included in this analysis were surveyed between 1 January 1999 and 27 September 2003. The NSS was based upon UNICEF’s conceptual framework on the causes of malnutrition15 with the underlying principle to monitor public health problems and guide
ARTICLE IN PRESS Malnutrition and morbidity in children without vitamin A supplementation policy decisions.16 The NSS was based upon stratified multistage cluster sampling of households in subdistricts of administrative divisions of the country and in slum areas of large cities.14 A purposive sampling design was used to target poor households. Within specific slum areas, poor households were considered those in which the housing location was along train tracks, rivers/gutters/ swamps, underneath toll roads/highways, near ‘waste station/dump areas’, around small alleys and/or near the beach, and where housing conditions included ‘box house’ (composed of cardboard, galvanized tin, plywood and bamboo), house with soil/uncemented floor, house attached to other houses and house with wood floors. The NSS in Indonesia involved the collection of data from approximately 40,000 randomly selected urban households every quarter. New households were selected every round. Data were collected by two-person field teams. A structured coded questionnaire was used to record data on children aged 0–59 months, including anthropometric measurements, date of birth and sex. The mother of the child or another 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 the age of 6 months, the mother, father or guardian was asked whether the child had received a vitamin A capsule within the last 6 months and about receipt of diphtheriapertussis-tetanus (DPT), oral poliovirus vaccine (OPV) and measles vaccine. Axillary temperature was recorded. Haemoglobin was measured using a HemoCue instrument (HemoCue AB, Angelholm, Sweden). Morbidity histories were obtained for each child, including history of diarrhoea in the previous week and diarrhoea on the survey day. Data were collected on the history of any deaths in the household before 1 month of age, before 12 months of age and before 5 years of age. The field teams measured and recorded the weight of each child aged 0–59 months 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 (Centers for Disease Control and Prevention, Atlanta, GA, USA), which uses the reference population of the US National Center for Health Statistics. Children with Z-scores o 2 standard deviations (SD) for WHZ, WAZ or HAZ
373
were considered wasted, underweight or stunted.17 Severe wasting, underweight and stunting were defined by Z scores o 3 SD. Children who had a mid-upper arm circumference o125 mm were considered to be at high risk of malnutrition.18 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 days 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 of the Declaration of Helsinki.19 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. The research plan was reviewed by the Johns Hopkins School of Medicine Institutional Review Board and granted an exemption on 14 July 2006 under Department of Health and Human Services 45, Code of Federal Regulations 46.404. Data analyses were restricted to children aged 12–59 months at the start of the most recent vitamin A capsule distribution round because these were the children who were eligible to receive 60 mg retinol equivalents (200,000 International Units) every 6 months in the Indonesian vitamin A capsule programme. Children who were aged between 6 and 12 months 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 was being implemented during the period of this study. For families with more than one child, the youngest child aged 12–59 months was selected to represent each family. Continuous variables were compared using Student’s t-test, and variable transformations were used when necessary to normalize the data. Categorical variables were compared using Chisquared tests. Anaemia was defined as haemoglobin
ARTICLE IN PRESS 374 o11 g/dl, according to World Health Organization criteria.19 Population-based weighting was used to account for differences in population size of the various provinces, and population-weighted results are reported.
Results The study population included 138,956 children, aged 12–59 months, of whom 87,675 (63.1%) had received a vitamin A capsule within the last 6 months. Non-respondents accounted for only 612 children (0.4%). Table 1 shows the demographic and other characteristics of children who did and who did not receive vitamin A supplementation. Children who did not receive a vitamin A capsule were significantly more likely to be younger, male, have WAZ and HAZo 2, have WAZ, HAZ and WHZ o 3, have fever on the survey day, have diarrhoea on the survey day, have a history of diarrhoea in the previous week, and have anaemia compared with children who received a vitamin A capsule. Children who did not receive vitamin A supplementation were significantly more likely to have mothers who were younger and less educated and fathers who were less educated. The mean distance and time to walk from the house to the ‘posyandu’ were significantly higher for children who did not receive a vitamin A capsule compared with children who did receive a vitamin A capsule. Childhood immunization coverage was compared for children who did and did not receive vitamin A supplementation (Table 2). Children who did not receive a vitamin A capsule were significantly less likely to receive the first, second and third DPT immunization, the first, second, and third OPV immunization, and measles immunization. A history of child mortality was compared in households where the children did or did not receive vitamin A supplementation (Fig. 1). In households where the child did not receive a vitamin A capsule, the proportions of deaths before 1 month of age, before 12 months of age and before 5 years of age were significantly higher than in households where the child received a vitamin A capsule. The general reasons given for not visiting the ‘posyandu’ are shown in Table 3. The five main reasons were that the child was afraid of being weighed, that the parents usually took the child to other health facilities, that the family had just moved to the survey area, that the health post was not active, and that they thought the child was too old to attend the ‘posyandu’.
S.G. Berger et al.
Discussion The vitamin A capsule supplementation programme in Indonesia has proved to be highly effective over the last 25 years in decreasing rates of severe vitamin A deficiency and increasing overall coverage rates.6,10 However, these results, based on the most recent data from the NSS conducted in Indonesia, show that the programme may not be reaching the children who are at highest risk for malnutrition and infectious disease morbidity in urban Indonesia. The evidence shows that in urban slum areas, children, aged 12–59 months, who had not received vitamin A supplementation in the previous 6 months were at greater risk of underweight, stunting and severe wasting. They were also more likely to be anaemic and to have higher rates of diarrhoea on the survey day, fever on the survey day and a history of diarrhoea in the previous week than children who had received vitamin A supplementation. In addition, children who did not receive vitamin A were more likely to be more severely underweight, stunted and wasted (Z scores o 3) compared with children who did receive vitamin A. The difference in value of the above indicators between children who did and did not receive vitamin A supplementation was not exceptionally large and the statistical significance of these variables was probably influenced by the large sample size of the study. Nevertheless, consistent differences in anthropometric and health characteristics in both real and statistically significant terms offer compelling evidence that the children who were not reached by the vitamin A programme were at much greater risk for malnutrition and morbidity. This analysis also shows that children who did not receive vitamin A capsules were less likely to receive DPT, OPV and measles vaccine, thereby placing them at higher risk for infectious disease morbidity and mortality from vaccine-preventable diseases. Lack of vaccine protection as well as lack of vitamin A supplementation may place children at especially high risk, especially with regards to measles. Vitamin A deficiency is known to increase the risk of measles morbidity and measles-related pneumonia, blindness and mortality. These findings suggest that children who are not reached by the vitamin A programme are unlikely to benefit from other primary care and preventive care programmes. It is clear that efforts to increase participation in vitamin A programmes should also emphasize participation in childhood immunization and other primary care programmes. Barriers to access were also examined. Mothers reported the child’s fear of getting weighed and use
ARTICLE IN PRESS Malnutrition and morbidity in children without vitamin A supplementation
375
Table 1 Demographic and health characteristics of children, aged 12–59 months, who did and did not receive a vitamin A capsule. Characteristic
N
Child age (months) (%) 12–23 24–35 36–47 48–59 Gender, % male
19,516 14,248 10,509 7010 27,210
38.1 27.8 20.5 13.7 53.1
31,073 26,649 19,039 10,913 44,749
35.4 30.4 21.7 12.4 51.0
Maternal age (years) (%) p24 25–28 29–32 X33
9435 13,115 14,465 14,085
18.5 25.7 28.3 27.6
14,391 22,612 26,427 24,120
16.4 25.8 30.2 27.5
0.0001
Maternal education (years) (%) 0–6 7–9 X10
28,447 11,339 11,302
55.7 22.2 22.1
40,452 21,418 25,576
46.3 24.5 29.2
0.0001
Paternal education (years) (%) 0–6 7–9 X10
20,902 12,556 16,204
42.1 25.3 32.6
29,588 21,325 34,648
34.6 24.9 40.5
0.0001
Number of children o5 years in household 1 2 3 4+
23,944 8486 688 45
72.2 25.6 2.1 0.1
55,564 14,344 797 73
78.5 20.3 1.1 0.1
0.0001
Year in which interview was conducted 1999 2000 2001 2002 2003
17,456 18,930 8833 3710 2353
34.0 36.9 17.2 7.2 4.6
16,012 28,251 16,676 15,026 11,711
18.3 32.2 19.0 17.1 13.4
0.0001
Weight-for-age Z (WAZ) score (%) WAZ o 2 WAZ o 3
21,986 4371
43.2 8.6
37,016 6791
42.5 7.8
0.012 0.0001
Height-for-age Z (HAZ) score (%) HAZ o 2 HAZ o 3
19,345 5399
38.3 10.7
31,589 8149
36.4 9.4
0.0001 0.0001
Weight-for-height Z (WHZ) score (%) WHZ o 2 WHZ o 3
5786 603
11.4 1.2
9805 873
11.3 1.0
0.541 0.002
MUAC o125 mm (%) Diarrhoea on survey day (%) Fever on survey day (%) Diarrhoea last week (%) Anaemic (%)
1642 3246 1427 5448 5788
3.2 6.3 2.8 10.7 56.2
2705 4534 1618 7036 9622
3.1 5.2 1.9 8.1 53.9
0.237 0.0001 0.0001 0.0001 0.0001
Distance to the ‘posyandu’ Metresa Minutesa
MUAC, mid-upper arm circumference. Geometric mean (95% confidence intervals).
a
Did not receive vitamin A
50,710 35,204
N
Received vitamin A
264.5 86,279 (259.2–270.9) 5.11 82,508 (5.07–5.15)
78.7 (77.8–79.5) 4.66 (4.64–4.69)
P
0.0001
0.0001
0.0001 0.0001
ARTICLE IN PRESS 376 Table 2
S.G. Berger et al. Relationship of vitamin A capsule receipt with childhood vaccinations.
Characteristic
N
Did not receive vitamin A
N
Received vitamin A
P
DPT vaccine dose 1 Received, with record Received, no record Not received Does not know
7710 18,309 6402 418
23.5 55.8 19.5 1.2
28,683 36,439 5188 232
40.7 51.7 7.4 0.3
0.0001
DPT vaccine dose 2 Received, with record Received, no record Not received Does not know
7072 17,043 8284 448
21.5 51.9 25.2 1.3
27,579 35,070 7652 253
39.1 49.7 10.8 0.4
0.0001
DPT vaccine dose 3 Received, with record Received, no record Not received Does not know
6582 16,044 9716 482
20.0 48.9 29.6 1.5
26,482 33,784 9868 329
37.6 47.9 14.0 0.4
0.0001
OPV vaccine dose 1 Received, with record Received, no record Not received Does not know
7949 18,325 6235 330
24.2 55.8 19.0 1.0
29,122 36,493 4646 233
41.3 51.8 6.6 0.3
0.0001
OPV vaccine dose 2 Received, with record Received, no record Not received Does not know
7480 17,210 7790 371
22.8 52.4 23.7 1.1
28,372 35,355 6520 252
40.2 50.1 9.2 0.3
0.0001
OPV vaccine dose 3 Received, with record Received, no record Not received Does not know
6993 16,294 9161 398
21.3 49.6 27.9 1.2
27,392 34,303 8515 273
38.9 48.7 12.1 0.4
0.0001
Measles vaccine Received, with record Received, no record Not received Does not know
5972 14,294 12,030 530
18.2 43.5 36.6 1.6
24,809 31,737 13,401 504
35.2 45.0 19.0 0.7
0.0001
DPT, diphtheria-pertussis-tetanus; OPV, oral poliovirus vaccine.
of other health facilities as the main reasons why their children did not participate in the national vitamin A capsule programme. Other major reasons given were that the family had moved to the area recently and the ‘posyandus’ were not active. Less than 2% of respondents cited distance to the health post as a reason for non-participation. Most reasons given by the mothers suggested a lack of knowledge about the health benefits of vitamin A. Other studies in Indonesia have shown that limited knowledge of the importance of vitamin A is associated with lower rates of participation in the
national vitamin A programme.13,20 In addition, it is clear that general lack of access to health posts, and thus to primary care, is likely to be an additional determinant of the increased morbidity among children who are not reached by the vitamin A capsule programme. Two studies from the Philippines and Indonesia examined the characteristics of children who did and did not participate in vitamin A supplementation programmes. However, these studies focused mainly on socio-economic and family characteristics.12,13 Another recent study from Bangladesh
ARTICLE IN PRESS Malnutrition and morbidity in children without vitamin A supplementation 10 9
No capsule
8
Capsule
*
7
%
6
*
5 4
*
3 2 1 0
Infant Died <1 Month
Infant Died <12 Months
Child Died <5 Years
Figure 1 History of infant dying before 1 month of age, infant dying before 12 months of age, and under-5 child mortality in families where the child did and did not receive a vitamin A capsule (*Po0.0001).
Table 3 Reasons given for not taking children to the health post (‘posyandu’). Reason
n
%
Child afraid of being weighed Usually take child to another health facility Just moved to survey area Health clinic not active Child is too old Mother is too busy Do not know schedule Health clinic too far away Immunizations are complete Need to pay Child is too young Child is weighed at home No food supplementation programme Other reasons
14,039
36.4
5319 2525 2376 1879 1124 1057 661 552 118 94 57 42 8727
13.8 6.5 6.2 4.9 2.9 2.7 1.7 1.4 0.3 0.2 0.1 0.1 22.6
377
primary preventive care programmes in Indonesia. The study also emphasizes the substantial impact of formal maternal and paternal education on vitamin A supplementation in children. Further investigation is necessary to determine how coverage rates of vitamin A supplementation may be increased through improvements in formal and nutrition education among parents and primary caregivers. The International Vitamin A Consultative Group (IVACG) recently suggested that vitamin A deficiency may affect a disproportionate number of the poor who are also least likely to access public health services.8 IVACG recommended that vitamin A supplementation should achieve coverage over 80%, acknowledging that the averted morbidity and mortality would probably be greatest among the lowest one-fifth of the population.22 Little quantitative data have been available regarding those who are not reached, and the study findings confirm that non-participants in urban areas suffer poorer nutritional status and higher morbidity than participants in the vitamin A capsule programme. Periodic high-dose vitamin A supplementation remains one of the most cost-effective means of reducing child mortality in developing countries, and unless coverage is expanded to reach the children in greatest need, the international community will fall short of reaching the Millennium Development Goals for reducing child mortality by two-thirds between 1990 and 2015.3,23 Ethical approval Medical Ethical Committee of the Ministry of Health, Government of Indonesia; plan for secondary data analysis reviewed by Johns Hopkins School of Medicine Medical Institutional Review Board and granted an exemption on 14 July 2006 under the US Department of Health and Human Services 45, Code of Federal Regulations 46.404. Funding
described disparities in vitamin A supplementation among ethnic minorities in Bangladesh.21 To the authors’ knowledge, the present study is the first to examine the health and nutritional characteristics of children who are not reached by a vitamin A capsule supplementation programme. In addition, the study highlights that the programme coverage rate among children aged 12–59 months living in urban slum areas was 63.1%, falling below the Indonesian Government’s target coverage rate of 80%10 and below the World Bank’s recommendation of 85%.8 These findings suggest that strategies need to be developed to reach children who do not receive vitamin A supplementation and basic
Lew R. Wasserman Award from Research to Prevent Blindness. Competing interests None declared.
References 1. Sommer A, Davidson FR. Assessment and control of vitamin A deficiency: the Annecy Accords. J Nutr 2002;132(Suppl. 9): 2845S–50S. 2. West Jr KP, Darnton-Hill I. Vitamin A deficiency. In: Semba RD, Bloem MW, editors. Nutrition and health in developing countries. Totowa, NJ: Humana Press; 2001. p. 267–306.
ARTICLE IN PRESS 378 3. Edejer TTT, Aikins M, Black R, Wolfson L, Hutubessy R, Evans DB. Cost effectiveness analysis of strategies for child health in developing countries. Br Med J 2005;331:1177. 4. Beaton GH, Martorell R, L’Abbe KA, et al. Effectiveness of vitamin A supplementation in the control of young child morbidity and mortality in developing countries. ACC/SCN State-of-the-Art Nutrition Policy Discussion Paper No. 13. New York: United Nations; 1993. 5. Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS. Bellagio Child Survival Study Group. How many child deaths can we prevent this year? Lancet 2003;362:65–71. 6. Muhilal, Tarwotjo I, Kodyat B, Herman S, Permaesih D, Karyadi D, et al. Changing prevalence of xeropthalmia in Indonesia, 1977–1992. Eur J Clin Nutr 1994;48:708–14. 7. Soekarjo DD, de Pee S, Kusin JA, Schreurs WH, Schultink W, et al. Effectiveness of weekly vitamin A (10000 IU) and iron (60 mg) supplementation for adolescent boys and girls through schools in rural and urban East Java, Indonesia. Eur J Clin Nutr 2004;58:927–37. 8. World Bank. Vitamin A. 2004. Available at: (web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTHEALTHNUTRITIONANDPOPULATION/EXTPHAAG/0,,contentMDK:20800011menuPK:1314810pagePK:642298). Last accessed 8 May 2006. 9. Lomborg B. Global crises, global solutions. New York: Cambridge University Press; 2004. 10. Helen Keller International. Summary and accomplishments of the HKI/GOI collaboration for vitamin A, 1999–2005. Jakarta: Helen Keller International Indonesia; 2006. 11. Semba RD, Susatio B, Muhilal, Natadisastra G. The decline of admissions for xerophthalmia at Cicendo Eye Hospital, Indonesia, 1981–1992. Int Ophthalmol 1995;19:39–42. 12. Choi Y, Bishai D, Hill K. Socioeconomic differentials in supplementation of vitamin A: evidence from the Philippines. J Health Popul Nutr 2005;23:156–64. 13. Pangaribuan R, Scherbaum V, Erhardt JG, Sastroamidjojo S, Biesalski HK. Socioeconomic and familial characteristics influence caretakers’ adherence to the periodic vitamin A
S.G. Berger et al.
14.
15.
16. 17.
18.
19.
20.
21.
22.
23.
capsule supplementation program in Central Java, Indonesia. J Trop Pediatr 2004;50:143–7. de Pee S, Bloem MW, Sari M, Kiess L, Yip R, Kosen S. High prevalence of low hemoglobin concentration among Indonesian infants aged 3–5 months is related to maternal anemia. J Nutr 2002;132:2115–221. de Pee S, Bloem MW. Assessing and communicating impact of nutrition and health programs. In: Semba RD, Bloem MW, editors. Nutrition and health in developing countries. Totowa, NJ: Humana Press; 2001. p. 483–506. Mason JB, Habicht JP, Tabatabai H, Valverde V. Nutritional surveillance. Geneva: World Health Organization; 1984. de Onis M. Child growth and development. In: Semba RD, Bloem MW, editors. Nutrition and health in developing countries. Totowa, NJ: Humana Press; 2001. p. 71–91. Dramaix M, Hennart P, Brasseur D, Bahwere P, Mudjene O, Tonglet R, et al. Serum albumin concentrations, arm circumference, and oedema and subsequent risk of dying in children in central Africa. Br Med J 1993;307: 710–3. World Medical Association. Declaration of Helsinki: ethical principles for medical research involving human subjects. Bull World Health Organ 2001;79:373–4. Pangaribuan R, Erhardt JG, Scherbaum V, Biesalski HK. Vitamin A capsule distribution to control vitamin A deficiency in Indonesia: effect of supplementation in pre-school children and compliance with the programme. Public Health Nutr 2003;6:209–16. Karim F, Rafi M, Begum SA. Inequitable access to immunization and vitamin A capsule services: a case of ethnic minorities in three hill districts of Bangladesh. Public Health 2005;119:743–6. Ross D. Recommendations for vitamin A supplementation. Proceedings of the XX international vitamin A consultative group meeting. J Nutr 2002;131:2902S–6S. Bryce J, el Arifeen S, Pariyo G, Lanata C, Gwatkin D, Habicht JP, et al. Reducing child mortality: can public health deliver? Lancet 2003;362:159–64.